[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 female patient presented to the Outpatient department with a chief complaint of swelling in the lower jaw since 6 months. There was difficulty in speech, mastication, and deglutition. There was no associated pain. She had no contributing medical history.
On extra oral examination a large well-defined swelling was noticed in the mandibular anterior region crossing the midline causing facial asymmetry [].
The swelling extended below the inferior border of the mandible and the skin over the swelling was stretched and smooth. She had difficulty in opening the mouth. No lymph nodes were palpable.
Intraoral examination showed a large swelling, which extended completely into the floor of the mouth and completely obliterating the lingual and buccal vestibules mediolaterally [].
The lingual frenum was pushed back. Anteriorly, it extended from the labial sulcus to the ramus posteriorly. There was no surface discharge present, the mucosa over the swelling was normal and its color was same as that of the normal tissue. All the mandibular incisors were missing. Generalized extrinsic stains were present.
On palpation the inspectory findings were confirmed. The swelling was bony hard, non-tender, and immobile. None of the teeth present showed mobility.
Routine blood and urine examination was normal. Fasting and post-prandial sugar levels were also normal.
Computed tomography showed a large multilocular osteolytic lesion extending from 37 to 47 region crossing the midline, destruction of both cortices and pathologic fracture was seen []. Soap bubble and honeycomb patterns were appreciable. A multi-centric growth pattern was seen showing a permeative type of destruction [].
A chest radiograph was taken to rule out any primaries in the lung.
A provisional diagnosis of ameloblastoma was established. A differential diagnosis of odontogenic keratocyst was made.
An incisional biopsy was performed under local anesthesia and microscopic examination revealed odontogenic island

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


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

[User]
RADIOLOGY NOTE:
The patient was a 76-year-old woman who had a history of surgery for papillary thyroid cancer and cesarean section with uterus bicornis.
She had consulted a previous physician complaining of fever and right lower quadrant abdominal pain. A marked inflammatory reaction was observed and enhanced computed tomography (CT) showed abscess formation around the cecum. An intra-abdominal abscess was diagnosed and the patient was treated conservatively with antibiotics, but her symptoms relapsed after discharge and she was referred to our hospital. The inflammatory reaction showed exacerbation and cancer antigen 125 (CA125) was mildly elevated (78 U/mL). Enhanced CT was performed again and showed a persistent abscess, a tumorous lesion in the mesentery and right hydronephrosis (Figure ). Because malignancy could not be ruled out, surgical treatment was selected.
At laparotomy, there were no ascites but encapsulated abscesses were present on the mesenteric side and outside of the ileocecal region (Figure a,b). When we raised the ileocecal region, a tumor was found to be fixed to the right ureter and there was leakage of white, solid tumor content (Figure c). This tumor content was submitted to intraoperative frozen section diagnosis, which demonstrated a ‘carcinoma’. Also, enlarged lymph nodes were observed along the ileocolic artery. For the above reasons, we performed ileocecal resection with D3 lymph node Dissection. A ureteral stent was then inserted into the right ureter, and the tumor was separated and removed from the ureter with scissors (Figure d). The ureteral stent was easily inserted without resistance and urine cytology was negative for carcinoma. After tumor removal, we searched the abdominal cavity thoroughly, but there were no abnormalities of the uterus and adnexa, nor any evidence of peritoneal dissemination.
The pathological diagnosis was poorly differentiated carcinoma, but there were no changes involving the mucosal surface of the cecum or the terminal ile

[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 female was diagnosed in Tunisia with stage IV synovial sarcoma originating from the soft tissue of the left trapezius with lung metastases, after complaining of shoulder swelling and pain back in July 2018. Written reports of the CT imaging obtained in Tunisia revealed that she had a 4 x 2 cm left paravertebral pleural formation, 1 cm left pleural nodule and 10 x 9 x 3.5 cm left posterior dorsal wall mass of muscular origin presumed to be the trapezius, at the time of diagnosis. Outside reports of the biopsy of the intramuscular mass revealed that she was diagnosed with a grade 2 monophasic synovial cell sarcoma. She had no family history of malignancy. She received 6 cycles of adriamycin and ifosfamide with mesna. The size of tumor decreased after the third cycle and continued to be stable afterwards. The plan was to start radiation after completion of chemotherapy, but she relocated to the United States before starting radiation therapy.
She established care in our institution in February 2019. A repeat CT revealed a left pleural nodule measuring 3.9 cm, left lower lobe nodule measuring 1.5 cm, and a right upper lobe nodule measuring 3.5 cm (Figures , ). The CT scan also revealed a trapezius mass measuring 8 x 4 cm (Figures , ). She was not a candidate for resection of chest wall tumor due to the extensive nature of the required surgery. Pazopanib 800 mg daily was started due to disease progression, in addition to palliative radiation to the left scapula for pain control. Radiation was completed in May 2019. Clinically, her symptoms improved, and she had stable disease on imaging. She developed leukopenia during radiation therapy, which was attributed to medication side effects, so pazopanib was held in May and was resumed after completion of radiation therapy. A fluctuating thyroid-stimulating hormone level was observed and was attributed to drug-induced thyroiditis, with transient subclinical hyperthyroidism followed by hypothyroidism

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old male patient had come to the Department of Oral Medicine and Radiology with a chief complaint of burning sensation throughout the oral cavity for the past 1-year. History revealed that initially the burning sensation was mild in intensity but gradually increased to the present state. He had also visited a local dentist for the same and had been given topical application and medication following which there was symptomatic relief during application only. He had no significant medical and dental history. Going on to details of his personal history it revealed that he was single and working as an agent for a financial company. Patient gave a history of smoking 8–10 cigarettes/day for past 15 years and also consumes alcohol around 90 ml/week for the past 10 years. On further probing, he gave a history of having sexual contact with multiple partners for the past 8 years. However, he also gave a history of having protected sex.
Intraoral examination revealed multiple raised white patches interspersed with areas of erythema in multiple sites of the oral cavity. These lesions were abundantly seen in the palate and tongue [Figures and ]. The other areas included upper and lower labial and alveolar mucosa and floor of the mouth [Figures –]. The areas were mildly tender and the white patches were scrapable and leaving a raw area behind. The history and the above clinical features led to a provisional diagnosis of erythematous candidiasis.
The routine hematological examination was normal except for the erythrocyte sedimentation rate level of 36 and 75 in half an hour and 1 h duration. An exfoliative cytology was performed which revealed plenty of candidal hyphae with spores confirming the diagnosis of candidiasis []. Furthermore, special investigation of HIV, ELISA was done, which turned to be positive and the report was read as antibodies to HIV I and II reactive. Thus, a final diagnosis HIV-induced erythematous candidiasis was made.

[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-years-old Caucasian woman presented to a private dental clinic with a chief complaint of asymptomatic swelling in the gingiva observed four years prior. A gradual increase in size and no history of previous treatment were also reported during the anamnesis. The patient signed the informed consent, which represents the ethical approval of the faculty committee. Her medical and socio-economic histories were not contributory. The extra-oral evaluation did not reveal changes. The intraoral examination revealed a sessile nodule with a color similar to that of the mucosa and a focal erythematous area with a fibro-elastic consistency measuring 1.5 cm in the largest diameter extending from the inferior right lateral incisor to the inferior right first premolar. The lesion involved the vestibular and lingual gingiva, causing displacement of the inferior right canine (Fig. ).
Panoramic reconstruction and parasagittal slices of the Cone Beam Computed Tomography (CBCT) showed a slightly superficial hypodense area between the inferior right lateral incisor and inferior right canine with reabsorption of the alveolar crest (Fig. ). Based on the clinical and immunological aspects, the main diagnosis hypotheses included peripheral ossifying fibroma, peripheral giant cell lesion, and ancient pyogenic granuloma. The peripheral odontogenic tumors were also included as a differential diagnosis. An excisional biopsy was performed and a clear separation was noted between the lesion and mandible bone during the trans-surgical approach. The histopathological analysis revealed a well-circumscribed proliferation comprising numerous islands and strands of epithelial polyhedral cells with well-defined borders and marked round nucleus in the connective tissue under the mucosal epithelium. Numerous nests, cords, and small islands of polyhedral cells with clear and vacuolated abundant cytoplasm were observed interspersed with the amorphous eosinophilic deposits (Fig. ). Immunohistochemistry w

