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

[User]
RADIOLOGY NOTE:
An 86-year-old male with a history of seropositive rheumatoid arthritis for 30 years. The treatment for his rheumatoid arthritis included methotrexate initially, but due lack of control, adalimumab 40 mg subcutaneously every 2 weeks was added with excellent control of his arthritis of hands and feet. This lasted for few years. However, he later on experienced activity of disease and he was switched from adalimumab to Tocilizumab 162 mg subcutaneous injections every 1 week. His arthritis was controlled on the latter regimen apart from his shoulders. At this time his lab investigations were normal including complete blood panel (CBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), Liver function test (LFT), Renal function test (RFT), and Bone profiles. He experienced an increasing pain and stiffness in his shoulders, in addition to an increasing limitation of shoulder movement in all directions. His other medical conditions include type 2 diabetes mellitus and hypertension. We are unaware of any history of adhesive capsulitis. His other medications are Methotrexate 10 mg oral once weekly, hydroxychloroquine 200 mg, alendronate 70 mg once weekly. X-rays of shoulders at the time (May 2012 and are shown in ). They showed punctate and linear calcification around the capsule. The patient received multiple intra-articular steroid injections with no notable benefit. Over the years of follow-up visits, his condition progressed, with increasing limitation of his shoulders movements. The Oxford Shoulder Score (OSS) were used to assess degree of pain and disability. Score for both shoulders were 7, indicating a great degree of disability.
 Repeated imaging on March 2017 was performed and is shown in and showed hypertrophic, global plaque-like calcification in the capsule. Meanwhile, X-ray of hands did not reveal any chondrocalcinosis or erosions and knee x-rays showed advanced osteoarthritis. Magnetic Resonance Imaging (MRI) of left shoulder was done in November

[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 previous pregnancy of a 37-year-old healthy Japanese woman (gravida 2, para 1) had been uncomplicated, and the resulting child was alive and well. She had no history of periconceptional tobacco smoking, alcohol intake, radiation exposure, or intake of other supplements and drugs. She had no clinical problems during the early period of the current pregnancy; however, she did not undergo an ultrasound examination during the first trimester. At 36 weeks of gestation of the current pregnancy, a routine ultrasound examination revealed an abnormal number of umbilical cord vessels. A fetal ultrasound examination was performed using a GE Voluson™ E10 ultrasound machine (General Electric Healthcare, Tokyo, Japan) with a 3.5-MHz convex-array transducer. The examination revealed the coexistence of a four-vessel part and a three-vessel part within the free loop of the umbilical cord (Fig. ). The fetal insertion site of the umbilical cord comprised four vessels (two arteries and two veins), whereas the placental insertion site comprised three vessels (two arteries and one vein). The blood flow was demonstrated in both veins by two sonographic specialists in maternal fetal medicine, and the flow was similar in each vessel. However, we were unable to prenatally detect the exact point at which the umbilical cord changed from a four-vessel to a three-vessel cord. The intra-abdominal umbilical vein was a single vessel that was connected to the ductus venosus and returned to the right atrium (Fig. ). No other sonographic congenital abnormalities were detected on fetal ultrasound screening performed in accordance with the recommendations of the International Society of Ultrasound in Obstetrics and Gynecology [].
At 38 weeks of gestation, a healthy female neonate weighing 2726 g was delivered by spontaneous vaginal delivery. The infant’s Apgar scores were 9 and 10 at 1 minute and 5 minutes, respectively. The neonatal physical examination at birth was normal.
Ultrasonographic examina

[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 male patient reported to the Department of Oral and Maxillofacial Surgery with a chief complaint of pain in the mandibular right posterior teeth for 8 days and swelling on the right side of his face for 5 days. The patient was a known hemophiliac (hemophilia A) with history of multiple factor VIII transfusions for joint bleeds in extremities. On local examination, a diffuse, firm, board-like, tender swelling was present on the right lower half of the face. An extraoral draining sinus was also noted over the right mandibular body region. Mouth opening was restricted (20 mm). Intraoral examination revealed deep dental caries in the right mandibular second molar which was tender on percussion. Buccal vestibule was tender on palpation. A diagnosis of cellulitis of the right submandibular and submasseteric spaces with periapical abscess with respect to the right mandibular second molar was made. Treatment was started with intravenous fluids, systemic antibiotics and analgesic administration [].
On routine blood investigations, hemoglobin was 12.9 g%.
Orthopantomogram showed dental caries involving enamel, dentin, and pulp in the distal surface of the mandibular second molar with periapical radiolucency suggesting chronic periapical abscess [].
2140 IU of AHF was transfused by the hematologist, and as the patient had given history of hemophilia A and multiple factor VIII transfusions (8 times), Bethesda assay was done to identify inhibitors to factor VIII which revealed the subject to be a low titer inhibitor positive hemophilia A patient with the inhibitor level of 4 Bethesda Units (BU).
The patient responded well to the antibiotics, and the swelling subsided within 5 days with marked improvement in the mouth opening, and tooth extraction was planned.
Transfusion of FEIBA was planned with low-dose protocols as the patient had FVIII inhibitors. 35 U/kg of FEIBA was transfused 1 h before the planned extraction of the involved molar tooth. Tooth

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


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

[User]
RADIOLOGY NOTE:
A 76-year-old female presented to the emergency department with complaints of the left thigh and hip pain and swelling for five days. She reported having a history of chronic left leg sciatic pain that contributed to a fall two days prior to the onset of these symptoms. Her past medical history was significant for colon cancer requiring a low anterior resection, which is eight years ago. The patient was noted to be confused and tachycardic. She was afebrile but had leukocytosis of 14,000. On physical examination, she was noted to have a significant crepitus to the left thigh and knee. Radiographs of the left leg confirmed subcutaneous emphysema consistent with necrotizing fasciitis (). Prior to surgical consultation, the patient also received a pelvic computed tomography (CT) scan to evaluate for hip fractures. This further confirmed the necrotizing fasciitis (Figures and ) but also identified a collection in the presacral space () that communicated to the left leg through the left sciatic notch, which is consistent with an AL. The patient was immediately taken to the operating room for debridement of the thigh and diverting colostomy.
An exploratory laparotomy with diverting colostomy was created to control ongoing contamination of the leg. Intra-abdominally, there were no abnormal findings, which is consistent with the extraperitoneal nature of the disease process. The decision, at this point, was to access the extraperitoneal collection through interventional radiology so as to minimize intra-abdominal contamination. After the colostomy was completed, the left thigh and hip were incised revealing a significant amount of feculent and purulent drainage. Necrotic, nonviable tissue was debrided down towards the knee, and the wound was left open and dressed. The patient was septic during the procedure and remained septic postoperatively. After an initial discussion with the patient's family, the plan was to perform percutaneous drainage of the presacral abscess postop

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


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

[User]
RADIOLOGY NOTE:
An 11-year-old boy had presented to the orthopedic department with the complaint of head tilt to the left along with facial deformity in the form of a small left side of the face and skull. He had a full-term normal vaginal delivery in hospital and was apparently normal at birth. The parents noticed a head tilt to the left when the boy was six months of age but they did not seek any medical help at that time. The condition progressed mildly over the years, however, no physical discomfort was experienced by the patient. The child had adjusted well to this tilt. There was no history of similar complaints in other family members.
On inspection, we noticed an asymmetry in the contour of the neck, the shoulder, and the bilateral scapula. Anterior neck muscles were prominent on the left with the the head turned to the left side (Figure ). The left shoulder was at a higher level than the right, the left scapula was elevated and there was mild scoliosis to the left (Figure ). The patient had no restriction in flexion and extension movements in the anteroposterior (AP) direction or tilting the neck to the left side, however, there was a significant restriction in tilting the head to the right side. In view of the above findings, a clinical diagnosis of contracture of left SCM was made and the patient was referred for imaging.
Due to asymmetry in the shoulder position, a radiograph of the neck (Figure ) was acquired to look for any bony anomalies. The radiograph of the neck (Figure ) and the chest (Figure ) were largely unremarkable and all the vertebrae and bilateral shoulder joints were normal. However, mild scoliosis was seen. Ultrasound (US) of the neck region was subsequently performed (Figure ). On examining the patient with a linear probe, the right sternocleidomastoid muscle was not visualized and was replaced by a fibrotic hypoechoic structure seen extending from the mastoid process