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


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

[User]
RADIOLOGY NOTE:
A 51-year-old Japanese woman admitted to the hospital after a low-trauma fall. Clinical and radiological examination revealed an atypical subtrochanteric fracture of her right femur. She had a history of tibia fracture when she was twenty years old and treated by intramedullary nail. The patient was of short stature (138 cm) with typical facial features due to micrognathia, abnormal dentition, and a prominent nose. She had no abdominal organomegaly and denied consanguinity in her parents.
Laboratory investigations revealed no evidence of systemic, metabolic, or endocrine disorder. Her blood count and blood chemistry were normal. Other bone turnover markers, such as bone ALP and N-terminal telopeptide, were also normal.
Radiographs of the right femur confirmed a noncomminuted, transverse subtrochanteric fracture with both lateral and medial cortical thickening, but without obliteration of the medullary canal, consistent with radiologic features of an atypical subtrochanteric femoral fracture [] (). Pelvic views demonstrated asymptomatic stress fracture in the left femur that involved the lateral cortex. A subsequent skeletal survey revealed cortical thickening of all long bones and an incompletely fused anterior fontanelle ().
For the treatment of fracture, open reduction and internal fixation with a plate and screws were performed. Drilling, particularly in the femoral neck, was quite difficult as bone was sclerotic. For the opposite sided stress fracture, prophylactic operation, an internal fixation with a plate and screws, was performed (). 10 days after operation of the left femur, fracture occurred at the distal screw and reoperation was performed using a long plate (). Fracture healed well in 3 months and then the patient was able to bear full weight.
One year and 4 months after operation, she was suffering from right hip pain and could not walk. Plain radiological examination revealed narrowing of joint space of the right hip joint and osteonecrosis of the fem

[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 19-month-old male child was brought to our pediatric hematology-oncology outpatient clinic for the management of recurrent anemia of unknown cause. There was a history of hydrops fetalis being detected on the patient's fetal ultrasound examination. The patient weight 2.29 kg at birth and had been delivered at 39 + 4 weeks’ gestational age via a vaginal delivery. As a newborn delivery, the patient had cried weakly and had a pale appearance and was consequently diagnosed with respiratory distress syndrome and anemia. He was treated with a surfactant and underwent 6 packed red blood cell (PRBC) transfusions in the neonatal intensive care unit within the first month of his birth. Subsequently, he continued to receive a PRBC transfusion every 3 to 4 weeks for persistent anemia, until he reached 3 months of age. Fortunately, his hemoglobin levels were sustained >9.0 g/dL from the age of 4 months. However, the patient continued to experience wheezing along with repeated episodes of upper respiratory tract infections. At the age of 19 months, there was a recurrence of anemia and he was transferred to the hematology-oncology outpatient clinic. The father informed us regarding the patient's course of admission in a neonatal intensive care unit for the first few months of his life for the management of persistent anemia of an undetermined cause. Other medical history included 2 operations, one each for inguinal hernia and congenital cataract at the ages of 3 and 7 months, respectively. On eliciting the family history, he also disclosed that an older male sibling to the patient had died of apnea at the age of 5 months.
On examination, the patient was severely anemic but anicteric. The patient weighted 7.2 kg, had a 75 cm, and his head circumference was 43.5 cm (all parameters <3rd centile for age). His right eye showed strabismus. The systemic examination revealed no abnormalities including hepatosplenomegaly. The developmental milestones for motor skills and language were fo

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


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

[User]
RADIOLOGY NOTE:
A 36-year old woman was admitted to our hospital because of a 10 kg weight gain during the previous 5 months and a left adrenal mass incidentally detected on abdominal ultrasonographic examination at another hospital. She had undergone total mastectomy due to right breast cancer (stage I) 10 months before admission and was receiving goserelin on a monthly basis. She had a moon face and a mild buffalo hump.
The chest radiography, routine hematology and biochemistry were unremarkable. The endocrine examination showed elevated serum cortisol, suppressed plasma adrenocorticotropic hormone, and loss of circadian rhythm (). The serum cortisol level and the urinary free cortisol excretion were not reduced after 2-mg and 8-mg dexamethasone suppression tests ().
Magnetic resonance imaging of the abdomen revealed a 12×10.3×9.7 cm sized, heterogeneous mass in the left adrenal gland, with possible internal hemorrhagic necrosis (). Whole-body positron emission tomography/computed tomography with 18F-fluorodeoxyglucose (18F-FDG) images showed significant 18F-FDG uptake in the huge left adrenal mass and no significant uptake at any other sites.
On the basis of the physical findings, endocrine data, and imaging studies, the patient was diagnosed with Cushing's syndrome secondary to an ACC. We scheduled an elective operation to remove the mass. However, the patient complained of sudden onset of left upper quadrant abdominal pain. An abdominal CT showed that the tumor mass in the adrenal gland had increased in size and that there was a hemorrhagic fluid collection in the left perinephric area. These findings were suggestive of a tumor rupture (). We performed a left adrenalectomy using an open transabdominal approach. The adrenal tumor was found to have ruptured, and the resected tumor, weighing 251 g, was internally hemorrhagic and necrotic. Histological examination of the specimen revealed an adrenal cortical carcinoma (). The histological findings fulfilled three of the modified W

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old man complained of spontaneous onset left shoulder pain and stiffness for around 2 weeks. X-ray showed an expansile and lytic lesion over the proximal humerus []. The cortical bone was so thin that it could not be well delineated. Magnetic resonance imaging (MRI) showed a T2 hyperintense expansile mass. The humeral head was deformed, but the lesion remained intraosseous. There was no extraosseous soft tissue component. Open biopsy of the lesion confirmed GCT [].
Treatment options of extended curettage versus wide local excision were discussed with the patient. He opted for joint preservation procedures. The patient also requested to try denosumab as a neoadjuvant treatment after we presented to him a few recent reports which showed that denosumab could induce ossification in GCT. Informed consent was obtained, and the patient received 6 doses of denosumab (120 mg subcutaneous injection on day 0, day 6, day 13, day 29, day 57, and day 85, respectively). The dosage and interval were similar to the protocol used by Thomas et al.[] Clinically, the left shoulder pain decreased although the motion was still limited. He was put on calcium and multivitamin supplement, and regular blood tests showed normal renal function and calcium level. The patient did not experience any side effect. Regular X-ray showed no progression of the lesion. In addition, the lesion became more sclerotic. There was progressive bone deposition in the tumor, and the cortex became more clearly delineated [Figure –]. A reassessment MRI showed no interval change in size or signal of the lesion.
The patient received operation on day 118 (around 4 months) after starting denosumab. An extended curettage was performed through a deltopectoral approach. We opened a cortical window at the metaphyseal area. The tumor tissue inside was found to be extremely hard and was significantly different from the soft texture of the usual GCT. Normally for

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


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

[User]
RADIOLOGY NOTE:
A 66-year-old female patient with a history of bilateral lower limb lymphedema reported the aggravation of the condition over the years, reaching stage III (elephantiasis). The patient was sent to the Godoy Clinic and reported having undergone several treatments throughout her life as well as several episodes of erysipelas. She did not marry due to the lymphedema and complained of the frequent occurrence of strangers staring at her leg, which upset her. The physical examination confirmed elephantiasis. The circumference of the left lower limb was 106 cm. Her body weight was 106 kilograms, height was 160 cm, and the body mass index (BMI) was 41.6 kg/m2 ().
The patient was submitted to intensive treatment for three weeks, which led to a 21 kg reduction in weight and 66 cm reduction in leg circumference ().
Intensive treatment with the Godoy Method consisted of eight hours per day of mechanical lymphatic drainage, 15 minutes of simultaneous cervical lymphatic therapy, and hand-crafted compression stockings made from grosgrain fabric. Mechanical lymphatic therapy consisted of an electromechanical device that performs plantar flexion and extension. After three weeks of intensive therapy, the patient continued treatment at home using the compression stockings. At the follow-up evaluation, the patient was submitted to electrical bioimpedance analysis as well as circumference measurements and volumetry. The bioimpedance analysis revealed a pattern of normality, with the reduction in lymphedema. Ten years after treatment, the patient has maintained the results with the compression stockings. In occupational therapy throughout this period, the patient has been encouraged to perform activities that she has always wanted to do to improve her wellbeing. She took up belly dancing, followed by tap dancing. She reports that these activities changed her life and she is very happy for being able to realize her dream of dancing, which is an activity that she began at the age of 76

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


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

[User]
RADIOLOGY NOTE:
A 37-year-old female with a known history of neuroendocrine carcinoma of the cervix (NECC) for the past 11 months who had undergone a partial hysterectomy presented to the neurosurgical service with a severe headache unresponsive to medical treatment after recently undergoing a follow-up completion hysterectomy with pelvic lymph node dissection. Figure presents imaging and pathology findings. A CT head without contrast demonstrated florid obstructive hydrocephalus and several intra-axial lesions occupying the pineal region, left frontal lobe, and posterior fossa (Figure ). A right frontal ventriculostomy was placed to temporize the hydrocephalus. Due to the degree of brainstem compression and the need to obtain a pathologic diagnosis, it was decided to proceed with a posterior fossa craniotomy for the removal of a single lesion. The frozen pathology yielded a small blue cell tumor with positive neuroendocrine markers cluster of differentiation 56 (CD56), chromogranin, and hematoxylin and eosin (H&E) stain consistent with a prior diagnosis of neuroendocrine carcinoma of the cervix (Figure ). The remaining lesions were left alone given the biologic responsiveness of neuroendocrine carcinoma to radiation therapy. An endoscopic third ventriculostomy (ETV) was then performed to remove the ventricular drain. The patient was then discharged from the hospital. She then went on to receive whole-brain radiotherapy (WBRT) for a total of 30 Grays (3000 cGy) over 10 fractions on an outpatient basis. A follow-up CT head without contrast was obtained (Figure ) that demonstrated the resolution of the pineal and left frontal lesions. The patient returned for follow-up ambulatory without any major concern. Subsequently, she presented to the oncologist with quadriparesis three months later. Magnetic resonance imaging (MRI) was obtained, which demonstrated drop metastasis in the cervical, thoracic, and lumbar area (Figure ) most likely related to biopsy, explaining the quadriparesis pr