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


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

[User]
RADIOLOGY NOTE:
A 45-year-old male with no known history of cancer presented to our institution with a lump in the left breast that had been gradually increasing for 14 months.
A physical exam revealed a large, fixed 10 cm mass occupied the entire right breast (-A). The mass itself was adherent to the chest but it did not invade the skin. There was no ulceration, nipple discharge, or retraction. There were no palpable lymph nodes. Clinical presentation had supposed initially as a sarcoma of the breast.
Preoperative unenhanced CT imaging showed well-defined round heterogeneous soft tissue density with hypo dense areas (-B), necrosis and peripheral and central calcifications measuring 07 cm × 10 cm × 11 cm. It was localized in the 4; 5 anterior thoracic rib. The tumor involves the intercostal muscles but respect the lung. CT scan detected no metastatic tumor.
A core-needle biopsy was taken, which was suggestive of chondrosarcoma grade II.
Surgery was initiated for wide excision. Intra-operatively, it was found to be arising from the 4; 5 th rib and pushing the lung without invading it. The whole tumor was excised en-bloc along with 4 th, 5th and 6th ribs with a surgical margin of more than 2.0 cm (-A, B). This resection left a defect measuring 23 × 15 cm on the anterior chest wall. Reconstruction of the defect was undertaken with polypropylene plate and ipsilateral pedicle latissimus dorsi muscle flap was placed on the alloplastic mesh (-D). Intercostal drain inserted. The patient was extubated one days after surgery and discharged in 10 days without complication.
In final histopathology report, grossly the tumor has blue-grey color and was attached to bone on one margin and covered by the breast in on one surface. The mass measured 18 cm × 14 cm×13 cm.
Histological section showed mesenchymal proliferation organized in lobulated architecture with abundant cartilaginous matrix and myxoide areas separated by fibrous

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


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

[User]
RADIOLOGY NOTE:
A 25-year-old female patient sought medical attention complaining of a three-month history of weight loss, intermittent fever, nonproductive cough, thoracic pain, abdominal pain and increased abdominal girth, nausea and vomiting. She presented syncope on the day she was admitted in the hospital. Symptoms had begun two weeks after her third deliver. Her past obstetrics history comprised three gestations without pre natal care all of them were uneventful. She denied any other comorbidity, allergy, smoking, alcoholism, prior blood transfusion or similar cases in her family. She lived in a Brazil’s northeastern state that is well known for high prevalence of schistosomiasis. Physical examination demonstrated tachycardia with pulse rate of 100 beats per minute, blood pressure of 90 × 60 mmHg, tachypnea with 25 respiratory movements per minute, temperature 37 °C, oxygen saturation of 96% at room air. Cardiac and pulmonary examinations were unremarkable while the abdominal exam showed signals of small ascites. Gynecological examination ruled out any abnormality and the transvaginal ultrasound was normal except for a presence of a small myoma. The initial laboratory tests are shown in .
The multi detector computed tomography (CT) of thorax and abdomen are shown in -.
The patient progressed, on the day after admission, with worsening of the abdominal pain, nausea and vomiting and respiratory distress. Besides the stability of hemodynamic parameters, the cutaneous perfusion got worse and serum lactate level rose.
shows the liver enzymes and prothrombine time evolution. She was referred to the Intensive Care Unit because of her clinical instability and respiratory insufficiency, where she presented cardiac arrest after vomiting and probable aspiration of gastric content.
Serologies for HIV and Hepatitis virus B and C were negative.
An autopsy was performed.
The abdominal and thoracic cavities were opened, revealing a mild serous ascites and bowel distension. The visceral perit