[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 male presented with a non tender hard atrophic left testicle. The rest of the examination was normal. There had been no previous scrotal surgery or trauma.
Tumour markers including lactate dehydrogenase (LDH), human chorionic gonadotrophin (HCG), alpha fetoprotein (AFP) and prostate specific antigen (PSA) were normal. His total white cell count was normal. An ultrasound of the scrotum demonstrated a localised tumour of the testis. Chest x-ray was normal. A standard left radical orchidectomy was performed by the inguinal approach. The tumour appeared to be confined to the upper pole of the testis and was clinically described as T1 or T2. Macroscopic histological examination suggested no involvement of the tunica albuginea, epididymis or spermatic cord. Microscopic examination demonstrated infiltration of the testis by uniform ovoid cells with clear cytoplasm, vesicular nuclei and prominent nucleoli consistent with seminoma (Fig ). Tumour involved the tunica albuginea but did not extend through it. There was no vascular invasion. Surprisingly, seminoma cells were present beneath the epithelial lining of the vas deferans extending to the spermatic cord resection margin but nowhere else within the spermatic cord. (Fig ). The microscopic slides gave the appearance of sub epithelial spread of seminoma cells along the vas deferans. Other structures in the spermatic cord were not involved.
A post operative CT scan demonstrated two separate masses. A 2.8 cm by 2.3 cm central abdominal mesenteric mass and a 7.6 cm by 5.4 cm irregular heterogeneous lobulated soft tissue mass within the pelvis arising from the prostate and extending into the mesorectal fascia. There were no enlarged retroperitoneal, pelvic, inguinal or thoracic lymph nodes. (Fig and ). The chest CT scan was normal. The patient has received chemotherapy and is currently under follow up according to standard EUA guidelines. There is no evidence of residual or recurrent disease. The CT scan performed

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


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

[User]
RADIOLOGY NOTE:
A 78 year old African American female presented to the hospital with slurred speech that developed over two days. She arrived at the hospital concerned that she was having a stroke. In addition, the patient described having dysphagia, odynophagia, and that she had noticed purple blotches inside her oral cavity. The patient had developed worsening anemia for past few months and had needed three blood transfusions for symptomatic anemia within past 2 months. She had undergone two endoscopies and was found to have a bleeding gastric ulcer both times, for which she was treated during the endoscopies. She also described having multiple spontaneous bruises and ecchymotic lesions sporadically throughout her body over past few months. In addition to recurrent GI bleeding, past medical history was significant for chronic iron deficiency anemia, type 2 diabetes mellitus and multinodular goiter requiring thyroidectomy. She denied any history of a bleeding diathesis in the family.
On presentation, patient was hemodynamically stable. Physical exam was notable for a large ecchymotic lesion along floor of mouth, as well as on ventral tongue, while the rest of the buccal mucosa was normal (). She also had multiple ecchymoses over her chest and upper extremities.
On admission, the differential diagnosis included possible angioedema, oral cavity malignancy, and autoimmune phenomenon. Lab investigations were significant for anemia with hemoglobin of 6.7 g/dL, and prolonged aPTT of 35–48 s (reference range 20–28 s) with normal PT. There were no signs of GI bleeding on admission this time and she was not receiving any heparin products. In this context, tongue swelling and ecchymotic lesion were believed to be limited to the submucosal area and diagnosis of a bleeding diathesis was considered. Due to the prolonged aPTT, a mixing study was performed and did not correct, suggesting presence of a factor inhibitor. Further testing revealed an extremely low factor VIII activity of <1%, high 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 56-year-old man presented to us with chronic, progressive midline low back pain associated with right lower extremity radiculopathy. The patient described the pain as radiating and achy. On the physical exam, the patient had decreased sensation in the lateral aspect of the right lower extremity. Radiological findings demonstrated multilevel central stenosis and neuroforaminal narrowing with a degenerative scoliotic deformity of the lumbar spine (Figures , ). A conservative trial for up to a year with physical therapy, chiropractic and interventional pain modalities provided partial and short-lasting relief. As the pain continued to progress, the patient decided to proceed with surgery.
Various surgical options were considered. Eventually the patient underwent an ALIF at the L3-S1 levels using a retroperitoneal approach followed by a T10-pelvis posterior spinal fusion and a right L4-L5 laminotomy and decompression in two stages (Figure ). The post-operative course was complicated by abdominal distention that occurred on post-operative day eight. Computed tomography (CT) scan of the abdomen and pelvis demonstrated a large collection of retroperitoneal fluid measuring 11 x 9 x 22 cm in the left pelvis and left flank area with mass effect on the left kidney and ureter causing hydronephrosis (Figure ). After a consult with the general surgery team and the approach surgeon, the patient underwent ultrasound-guided drainage of fluid with temporary drain placement.
The fluid was serosangionous in nature with a high output of greater than 1500 cc/day. Fluid gram stain showed no organisms and cultures also revealed no growth. He was discharged home with the drain in place for a total of 22 days after which the drain was discontinued upon clinic follow-up. The lymphocele recurred four days after the drain was removed, and the patient presented back to the emergency room with recurrence of abdominal distension. A new drain was placed again in the fluid collection, and was fina

[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 female presented with chief complaints of intermittent palpitations and chest tightness for 6 years, aggravated for 3 days. Six years ago, the patient got palpitation, chest tightness, and pulse acceleration (self-measured and the specific data was not clear) with no obvious causes. Five years ago, the patient had irregular uterine bleeding. When the hemorrhagic amount increased, the patient was prone to palpitations and chest tightness. She visited a local hospital for treatment and the coronary angiography showed no abnormalities. Three days prior to the admission, the symptoms of palpitations and chest tightness aggravated after activities, and nocturnal paroxysmal dyspnea appeared, accompanied by intermittent abdominal pain. Thus, she went to the local hospital again, electrocardiogram showed III degree atrioventricular block. The local diagnosis was coronary atherosclerotic heart disease, arrhythmia, and she received appropriate treatment, however, the symptoms did not improve significantly. Therefore, on the fourth day, she visited outpatient clinics and was admitted to the department of cardiology with the diagnosis of coronary atherosclerotic heart disease in our hospital. Physical examination revealed the body temperature of 35.7°C, heart rate of 78 beats per minute, respiratory rate of 18 breaths per minute, and blood pressure of 114/80 mm Hg. The patient was alert and cooperative. There was no cyanosis on the lips and no dilatation of bilateral jugular vein. Moist rales, without dry rales, can be heard in the left lung. The heart rate was 78 beats per minute with regular rhythm and no murmur was heard in the area of each valve auscultation. The abdomen was soft without tenderness or rebound tenderness. Liver and spleen were not palpable. Mobile dullness was negative. There was no lower extremity edema. Preliminary diagnosis was arrhythmia, III degree atrioventricular block, heart failure, irregular uterine bleeding cause to be investigated.

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old man presented with a tingling sensation in the fourth and fifth digits of his left hand, which had developed after compression of the left arm by his body while in a drunken state some fourmonths previously. Touch sensation was reduced in the distributions of the left ulnar and dorsal ulnar sensory nerves. According to the Medical Research Council guidelines, the left abductor digiti minimi (ADM) and first dorsal interosseous (FDI) muscles were grade two, and thewrist (ulnar side) and finger flexions at the distal interphalangeal joints of the fourth and fifth digits were grade three. His other muscles were grade five. Froment's sign was positive on the left. The sensory nerve action potentials of the left ulnar digital branch and the dorsal ulnar cutaneous nerve were attenuated (13 uV and 9 uV, respectively ). Motor nerveconduction studies of the left ulnar nerve showed a significant conduction block (23% and 46 %, respectively) but normal conduction velocity (56 m/s and 54 m/s, respectively) in the forearm segment, nearly complete conduction block (85 and 100 %, respectively) and slow conduction velocity in the arm segment using ADM and FDI recordings () (). Precise localization was assessed by inching technique in the arm, which demonstrated the lesion was between 13 cm and 14 cm from the ME in ADM recording and between 12 cm and 13 cm proximal to the ME in FDI recording (). Considering the significant conduction block and the normal conduction velocity in the elbow found in the left ulnar motor nerve conduction study, the presence of MAG could be suspected. To confirm this, the median nerve was stimulated with FDI muscle recording, and significant waveforms of compound muscle action potentials (CMAPs) were produced by stimulation of the left median nerve at the elbow, not at the wrist, confirming MGA (). Similar findings were observed in the right side (). The right ulnar motor nerve conduction studies with