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


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

[User]
RADIOLOGY NOTE:
In October 2012, a 46-year-old woman was referred to our center for the presence of a large mass (50 × 70 mm) in the superior lobe of the left lung with homolateral pleural effusion. The patient was never smoker, without family history of cancer and without comorbidity. The cytological diagnosis was made using a CT-guided fine needle aspiration of the primary tumor and revealed an adenocarcinoma of the lung (TTF1+, CK7+) with the EGFR ex19del mutation. A PET-CT demonstrated the presence of liver and bone metastases and a nodule in the right breast, confirmed as a metastasis by fine needle aspiration. The patient received zoledronic acid 4 mg every 28 days and gefitinib 250 mg daily since November 2012 obtaining a partial response (PR). In August 2013, a disease progression (PD) was documented, with an increase in size of the primary tumor and size and number of liver metastases. A brain MRI revealed the presence of two cortical nodules, which were treated with stereotactic radiotherapy. The patient was enrolled in the IMPRESS trial and received 6 cycles of cisplatin and pemetrexed plus gefitinib obtaining again a PR that lasted until June 2014. Thereafter, a new lung metastasis appeared in the superior lobe of the left lung and the mammary nodule increased in dimensions. From June 2014 to December 2014 the patient received erlotinib 150 mg daily obtaining an initial stabilization of the disease (SD); however, within 6 months, she experienced again a PD with the increase of the mammary nodule and the appearance of a new bone metastasis in the sacrum. In December 2014, EGFR ex19del and T790M mutations were detectable in a new needle biopsy of the primary tumor; only at this time a digital PCR-based method was available for the analysis of circulating tumor DNA (ctDNA). Briefly, the method was optimized in order to recover a suitable amount of ctDNA for molecular analysis from 3 ml of plasma using the QIAmp Circulating Nucleic Acid Kit

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


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

[User]
RADIOLOGY NOTE:
We present a case involving a 76-year-old female patient who was first seen by her doctor for problems and discomfort with deglutition. Upon an objective examination, the thyroid gland appeared to be mildly enlarged (more on the right side of the neck) with a hard consistency, but mobile relative to the underlying tissues. The only comorbidity was a mental illness.
An ultrasound (US) of the neck was immediately performed and revealed a multinodular retrosternal goiter, for which the larger nodule in the right lobe presented with a diameter of approximately 6 cm and complete ring calcification. The goiter extended into the upper mediastinum and was lying on the aortic arch.
Due to the goiter’s retrosternal configuration, we performed a CT scan of the neck and thorax. The scan showed the posterior dislocation of the epiaortic vessels and lateral dislocation and compression of the pharynx. The large nodule described previously based on US exhibited a mixed type of calcification; in fact, in the context of a large egg-shell calcification, multiple spots with microcalcifications were observed (A and B).
Given the notable dimensions of the goiter, its symptomatic disposition and the extreme calcification of the nodule, we chose to avoid an ultrasound-guided ago-biopsy due to the low probability of obtaining a good tissue sample and the consequent diagnosis, and in agreement with the patient’s endocrinologist, we decided to directly perform a standard thyroidectomy through a cervicotomy. The primary difficulty during the operation was the complete calcification of the entire right lobe, which was adherent to the trachea and vascular structures (A and B). However, no major bleeding or complications occurred during surgery.
Macroscopically, the pathologist described a nodule with a weight of 130 g that was partially cavitated and extremely hard when cut (A and B).
A microscopic histological examination excluded the presence of atypical cells and revealed nodular hyperplasia