[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 62-year-old woman was referred by her dentist to our department in May 2013 with a suspected malignancy of the right tongue. The patient did not complain of pain, but uncomfortable stiffness of the tongue. She had no history of trauma, disease, surgery, or smoking, and only a small amount of daily drinking. Physical examination showed an ulcerative lesion measuring 14 × 10 mm with induration was recognized on the right lateral edge of the posterior tongue at the first visit (Figure ). The submandibular LNs of 8 mm diameter were palpable, mobile, and not tender. The results of cytology of the lesion in the oral cavity showed Class IV. Ultrasonography showed the presence of a tumor with a thickness of about 8 mm inward at the lesion site. Head and neck contrast-enhanced computed tomography (CE-CT) imaging strengthened the clinical suspicion of an OC of the right lateral edge of the tongue. Magnetic resonance (MR) imaging revealed the primary tumor extended into the right tongue region, inward with thickness of 10 mm or more, and LNs enlarged at the right superior internal jugular region (Figure ). Correspondingly, positron emission tomography (PET)-CT showed abnormal accumulation of FDG in the right lateral edge of the tongue (SUVmax = 6.98) and LNs at the right superior internal jugular region (SUVmax = 3.27), and no abnormal accumulation of FDG in other organs (Figure ). As a part of the staging and planning procedures, biopsy was performed, and the result was confirmed to be squamous cell carcinoma (SCC). Accordingly, the patient was clinically diagnosed with T2N1M0 stage III in the TNM classification of the 7th edition at that time.
In June 2013, we performed partial tongue resection including tumor lesion and modified radical neck dissection (type III; preserving sternocleidomastoid muscle, internal jugular vein, and accessory nerves) at the right side. The histopathological examination of the resected tongue

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


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

[User]
RADIOLOGY NOTE:
A 26-year-old female presented with complaints of posterior cervical headaches for many years with on and off tingling and numbness involving right arm, trunk, and leg. There was no history of bowel or bladder dysfunction. There was no significant past medical history or preceding trauma. The general physical examination was within normal limits. Neurological examination revealed presence of subtle spastic hemiparesis on the right side (Medical Research Council grade 4+/5) with exaggerated deep tendon reflexes as compared to left. She has positive right Hoffmann's sign. Computed tomography scan of the cervical spine revealed slight kyphosis and degenerative changes within the subaxial cervical spine with an expanded hyperostotic right posterior arch of C1 (). Magnetic resonance imaging of the cervical spine showed constriction of the dural sac with presence of possible right posterior arch of C1 lesion which was hypointense on T1 and T2W images and no contrast enhancement with a small area of increased signal within the spinal cord on the T2 weighted imagesb (). The patient was referred to us with a diagnosis of a benign bony tumor of C1 and a surgical removal was performed. Tc-labeled bisphosphonate nuclear bone scan performed did not reveal any abnormal focal uptake by the lesion which has been described in osteoid osteomas of the spine. Considering the dubious nature of the lesion with equivocal diagnosis, surgical resection was planned. Posterior exposure of the cervical spine in the C1-C2 regions was performed. There was no obvious anomaly seen externally with a normal appearing ligamentum flavum. The right posterior arch of the atlas was hypertrophied with no other abnormality suggestive of neoplastic lesion. The lesion was excised with performance of right hemilaminectomy of the atlas carefully preserving the C1/C2 joint. Final histopathology of the lesion showed the presence of normal bone tissue with no evidence of tumor confirming the diagnosis of hypertro

[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 previously healthy 39-year-old female, admitted to the THP with a history of fever for 4 days. She had nausea, vomiting, arthralgia, myalgia and headache. She did not have any bleeding manifestations or abdominal pain. On examination, she had mild dehydration with low volume pulse. Blood pressure was 100/80 mmHg in supine position and 90/80 mmHg on standing. Right lung base was stony dull on percussion and had absent breath sounds. Ultrasound scan revealed a right sided plural effusion with free fluid in the abdomen. The patient was managed as critical phase of dengue haemorrhagic fever (DHF) with meticulous titration of fluids according to the haematocrit values. She remained hemodynamically stable with a stable haematocrit values during the critical phase. On day 7 of illness, dengue serology showed positive IgM and IgG titers. After completion of critical phase on 7th day of the illness, she complained of abdominal pain and back pain. Clinical examination found s mild icterus and tense ascites. Laboratory investigations revealed a marked rise in liver enzyme levels (ALT 204 to 1391 u/L and AST 505 to 4519 u/L) with an INR of 1.9. Diagnosis of acute hepatitis leading into acute liver failure was made and viral hepatitis was excluded by doing hepatitis A IgM, hepatitis B surface antigen and hepatitis C IgM which were negative. She denied self-medication with high doses of paracetamol. Further, she was treated with intravenous N acetyl cysteine 150 mg/hour infusion as an empirical treatment. Her low albumin level was corrected with intravenous human albumin administration. Antibiotics including oral metronidazole and intravenous ceftriaxone was administered at the same time to cover bacterial infections. She was given intravenous vitamin K for 3 days to prevent clotting factor depletion whilst monitoring liver transaminases and clotting parameters. Finally she was discharged on 12th day of the illness with near normal liver transaminases and normal clotting profil

[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 38-year-old woman with 27.3 BMI needed an emergency caesarean section in the fourth delivery 14 months ago in public hospital. After caesarean section, the surgeons had to perform hysterectomy due to continued bleeding. Medical record revealed no postoperative complication and the patient was discharged after one week from the hospital. In the follow up, the patient suffered sometimes from mild intermittent abdominal pain only. However, the surgeons did not perform advanced examinations and the problem was explained with postoperative adhesions. The patient was satisfied with surgeons' statements and did not continue the followup. But, after 13 months of operation, mild intermittent abdominal pain was converted to mild abdominal colic and the patient felt discomfort. Hence, last week before admittance to hospital, intermittent fever, which reached up to 39°C, and severe abdominal colic emerged. The patient was admitted to emergency department with above mentioned symptoms. Physical and laboratory examinations showed that the blood pressure was 100/80 mmHg, pulse was 110/min, body temperature was 38.5°C, WBC was 6.3 × 103/µL, and CRP was 241 mg/L. Abdominal USG shows a mass in pelvic area, but the source is not certain. CT demonstrated that a mass (15 × 13 cm) with a dense central part and an enhancing wall (gossypiboma) was located in the pelvic area (). The patient underwent emergency surgery and exploratory laparotomy shows that an encapsulated abdominal compression is surrounded by omentum (Figures and ). Retained abdominal sponge caused perforation of jejunum at the 50 cm below the ligament of Treitz and was surrounded by intestinal content, which caused regional contamination (). After removal of abdominal sponge, adhesiolysis and segmental small bowel resection with end-to-end anastomosis were performed. The abdominal cavity was irrigated with 8–10 L saline and three abdominal drains were inserted. Bowel sound was begun and serous drainage content decreased

[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 y/o female presented with Gorham’s disease in the ulna. The disease first started in the ulna and later involved the lower end of the radius and the lower humerus. The patient had referred to her doctor 9 years earlier with pain in the ulnar side of her forearm after getting hit by a heavy object. Clinical and radiographic examinations had failed to reveal any particular pathology and the patient was then referred to a physiotherapist. One year later, the patient returned to her physician with severe pain in the forearm. Plain X-rays were apparently normal, however MR imaging revealed nonspecific lesions in the ulnar bone marrow. These lesions were suspected to be chronic osteomyelitis. Radionuclide and CT scans revealed low density areas in the ulna. Laboratory, microbiological, immunological, hormonal and biochemical tests, including parathyroid tests were all within normal limits. The patient had a biopsy taken by her orthopedic surgeon. The biopsy was apparently consistent with the diagnosis of osteomyelitis, but the culture returned negative. After a while, the patient sustained a fracture in the same bone while asleep which was treated with a cast and healed without surgery. The patient has been complaining of pain and weakness in the left forearm for the past 5 years. Radiographs revealed bone absorption in parts of the ulna (). Five months ago, while attempting to lift a glass, the patient twisted her forearm and broke her radius. Her radiographs showed complete resorption of the ulna (); her arm was subsequently immobilized in a long arm cast. She came to our center and radiographs of her arm revealed non-union of her latest fracture. They also showed bony absorption of the lower end of the radius ( A,B and C). The patient's elbow ROM was nearly normal, so was the wrist ROM except for the final degression of flexion and extension. MTPs and finger motion were normal and the patient's fingers were spared.The neurovascular status had been normal from 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:
We report the case of a 52-year-old man with synovial sarcoma of the right kidney. Laparoscopic nephroureterectomy was performed in January 2012, under the suspicion of renal cell carcinoma (fig. ). The postoperative course was complicated by pulmonary embolism. The patient was put on anticoagulant therapy with low-molecular-weight heparin.
Surprisingly, the histologic findings were compatible with synovial sarcoma, verified by the detection of the typical t(X, 18) translocation and the SYT/SSX fusion gene. The initial assessment confirmed stage III disease: pT2b (maximum tumor size 8.2 cm), Nx M0 V1 (formation of a tumor thrombus in the right renal vein) G3.
According to a meta-analysis published in 1997, adjuvant chemotherapy can prolong progression-free survival, and there is a trend towards prolonged overall survival []. Further prospective studies have evaluated this question, and in high-grade soft tissue sarcomas adjuvant chemotherapy can be considered []. Adjuvant chemotherapy was discussed with our patient and, bearing in mind the high risk of recurrence in this case (tumor size, histologic grading and angioinvasion), 4 cycles of adjuvant chemotherapy with doxorubicin and ifosfamide were applied []. At the end of the treatment visit, a CT scan was performed and no tumor could be detected, but there was still evidence of a pulmonary embolus in the left inferior lobe. Subsequently, the patient was kept on anticoagulant therapy with low-molecular-weight heparin.
At the first follow-up visit 4 months after the completion of adjuvant chemotherapy, there was still no evidence of local tumor recurrence or metastases; however, in the area of the left inferior lobe pulmonary artery, a persisting soft tissue formation of unknown etiology could be documented. This entity was deemed most likely to be scar tissue after thromboembolism with pulmonary infarction or residual thrombus.
In the further follow-up period 3 months later, a CT scan showed progression of this soft

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


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

[User]
RADIOLOGY NOTE:
A 75-year-old woman presented at our emergency department with a complaint of progressive epistaxis. The patient had a 3-year history of nasal obstruction and intermittent epistaxis and absence of specific underlying systemic disease or trauma in her medical history. In the nasal endoscopic examination at the time of visit to our hospital, a hemorrhagic mass filling up the left nasal cavity without any ulceration was observed (Fig. A). In the laboratory tests, unremarkable findings were noted, which did not suggest a diagnosis of the nasal mass. A 3.7 × 2.5-cm bulging mass with heterogeneous enhancement in the left nasal cavity, and blurred boundary of the paranasal sinus was observed in the computed tomography (CT) scans (Fig. B and C). Destruction of the bone of the nasal floor or medial wall of the maxillary sinus was not evident.
A presumptive diagnosis of malignancy was made based on the aggressive appearance, despite the lack of significant cervical adenopathy. Due to active bleeding caused by the mass in the nasal cavity, diagnosis through biopsy of the mass preoperatively was not possible. Therefore, excisional biopsy and surgical resection via endonasal endoscopic approach were performed in the patient under general anesthesia. Intraoperatively, the nasal floor and lateral nasal wall were free from attachment to the tumor, but the inferior turbinate was remodeled by the tumor (Fig. A); possible origin of the tumor at the nasal septum without infiltration of the septal cartilage was observed (Fig. B). Mitotic figures in the tumor cells were observed in the intraoperative frozen section biopsy; however, differentiating between the presence of benign or malignant tumor was difficult. Subsequently, continuous peeling of the affected septal mucosa and finally, complete extirpation of the lesion was performed by the surgeon.
In the final pathology report, two components of the tumor cells including the luminal ductal inner epithelial cells with nuclear polymorphi

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

[User]
RADIOLOGY NOTE:
A 10-year-old girl visited our affiliated hospital, complaining of pudendal deformity. The patient was born at 39 weeks of gestation by normal delivery as the second child, and the birth weight was 3,144 g. There was no disorder in the course of pregnancy in her mother. Intake of androgenic medicine or the disorders of ovaries and uterus was not observed by a periodic medical examination. No pudendal deformity was clearly observed at birth, but lateral asymmetry of the pudendal region was noticed at about 4 years old. A child care worker pointed out that she pressed her heel to the crotch while sitting on her folded legs. After 5 years old, her mother confirmed that her clitoral hood clearly hypertrophied. After entering primary school, a teacher in charge pointed out that she pressed her crotch to a chair or bar, and the mother told her to stop it, but she repeated this behavior every day. When she strongly wanted to be absent from an overnight school trip at 9 years old, the mother brought her to the Pediatric Department. Various tests were performed suspecting disorders of sex development (DSD). On the first visit, the height was 132 cm and the body weight was 26 kg. The clitoral hood was enlarged. The appearance was similar to the vulva in children with congenital adrenal hyperplasia, and the clitoris size was 8 x 5 mm. Labial fusion or adhesion was not detected, and the urinary tract and vagina were open at the normal positions. No masculinization, such as acne and polytrichosis, was noted (). Intake of androgenic medicine or the disorders of prepuce was not observed. In the blood test, the sex chromosome was 46, XX. The blood count, blood chemistry, and hormonal test were normal (). On abdominal ultrasonography, the uterus and ovaries were present. Abdominal CT and MRI examinations showed no tumor

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


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

[User]
RADIOLOGY NOTE:
A 73-year-old female with a past medical history of chronic pancreatitis, type 2 diabetes mellitus, gastroesophageal reflux disease, lower gastrointestinal (GI) bleed, hypertension, paroxysmal atrial fibrillation, cerebrovascular accident, seizure disorder, and pulmonary embolism (PE) presented to an outside hospital after a reported seizure at her nursing home. Emergency medical services were called at the nursing home and the patient was reportedly hypoxic with oxygen saturation in the 70s on room air with subsequent development of agitation and lethargy after the seizure. The patient was transferred to an outside hospital's emergency department (ED), where additional tonic-clonic activity was noted. She subsequently developed hypotension with a blood pressure of 52/36 mmHg that was refractory to crystalloid intravenous fluid resuscitation. Central venous catheter (CVC) was placed and norepinephrine was started for persistent hypotension. Labs were notable for leukocytosis, troponin elevation, and low mixed venous saturation on CVC venous blood gas. The patient was subsequently transferred to a tertiary care facility cardiac intensive care unit for evaluation of cardiogenic shock.
Upon arrival, the patient was alert and following commands, but disoriented. She was still requiring supplemental oxygen and norepinephrine for hypotension. Given the concern for cardiogenic shock, a stat bedside transthoracic echocardiogram was obtained, which demonstrated a large pericardial effusion with tamponade physiology. The patient was urgently taken to the cardiac catheterization lab for pericardiocentesis with a drain placement. This yielded 580 ml of hemorrhagic fluid with rapid improvement in hemodynamics following drainage. During the pericardiocentesis, fluoroscopy demonstrated two embolized fragments of the IVC filter within the right ventricle (RV). Review of past imaging revealed that the embolized fragment was visualized on computer tomography (CT) of the chest one yea

[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 girl presented with a 2-day history of constant right-sided flank pain with intermittent episodes of increased intensity. Movement and laying supine exacerbated the pain, whereas some relief was found with paracetamol. There was no trauma to the area, but the patient reported playing netball shortly before the pain started. There was no associated nausea, vomiting, or change in bowel or urinary habit. There was no fever and no symptoms of cough or breathing difficulties.
The patient had no significant medical history and immunisations were up to date. On examination, she was apyrexial with a heart rate of 110 beats per minute, oxygen saturations of 99% on room air and respiratory rate of 22 breaths per minute. She was warm and well perfused with a central capillary refill time of <2 seconds. She appeared distressed when laying down reporting worsening pain; however, the abdomen was soft and non-tender to palpation. Systemic examination was otherwise unremarkable.
Urine analysis showed no evidence of infection and blood tests revealed a C-reactive protein (CRP) of 23 mg/L and a normal full blood count with white cells of 13.4 × 109 cells/L. Liver function tests, urea and electrolytes, and venous blood gas were also normal.
With normal observations, examination and investigation results and a good response to analgesia in the department, the patient was discharged with a planned review.
On re-assessment the following day, she continued to complain of significant pain on the right side of the abdomen with similar features on examination. Owing to the persistence of symptoms, chest radiography (Fig. ) and abdominal ultrasound were performed. Both were reported as normal. With no surgical or medical cause of the pain identified, it was deemed musculoskeletal in origin, associated with playing netball. She was discharged with advice to take regular analgesia and to return if symptoms were not settling.
The patient represented the following day looking unwell