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


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

[User]
RADIOLOGY NOTE:
A 32 year old female Cameroonian gravida 4 para 3 at 34 weeks of gestation presented to the labour and delivery unit of Mbalmayo district hospital with 8 h history of severe generalized headache, expressive aphasia and right sided paralysis in an afebrile context. This was associated with blurred vision but no convulsions. There was no epigastric pain and no difficulty breathing and no history of trauma or fall. For this current pregnancy, antenatal care (ANC) was started at 18 weeks with a booking blood pressure of 100/70 mmHg. She did four ANCs and all were uneventful. During her routine four ANCs here blood pressure was always less than 140/90 mmHg and her urine dipsticks done during the four ANCs were all negative for proteinuria. She refused neurological symptoms such as headache during pregnancy. She has a history of gestational hypertension in her third pregnancy. There was no family history of chronic hypertension, diabetes and chronic kidney diseases. On examination she was afebrile with a blood pressure of 182/126 mmHg and pulse of 112beats/minute. Neurological examination revealed Glasgow coma score of 13/15, right sided hemiparesis and expressive Broca’s aphasia, no signs of meningeal irritation. The abdomen was distended by a gravid uterus with a fundal height of 35 cm, foetus in a longitudinal lie and cephalic presentation. The cervix was long, posterior, soft and closed with a station of − 1. We had a working diagnosis of severe pre-eclampsia complicated by stroke. Shown on Table are laboratory investigations done and their results.
An emergency obstetric ultrasound showed a life foetus with an estimated foetal weight of 2300 g at 33 weeks of gestation. Emergency cerebral non contrast-CT scan showed a 3.2 cm hyperdense region in the left parietal lobe with surrounding hypodensity due to clot retraction as shown on Fig. . Emergency management by the obstetrician consisted of MgSO

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


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

[User]
RADIOLOGY NOTE:
An otherwise healthy 33-year-old woman, gravida 3, para 2, from a Sephardic Jewish origin, was initially referred to our institution at 30.6 weeks of gestation due to a large neck mass found on prenatal ultrasonography (US). Her previous two pregnancies were uncomplicated. The fetal sonogram showed a 10 by 8 cm mass on the right side of the neck, which was not present in detailed scans taken at 14 and 22 weeks. The mass was composed of a cystic portion and a solid portion containing blood vessels and was growing rapidly in subsequent ultrasound studies. A significant polyhydramnios with amniotic fluid index (AFI) of 50 suggested an upper gastrointestinal obstruction and a highly possible airway obstruction as well. Findings were confirmed by fetal magnetic resonance imaging (MRI). In anticipation of the difficulty in establishing a secured airway at birth and the potential complicated resection of the giant tumor after birth, the mother was referred to our hospital for consultation.
The parents were in consultation with the maternal fetal team, neonatologist, anesthesiologist, pediatric surgeon, and otolaryngologist. The parents were presented with a guarded prognosis but insisted that the pregnancy continue with maximal efforts during delivery and during the neonatal period.
Therefore, a planned EXIT procedure, which provides the best chance to establish a patent airway, was offered to our patient, presenting the risks []. Specifically, we informed the parents about the risks for the mother, including significant hemorrhage from the uterus due to the uterine relaxation necessary to avoid placental separation, with a possible uterine resection in the case of a life-threatening hemorrhage.
Knowing the risk of an unplanned preterm delivery due to polyhydramnios and uterine contractions, we scheduled our patient for a planned cesarean delivery at 34 weeks organizing and preparing a multidisciplinary team ready to perform the EXIT procedure.
A multidisciplinary team inc