[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 73-year-old male patient presented to an emergency department with bilateral lower extremity weakness and abdominal pain. He was hospitalized and underwent extensive neurologic workup due to a rapidly progressive sensorimotor neuropathy. Diaphragmatic involvement and subsequent ventilator dependence required tracheostomy placement and prolonged hospitalization. The patient was determined to have an inflammatory neuropathy due to anti-neurofascin 155 antibodies. Treatment options for this pathology are limited and poorly defined, but theoretic benefit could be achieved via anti-CD20 biologic therapy with rituximab. A six-dose course was planned and initiated.
The hospitalization was complicated by voluminous respiratory secretions and three separate clinical syndromes consistent with ventilator-associated pneumonia. Despite aggressive nursing care, the patient developed a sacral wound which progressed to stage 3. Given need for multiple antibiotic and vasoactive infusions over the course of his stay, a peripherally inserted central catheter (PICC) was placed on hospital day fourteen. These infections created delays in biologic therapy for his inflammatory neuropathy. However, he was able to receive his second of six planned rituximab infusions on hospital day fifty-eight.
On hospital day sixty, the patient developed hypotension, hypoxia, and leukocytosis consistent with sepsis physiology. Two blood cultures were collected peripherally forty minutes apart as part of broad workup for decompensation. Neither was drawn from the PICC line. After twenty-one hours, the first culture resulted as Gram-positive cocci in clusters, and rapid multiplexed polymerase chain reaction (PCR) testing by the FilmArray blood culture identification panel (BioFire Diagnostics LLC, Salt Lake City, UT) suggested coagulase-negative staphylococcus with resistance due to mecA. No change in clinical management was made at that time, as the single blood culture demonstrating CoNS was suspected

[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 40-year-old, gravida 3, para 2, woman presented with change in bowel habits and bright red rectal bleeding which had lasted for 1 year. She had a history of subtotal abdominal hysterectomy for uterine leiomyoma performed 3 years before and a history of right ovarian cystectomy. She denied any symptoms or presentations of endometriosis and had no history of hormone replacement therapy. Digital rectal examination revealed a fixed and firm mass with blood. Her serum carcinoembryonic antigen levels were in normal limits. The laboratory tests showed no remarkable abnormality except for a moderate anemia. Abdominal and pelvic computed tomographic (CT) scan demonstrated thickening of rectal wall with inhomogeneous enhancement and a 4 cm soft tissue mass that involved the rectum and left ovary (). The CT scan also revealed right hydronephrosis and hydroureter. On colonoscopic examination, a protruding lesion in the rectum and segmental stenoses of the rectosigmoid lumen were found. Endoscopic biopsy reported tubular adenoma and proliferation of spindle cells at the edge of tissue. Laparotomy was performed under the clinical consideration of gastrointestinal stromal tumor (GIST) or carcinoma developed on the rectum. On operation, nodular masses (1–3 cm in diameter) were found generally scattered in the intestinal walls and mesentery. Frozen section examination of nodules reported the exhibition of endometrial glands and whirling proliferation of plump spindle cells, considering extrauterine ESS as a clinicopathologic diagnosis. Because of the extensive intra-abdominal metastases and adhesion, the lesion was unresectable. The patient underwent intraoperative peritoneal chemotherapy and palliative transverse colostomy to relieve the stenosis. On immunohistochemical stain, the tumor cells were diffusely positive for CD 10, estrogen, and progesterone receptors (and 7% positive for Ki-67) but negative for CD 117, α-inhibin, desmin, smooth muscle actin, caldesmon, CD 34, and S-1

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old man was admitted to our hospital with recurrent aspiration pneumonia, dysphagia and neck pain in June 2014. The patient was paraplegic due to a C6 to C7 fracture and dislocation and had been operated on 8 years previously. At that time of trauma, initial surgical treatment was ACDF C6 to C7 and posterior wire fixation (). He had a chronic ill appearance due to daily spiking fever. Simple chest X-ray showed haziness on right lower lobe suggestive of aspiration pneumonia. Lateral cervical radiograph indicated a good fusion, normally positioned cervical plate, screw and interspinous wiring. Serologic tests showed increased erythrocyte sedimentation rate and C-reactive protein. The patient also complained of dysphagia and neck pain and cervical esophagoscopy was accordingly performed. Esophagoscopy indicated the site of perforation with exposed metal plate in the esophageal lumen at the approximate level ofthe cricoid cartilage and extending slightly below (). Computed tomography (CT) at the cervical level revealed communication of the esophagus and the plate (). Patient was subsequently scheduled for surgery. Before surgery, patient underwent preoperative vocal cord inspection, in order to plan approaches based on this result. Since vocal cord inspection was normal, the surgical approach was in the opposite direction as the previous cervical surgery to avoid revision-related complications. A thoracic surgeon joined the operation team to repair the defect of the esophagus. Dissection between the plate and esophagus was difficult because of severe fibrosis. After debridement of fibrosis between the posterior wall of esophagus and plate, the medial and lateral surface of the right sternocleidomastoid muscle was exposed and a superior-based pedicled flap was prepared. The closure was reinforced with a sternocleidomastoid muscle flap by the thoracic surgeon.
After surgery, intravenous antibiotics were administered, while placing nasogastric feeding tube for 3

[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 31-year-old primigravida with an unremarkable medical and family history was referred to our hospital at 26 weeks of gestation for the evaluation of a growing left supraclavicular lymph node that was suspected to be malignant lymphoma. She first noticed a cervical mass 2 weeks prior to her visit to our hospital. Her pregnancy had been uneventful, and she reported no digestive symptoms until 26 weeks of gestation.
Her examination revealed a swollen, hard, and immobile left supraclavicular lymph node. Biopsy of the node was performed, and histopathological examination revealed poorly differentiated adenocarcinoma with signet ring cells (). Esophagogastroduodenoscopy revealed type 2 to 3 lesions extending from the upper and middle body to the angular incisure and antrum of the stomach. Biopsy of the gastric tumor revealed that this lesion was histologically similar to the supraclavicular node, and a diagnosis of gastric cancer with metastasis to Virchow's node was confirmed. The serum carcinoembryonic antigen level at that time was 0.7 ng/mL (reference range<5.0 ng/mL).
After her biopsy, the patient's general status worsened, and her Eastern Cooperative Oncology Group performance status changed from 1 to 3. She developed progressively worsening epigastric and back pain, requiring the use of opioid medications. Considering the comparatively mature gestational age of the fetus and her general condition, we decided to perform cesarean delivery and initiate chemotherapy soon after delivery. Labor induction for vaginal delivery was not attempted because of an unripe uterine cervix.
At 29 weeks of gestation, she delivered a male infant weighing 1,288 g, with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. No gross disseminated lesions were observed during surgery. However, microscopic examination of the placenta revealed poorly differentiated adenocarcinoma cells invading the intervillous space, with necrosis but without invasion of the villi (). Histopathologica

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old man presented in 2017 after discovery of a hypervascular, expansile, 7 cm pancreatic body mass involving the splenic vein on routine surveillance CT scan (). He endorsed 1 year of diarrhea and steatorrhea that he had not sought medical care for but denied weight loss, appetite changes, fatigue, pain, or jaundice. He had a history of RCC and underwent a left nephrectomy and adrenalectomy in 2002. Additionally, he developed adenocarcinoma of the ampulla of Vater and was treated with pancreaticoduodenectomy in 2003.
He developed pulmonary metastases from the RCC and was treated with right lung segmentectomy in 2006 and three bilateral CyberKnife treatments in 2010, 2011, and 2013. He had surveillance CT scans roughly every 6 months from the discovery of the 2010 lung metastasis until 2015 and then yearly thereafter. He never received any chemotherapy for either the RCC or PDA. He is a former smoker.
Unfortunately, records of his prior malignancies, treatments, and surgeries were limited. His metastatic workup consisted of a CT scan of the head, chest, abdomen, and pelvis, which revealed no other sites of tumor except the 7 cm mass in the body of the pancreas, and testing his carcinoembryonic antigen (CEA) tumor marker level, which resulted as 0.9 ng/mL. The two main differential diagnoses were metastatic RCC versus recurrent PDA. Imaging characteristics, timeline of the mass development, and normal CEA level were the investigations used to determine that metastatic RCC was most likely and supported the decision to resect the mass.
The patient underwent completion pancreatectomy and splenectomy to resect his newly discovered pancreatic lesion. Surgical exploration and dissection revealed that the previous pancreaticoduodenectomy had been completed entirely antecolic. The gastrojejunostomy was able to be left intact throughout the duration of the procedure, whereas the hepaticojejunostomy was reconstructed due to its initial position being too far anterior