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


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

[User]
RADIOLOGY NOTE:
A 59-year-old gentleman presented to our institution with anemia (hemoglobin: 9.4 g/dL) noted during preoperative evaluation for a cataract surgery. He was asymptomatic and had no history of immunodeficiency. His only previous history was a cholecystectomy performed 11 years prior to his current admission. He was noted to have a positive fecal occult blood test prompting colonoscopic evaluation revealing an 8 mm sessile polyp in the sigmoid colon which was resected. A second polyp, 3 mm in size, was identified within the ascending colon. No other large masses or mucosal ulcerations were identified. A few weeks later, the patient presented with abdominal pain and nausea, and a Computed Tomography (CT) scan of the abdomen was performed which revealed a vague mass like area within the pancreas. This was followed up with an endoscopic ultrasound which revealed a 33 × 32 mm mass with well-defined borders involving the pancreatic head. No cystic areas were present within the mass. No other abnormalities were detected in the remainder of the pancreas, bile duct, or liver. A fine needle aspiration of the pancreatic mass was performed.
During the next 3-4 weeks, the patient developed gradually worsening abdominal pain, fatigue, and weight loss. A repeat abdominopelvic imaging study revealed ascites and the pancreatic mass which had slightly enlarged. Cultures of the ascitic fluid grew Escherichia coli and hence antibiotic therapy was initiated. Impaired glucose tolerance was detected in the ensuing hospital stay. His general condition remained unimproved and he continued to experience reduction in weight and loss of appetite. Having counseled the patient on the possibility of a malignancy occurring in association with malakoplakias and in the absence of any other cause for his cachectic symptoms, the patient elected to undergo a pancreaticoduodenal resection (Whipple procedure). The patient reported improvement in his symptoms following surgery. Three months after surgery, h

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old man was referred to our surgical colleagues for rectal bleeding in November 2006. He had a colonoscopy which showed a tumour few centimetres proximal to the anal verge, and the biopsy confirmed a moderately differentiated adenocarcinoma. A computed tomography (CT) scan of thorax, abdomen and pelvis showed the presence of multiple liver metastases which were confined to its right lobe. A magnetic resonance imaging (MRI) scan of his pelvis showed a 7-cm nodular tumour which circumferentially surrounded the rectum, and the local invasion of this tumour was also noted. The whole-body positron emission tomography–CT (PET–CT) scan confirmed the same and showed no evidence of tumour dissemination to any other sites (apart from local invasion and to the right lobe of the liver). He had a successful course of palliative radiotherapy for his rectal bleeding and was started on chemotherapy with 5-fluorouracil and leucovorin on a weekly schedule for 6 weeks with a 2-week break. However, the repeat CT scans in April 2007 showed no response to this treatment. His chemotherapy was then changed to a combination of oral capecitabine plus intravenous infusions of oxaliplatin in May 2007; however, he developed significant myelosuppression and hepatotoxicity, and was taken off this regimen. In September 2007, he had a synchronous resection of his liver metastases and the resection of primary rectal tumour with colostomy. Subsequently, his chemotherapy was changed to irinotecan. Unfortunately, in January 2008, his PET scan showed an uptake at the primary tumour site and also in the right lobe of liver; this was also accompanied by the episodes of rectal bleeding. In June 2008, he had resection of local recurrence, along with local radiotherapy to his primary site. His K-ras mutation status was of wild-type, and it was decided to commence him on monoclonal form of chemotherapy.
He had the first session of a combined therapy with cetuximab and 5-fluorouracil (5-FU) in March

[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 man aged 35, works as a laborer, admitted because of problems with urination as a feeling of pressure and pain during micturition, which persist for the last few months. In the regional medical institution treated as acute prostatitis. Good general condition, and the physical examination findings orderly. The laboratory findings of elevated CRP: 145mg / l, while the other parameters were of the reference values. On the ultrasound examination of the urinary tract, in the bladder was revealed tumor change the largest diameter to 70mm, which covers the front wall of the bladder, and whose origin cannot be determined. Computed tomography revealed that in the pelvic there was edge well vascularised formation that covers the front wall of the bladder, with visible signs of infiltration of the musculature of the anterior abdominal wall measuring 75x80mm, which was seen as a change of bladder tumor (, , ). On uretrocistscopia the capacity of bladder easy decreased and on the front wall of the urinary bladder more over the left side of the suspicious bullous edema and external signs of infiltratation of the wall of the bladder. Colonoscopically, except for internal hemorrhoidal plexus other findings were normal.
Endoscopic transurethral revealed on the front wall of the bladder solid tumor diameter 40x50x10mm entering the lumen of the bladder, and mucosa above the change is largely intact and marginally more toward the back wall bullous and cerebriform. It was taken biopsy of change which as microscopic showed the elements of proliferative lesion binders most by type of fibromatosis.
The patient underwent resection of pelvic tumors with partial cystectomy and Right Hand iliac lymphadenectomy. Intraoperatively, dilated small bowel diameter twice large compared to the usual size was seen and identified tumor of pelvic diameter 70x80mm, which invaded the anterior wall of the bladder, m.rectus abdominis from the right and parietal peritoneum anterior lateral abdominal wall, re

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


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

[User]
RADIOLOGY NOTE:
A 21 year-old, healthy, white female presented to our comprehensive breast health services facility with multiple bilateral breast lesions that were presumed to represent multiple bilateral fibroadenomas. She reported having previously undergone a surgical excision procedure of a fibroadenoma of each of her breasts at a local community hospital at a time of approximately three years prior to her current presentation.
Prior to her current presentation at our facility, the patient was evaluated at an out-of-state university medical center and was noted to have multiple ultrasound lesions within both of her breasts. Due to the multiplicity of the bilateral breast lesions and the complexity of her particular case, the breast surgeon at that out-of-state university medical facility told the patient and her family that her "only realistic option" was for bilateral nipple-sparing mastectomies and expander-to-implant reconstruction.
Upon her presentation to our facility, the patient reported that she had noticed an enlarging mass of her central right breast over the last two years and two smaller palpable masses of her left breast. On clinical breast examination, she had medium-sized breasts (36-C cup size). She had an old surgical scar extending from the 8 to 10 o'clock axis of the periareolar aspect of her right breast and similar surgical scar extending from the 10 to 12 o'clock axis of the periareolar aspect of her left breast. Most remarkably, she was noted to have a 10 cm × 7 cm × 5 cm clinically palpable mass encompassing her entire right breast and an overlying 1.5 cm clinically palpable mass in the in the 3 o'clock axis of the periareolar aspect of her right breast. Two palpable masses were also noted in her left breast, clinically measuring 3 cm in size in the 3 to 4 o'clock axis of the mid-breast field and 2 cm in size in the subareolar region. No axillary, supraclavicular, or cervical adenopathy

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


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

[User]
RADIOLOGY NOTE:
Our patient was a 25-year-old Caucasian Iranian man who was referred to our center in 2010 for further evaluation of paraparesis and urinary incontinence. There was no significant point in his past medical or familial medical history. He was well until 2008, when he developed blurred vision in his right eye and was admitted to a local center with the clinical impression of optic neuritis. He received intravenous methylprednisolone 1000mg for 5 days without a good response. Two months later he experienced optic neuritis in his left eye, but he had a good recovery after receiving intravenous methylprednisolone. According to his medical records, his physical examination was normal at that time, with the exception of mild optic atrophy of the right eye. Brain MRI was performed, which revealed some hyperintense T2-weighted lesions around the ventricles, with linear callosal involvement. The lesion was nicely enhanced in a linear pattern in a T1-weighted image with contrast agent (Figs. and ). Linear enhancement of ventricular surfaces (pencil-thin appearance) in both the frontal and occipital horns was another important finding in this patient.
The patient was diagnosed with MS and received interferon (IFN) beta 1a three times per week. Six months later he developed another episode of optic neuritis in his left eye, and he had a less than 50 % recovery with intravenous steroids and plasmapheresis. After 1 year, he developed paraparesis and urinary incontinence while receiving IFN beta 1a three times per week. He was admitted to a local hospital and received intravenous methylprednisolone 1000mg/day for 5 days. He responded to this therapy and was able to walk in 4 weeks. At that stage, the patient was referred to our center to escalate the disease-modifying therapy.
A neurologic examination of the patient revealed bilateral optic atrophy, weakness of both lower limbs (grade 4/5) and bilateral Babinski sign. Although we did not perform detailed neuropsychological tests, t