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


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

[User]
RADIOLOGY NOTE:
A 12-year-old girl, weighing 25 kg, was brought by her parents to our out patients department with complaints of inability to bear weight on the right lower limb since 3 months. There was no history of significant trauma. Her parents revealed a history of normal infancy and early childhood followed by delayed milestones from 3 years of age onwards, mental stunting, loss of ability to speak proper words, drooling, and abnormal involuntary movements of upper limbs. The child was a product of a consanguineous marriage and had two younger siblings, who were apparently free of inherited diseases. The parents in the past had consulted various pediatricians during the patients early childhood, but reported that no conclusive diagnosis had been made. Prior to the development of current complaints, she was able to walk independently with a jerky, clumsy gait as described by the parents.
General physical examination revealed short stature, thin build, mask–like facies, hypertonia and flexion attitude of elbows, knees and hips. She had abnormal choreoathetoid movements of both upper limbs on rest. The right hip was tender on palpation and patient did not allow assessment of passive movements due to pain. The limb was kept in an attitude of adduction, flexion of 70° at hip and 120° at knee. The greater trochanter was more prominent on palpation on the affected side, but patient did not allow assessment of telescopy and active straight leg raising. Any attempted movement of the knee was also resisted by the patient, which had led to development of flexion contracture at hip and knee. Our provisional diagnosis was a non-union of pathological fracture of neck of femur.
Radiographic examination of the hip revealed a suspected varus malunion of fracture neck of femur on antero-posterior view (). However, to confirm the diagnosis, lateral view radiograph of the hip could not be obtained due to inability to place the patient in the desired position. Computed

[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 December 2010, a 61-year-old male from a remote mountain area in Fujian, China presented with pain in the left lower extremity and limited activity for one week on admission, and was highly suspected of having bone metastasis from an unknown primary focus. There was no obvious cause of the patient’s pain and swelling in the left knee joint in the morning, walking was limited, and the pain symptoms were alleviated after rest. No significant change in skin color or temperature of both lower limbs was observed after onset. Computed tomography (CT) and X-ray of the left knee joint in hospital showed enlargement of the tibial medullary cavity, thinned cortical bone, and a high-density shadow in the left upper tibia, which was considered to be a bone neoplasm, the nature of which was to be determined (Figure and ). Routine urine analysis showed ERY +++, PRO ++, and LEU negative. Past history showed that 20 years before admission, the patient had an exploratory laparotomy for acute abdomen in a local hospital, but the cause was not determined. The incision failed to effectively heal, resulting in a long-term intestinal mass swelling at the incision which formed an abdominal hernia (Figure ). The patient also had psoriasis on both lower extremities (Figure ). He had a smoking history for more than 30 years (approximately 20 cigarettes/day), no drinking, no history of blood transfusion, no history of venereal disease and no relevant family history. Physical examination showed that systemic skin color was dark, a 10 cm surgical scar 3 cm from left side of the umbilicus, a soft intestinal mass in the scar the size of a fist could be pushed into the abdomen. Diffuse erythema and scales in both lower extremities, which manifested as erythema with clear boundaries, different shapes and sizes, covered with multiple layers of silvery white scales, and Auspitz’s sign was positive. Admission diagnosis was a bone space occupying

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old African American male initially presented to the hospital with an elevated prostate-specific antigen (PSA) level of 9.41 ng/mL. The PSA from a year prior was normal at 0.80 ng/mL. The patient’s symptoms included occasional dysuria and infrequent nocturia. The patient denied any other lower urinary tract symptoms, hematuria, abdominal or pelvic pain, bowel abnormalities, hematochezia, weight loss, night sweats, or loss of energy. The digital rectal exam at the time revealed a large volume prostate with induration along the left side of the gland.
The patient was scheduled for a prostate biopsy. However, about two weeks after his initial visit, he presented to an outside hospital with complaints of urinary retention. He was found to have acute kidney injury from progressing bladder obstruction due to a combination of benign prostatic hyperplasia and his malignancy. A urinary Foley catheter was placed, but the patient quickly developed hematuria due to traumatic catheter insertion. When this did not resolve, he presented to this institution for further evaluation, during which time the patient denied any further subjective complaints. His kidney function eventually improved, and the patient subsequently underwent a transrectal ultrasound with a 12-core needle biopsy of the prostate. During the exam, the prostate appeared to have irregular prostatic tissue extension from the left base of the prostate. Pathology revealed small cell neuroendocrine carcinoma that was present bilaterally in the base, mid-prostate, and apex of the prostate gland (12 out of 12 cores positive) (Figures -). There was evidence of perineural invasion. Immunostains showed cytokeratin and synaptophysin positivity, with a weakly positive PSA.
Shortly after his biopsy, the patient again presented to the hospital with worsening renal function. Ultrasound at this time revealed bilateral hydronephrosis. A CT of the abdomen and pelvis showed a prominent nodule in the inferior aspect of the

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


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

[User]
RADIOLOGY NOTE:
A 42-year-old man visited our outpatient clinic presenting with both leg weakness. Eight months before the visit, he had been diagnosed with elevated intraocular pressure accompanied by continuous headache and eyeball pain. Despite treatment for the glaucoma, the symptoms persisted and became aggravated. A week before admission, he experienced a seizure attack for several seconds, and a computed tomography scan at another hospital revealed hydrocephalus without intracranial causes. He complained of progressive both leg weakness, and sensory change below the T2 dermatome was found. He was then transferred to our institute. He had no other medical history. He had lost weight of more than 10 kg for the last 7 months. He complained of difficulties in urination and defecation. The neurologic examination showed hypoesthesia below the T2 and hyperactive deep tendon reflexes of the lower extremities.
Spinal magnetic resonance image (MRI) was done with contrast dye enhancement (). An intradural extramedullary (IDEM) mass lesion was found at the T2 level, ventral side to the spinal cord. The mass demonstrated a lower signal intensity than the spinal cord, and well enhancement of gadolinium in the T1-weighted image. The dorsal portion of the dura mater was slightly enhanced. There was no other lesion on the whole spine image. A brain MRI was performed, which showed no definite identifiable lesions.
Surgery was performed with respect to the benign IDEM tumor. A posterior midline approach was performed followed by a T2 laminoplasty. The dura matter was dark gray in color and was opened (), which showed a dark gray-colored mass that was severely adhered to the spinal cord and roots. After dissection, normal spinal cord was identified and the mass was removed as much as possible grossly. The black colored arachnoid membrane was also removed, but total resection was impossible. After decompression of the spinal cord, the dura was closed and sealed. There was no adverse event 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 34 year old woman from the east of Morocco, married and mother of two children, was admitted to the emergency room with intense periumbilical and pelvic abdominal pain associated with acute vomiting without any notion of metrorrhagia. The clinical examination revealed a conscious patient with an irreducible and impulsive painful mass at the umbilical level reminiscent of a strangulated inguinal hernia (). We performed an abdominal ultrasound scan which showed an evolving mono-fetal pregnancy; with an estimated weight of 1 kg, and a normal amount of amniotic fluid; strangulated through an umbilical orifice (). Faced with this exceptional diagnosis, the case was quickly discussed in a multidisciplinary team and the decision was made to perform an MRI. It was done without injection because of the teratogenic nature of the scan (, ).
Our radiological examination showed a strangulation of a pregnant uterus through an orifice of 6 cm, which resulted in a strangulated hernia of a pregnant uterus at the umbilical level with the right ovary. There was however no intestinal loop. After discussion with the patient, a multidisciplinary discussion was quickly made in front of this exceptional presentation and opting for a ceolioscopic exploration. It was made by the head of visceral surgery under general anesthesia was performed. It reduced the gravid uterus and the right ovary by a carefully dissection of the hernia sac and external manual assistance. Prior to the placement of the intraperitoneal plate, an obstetrical ultrasound scan had shown an evolving pregnancy (, , ).
The procedure went well, and it was tolerated by the patient without any adverse event allowing a good postoperative evolution The patient was discharged two days later and a cesarean section was scheduled at the end of the pregnancy, giving birth to a 2.5 kg male infant with good psychomotor development. Our patient had opted for tubal ligation, and the two-year follow-up did not show any recurrence.

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


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

[User]
RADIOLOGY NOTE:
Patient 1 was a 38 years-old male. In May 2010, this patient was diagnosed with glioma soon after an episode of seizures. MRI showed intra-axial expansive and infiltrative lesions that were cortical and subcortical, and which affected the anterior half of the right temporal lobe and extending from the pole to the Sylvian fissure superiorly and to the right parahippocampal gyrus, posteriorly, and medially. Partial surgical resection was performed in August 2010 and the first pathologic diagnosis was astrocytoma grade II. He underwent chemotherapy with TMZ at a dose of 2,000 mg with cycles every 28 days for 5 days in the years 2011–2013, with no tumor regrowth until the beginning of 2015. At this time, he underwent MRI, which was used to compare the discrete extension of the signal alteration areas, especially the subinsular regions. In March 2015, he resumed chemotherapy with TMZ at a dose of 100 mg/day and the patient then lost 12 kg of body weight, which was associated with anorexia, insomnia, and depression. In May 2015, he suffered a seizure requiring hospitalization. In June 2015, the patient resumed the old chemotherapy regimen with TMZ (2,000 mg every 28 days for 5 days), and a follow-up with MRI; however, the tumor size continued to increase. In January 2016, the neuro-oncology team decided to discontinue treatment with TMZ considering the risk/benefit and planned a surgical re-approach. This was followed by chemoradiation and lasting 6 cycles of PCV associated with CBD. The CBD dosage was ranging from 300 to 450 mg/day.
During chemoradiation, the patient had an excellent clinical performance, practiced sports and had few symptoms of fatigue and/or nausea.
At 1 month after the end of chemoradiation, control MRI (Figure ) was characterized by exacerbation and the ultra-precocious phenomenon of PSD with increased edema and inflammatory disease characterized by extensive areas of contrast enhancement associated with tissue hypoperfusion

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


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

[User]
RADIOLOGY NOTE:
A 76-year-old woman visited our hospital with a complaint of right intermittent epistaxis that started 2 years ago. The epistaxis gradually worsened several weeks before her visit to our hospital.
She had a medical history of PTC for 8 years and underwent total thyroidectomy, neck dissection twice, stereotactic radiation therapy for metastases to the cervical vertebrae and parapharyngeal space, and radioactive iodine therapy. A year ago, another cervical lymph node metastasis was noted. The surgery had already been scheduled at another hospital when she visited our hospital.
Sinonasal endoscopy showed bleeding from the accessory ostium of the right maxillary sinus. Contrast-enhanced computed tomography showed a mass, filling the right maxillary sinus without any angiogenesis, bone destruction, or calcification. Magnetic resonance imaging showed a well-circumscribed and smoothly marginated tumor with a peripheral low area and central inhomogeneous area on T1-and T2-weighted images, primarily suggesting an organized hematoma () [].
To stop the bleeding, endoscopic sinonasal surgery (ESS) was performed to examine the tumor and excision. We approached the right maxillary sinus with endoscopic-modified medial maxillectomy. The tumor was approximately 3 × 2 cm with a stem including a feeding artery based on the anterior wall of the right maxillary sinus. We cauterized the feeding artery and resected the tumor en bloc with a mucosa margin of 1 cm around the stem (Figures and ). Histopathological diagnosis revealed a metastatic PTC tumor to the maxillary sinus (). Regarding its subtypes, we did not find any characteristic findings for specific variants type of PTC. We presented the report to her attending oncologist, who discussed with the patient about additional examination and therapy. The decided treatment policy was to undergo planned lymph node resection and no additional examination because of her advanced age and history of total thyroidectomy and radiation therapy.

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


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

[User]
RADIOLOGY NOTE:
This was a 13 days old baby boy, who was born via spontaneous vaginal delivery at term in our tertiary care hospital without any postnatal complications. He was discharged 24 hours after delivery. He was brought back to our ER with left eye purulent discharge, which was noticed since birth, and swelling of his left upper eyelid of 2 days duration.
There was no associated fever or history of decreased level of activity or feeding. There was no history of rashes or seizures.
The pregnancy course was remarkable only for gestational diabetes and the fact that the mother had a history of vaginal discharges, which was treated as vaginal candidiasis during the last trimester. Group B streprococcus screening on the 37th week of gestation was negative. Similarly, HIV and hepatitis B serology were negative one day prior to delivery. There was no maternal history of genital lesions, vesicles, or ulcers.
Examination was normal apart from the purulent eye discharge & swelling of the left eye upper eyelid. The eye secretions were yellowish sticky, copious, and profound. Fontanelles were soft & primitive reflexes were present and normal.
Due to suspicion of gonococcal ophthalmia neonatorum, a full septic workup was obtained including CBC, blood culture, urine analysis and culture, CSF analysis and culture, and left eye swab for culture and Chlamydia antigen (). He was subsequently started on meningitis dose of Cefotaxime, in addition to Gentamycin ophthalmic drops while waiting for the previous cultures' results. Azithromycin was added as well to cover the possibility of an associated chlamydial infection.
The eye swab culture revealed Neisseria gonorrhea, which was sensitive to Cefotaxime, so the antibiotic was continued while waiting for the results of the CSF culture.
Blood and urine cultures were negative. The CSF culture revealed Gram-negative rods after one day, which was identified as S. maltophilia on day 5 of admission. The organism was sensitive to Trimethoprim-Sulfameth

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old ethnic Han Taiwanese male was healthy until he visited the ophthalmological clinic at Chang Gung Memorial Hospital due to the sudden onset of horizontal diplopia for a week and stated that the ocular symptom was more prominent in the early morning. On ocular examination, mild ptosis of the right eye with exotropia of 25 prism diopters was detected using Krimsky method, and limitation of eye movements in all directions was identified by diplopia test. Importantly, adduction, supraduction, and infraduction of both eyes were found to be impaired []. Moreover, the left eye levator and bilateral pupils were unaffected. The remaining results of his ocular and physical examinations were unremarkable. The complete blood counts, prothrombin time, activated partial thromboplastin time, blood chemistry profile, including serum vitamin level, and thyroid function test were all within normal limits. Although an initial diagnosis of myasthenia gravis was suspected, cerebral magnetic resonance imaging was arranged 3 weeks after the onset of diplopia, and the result revealed a midbrain hemorrhage [circles, ]. Mono-ocular occlusion was arranged with improved symptoms, and the patient was referred to a neurologist for further management where edrophonium test showed negative result. Two months after the onset of diplopia, sudden onset dizziness accompanied by nuchal pain as well as bilateral leg muscle weakness were noted, and then, cerebral magnetic resonance angiography [circle, ] revealed a hemorrhage over the brainstem that was associated with mass effect and hydrocephalus, but no vascular anomaly was noted []. Then, the patient became bedridden, and the follow-up neurological examination identified headache insomnia, dysarthria, dysphagia, and decreased muscle power (Grade 4 at upper limbs and Grade 2 at lower limbs). Nine months after the onset of diplopia, the patient exhibited poor appetite, yellowish sputum, and general weakness after choking before being admit

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


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

[User]
RADIOLOGY NOTE:
A 20-year-old male patient was consulted to the emergency service, nearly 6 hours after a firearm injury directed at his left infraclavicular region. Arterial blood pressure was 100/60 mm Hg, and heart rate was 105/min. Presumed bullet entrance hole was located nearly 3 cm above the left scapula, and its exit hole was approximately 12 cm above the left nipple. On the anterior aspect of the left hemithorax, a marked swelling when compared with the right hemithorax, hematoma, and subcutaneous emphysema which caused respiratory distress were noted. Presumably venous blood was oozing from the exit hole on this site. Arterial pulses were palpable, and any sign of ischemia was not detected on the upper extremity. Radiograms obtained did not show any evidence of pneumothorax, hemothorax, or bone fracture. Computed tomograms revealed a widespread subcutaneous hematoma, emphysema covering all over the anterior aspect of the left hemithorax, diffuse contusion of the left lung, and mediastinal air. The patient was taken into the angiography unit. Selective left subclavian artery imaging demonstrated intact subclavian artery. Venographic examination disclosed extravasation in the subclavian vein extending from just proximal to the axillary vein (). The patient was urgently operated with a severely decreased hematocrit (18%). Through a 5 cm long incision, axillary artery and vein were explored. Still through a nearly 15 cm long incision extending from one-third medial of the clavicula in the left infraclavicular region and encompassing the wounded area, pectoralis major muscle was partially excised, and on the medial side, subclavian artery and vein were explored. Distally, at the shoulder level a nearly 5 cm defect created by axillary vein rupture extending up to its insertion into the subclavian vein which roughly corresponds to the midpoint of clavicula was observed. Abundant venous bleeding was noted oozing through this site. Proximal and distal explorations revealed termina

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old man with severe chronic obstructive pulmonary disease (COPD) was admitted with a four-day history of chest pain and worsening shortness of breath. He explained the chest pain started suddenly when he tried to reach out for something on his computer table. It was located on the right anterior chest, sharp in nature, 7/10 in intensity, pleuritic, and worse with coughing and deep breathing. He had a past medical history of severe COPD with frequent exacerbations recently necessitating multiple antibiotics and steroid courses, coronary artery disease, gastroesophageal reflux disease (GERD), and hypertension. He had a 30-pack per year smoking history and quit about 10 years ago. He was a retired fireman living with his family.
Vitals signs in the emergency department (ED) were stable; he was breathing on ambient air. The physical examination demonstrated decreased breath sounds bilaterally without any wheezing or Ronchi. Moderate tenderness was present in the mid-axillary line in the fifth intercostal space, but no other abnormalities were noticed. Laboratory investigations were negative for any leukocytosis, troponin, or any other abnormalities. The electrocardiogram (EKG) showed a normal sinus rhythm. Computed tomography (CT) angiography was done to rule out pulmonary embolism (PE). The CT was negative for PE but showed mild peribronchial infiltrate in the right middle lobe and posterolateral lung herniation between the seventh and eighth ribs, with minimal subcutaneous emphysema along the right chest wall (Figure ).
The patient was admitted to the hospital and managed conservatively on broad-spectrum antibiotics, including vancomycin, levofloxacin, and 40 mg per day of prednisone. Two days later, his face swelled up suddenly with a change in the quality of his voice while he was eating dinner. An examination showed a swelling in the neck, diffuse crepitations on his body involving the face, all the way down to the buttocks. Repeat CT chest and neck showe

[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.