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


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

[User]
RADIOLOGY NOTE:
A 68-year-old female presented to the Radiology Department with complaints of abdominal pain and vomiting. In spite of conservative treatment her condition worsened. She was unable to pass stools for a week and subsequently developed abdominal distension. There was no history of fever or weight loss and her abdominal examination revealed guarding and rigidity in the right iliac fossa.
Contrast enhanced computed tomography (CT) of abdomen and pelvis done on Asteion Toshiba single-slice spiral CT scanner revealed ileocolic intussusception with the lead point being an intraluminal heterogeneously enhancing mass in the cecum with associated irregular wall thickening [Figures and ] resulting in small bowel obstruction. The mass measured 3 × 3.5 cm in size. Few of the distal ileal loops showed thickened walls with mesenteric haziness in the right iliac fossa and minimal ascites, multiple enlarged mesenteric nodes ranging from 10 to 14 mm were seen in the right lumbar and the right iliac fossa with few of them showing central necrosis [].
Patient underwent right hemicolectomy. Cut surface revealed a polypoidal growth in the cecum measuring 3.5 × 3.0 × 2.5 cm. Macroscopic tumor perforation was present and microscopically tumor was adherent to other organs and was infiltrating the peritoneum, pericolic fat, and appendicular wall. Serosal margin was infiltrated by the tumor. The proximal and distal resected margins of the specimen were free from tumor involvement. Thirteen out of 14 lymph nodes were positive.
Histopathology examination of the cecal mass revealed sheets, cords, and islands of monomorphic large cells with large round nucleus and abundant cytoplasm [Figure and ] infiltrating the layers of cecum up to the peritoneum. Nests and islands of tumor with vague glandular structures amounting to more than 30% of the tumor [Figure and ] were seen originating from cecal mucosa and infiltrating the wall amidst pools of extracellular mucin. Few signet ring cells were seen in

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


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

[User]
RADIOLOGY NOTE:
A 27-year-old man presented himself to us with the chief complaints of pain in the mid-back from 6 months prior with no radicular symptoms or weakness. Neurological examination was normal.
The patient had been under anti-tuberculous treatment by the previous treating surgeon for thoracic tuberculosis from 5 months prior due to magnetic resonance imaging (MRI) findings. Details of the MRI films were not available. He had no relief with these medications. The radiograph of the thoracolumbar spine was performed and showed thoracic scoliosis with sclerosis around the T10 pedicle with no obvious bony destruction (). Haematological studies showed alkaline phosphatase was slightly raised.
We performed a new MRI which showed an extradural lesion in the region of the right T10-11 neural foramen with an intense marrow edema in the right half of the T10 vertebra and minimal right paravertebral edema from the T9 to T11 vertebral levels. Disc spaces were well maintained (). Since the findings were non-specific and a lesion was appreciated in the T 10 vertebra, we performed a computed tomography (CT) scan indicates dedicated study only at pathological level.
The CT scan showed a well-defined round lesion with ossified rim, majority lytic component, and a speck of calcification below the right pedicle and underneath the right pars interarticularis (it commented to be nidus by the radiologist, or it was a sequestrum as rare possibility due to a history of long-standing infection). There was subtle scalloping of the posterior cortex of the T10 vertebral body anteriorly and of the superior articular facet posteriorly. There was sclerosis of the adjacent vertebral body and pedicle. No obvious communication with the vertebral body/pedicle was seen. No evidence of bony destruction/erosion was seen. The lesion did not arise from any bony tissue and was extraosseous ().
The bone scan was available (done by one of the previous treating surgeons) and showed normal findings in the 1st phase

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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 47-year-old male, with no previous medical history, visited the outpatient Department of Rehabilitation in our hospital with a chief complaint of severe left upper abdominal pain. In fact, his abdominal pain initiated 2 years ago, and the symptoms had been progressing for past several months. He denied of any history of trauma prior to the onset of the pain. He underwent extensive gastroenterological workup including upper gastrointestinal endoscopy and computed tomography of abdomen, but the results showed no significant abnormalities. The abdominal pain was described as somewhat pricking but not obvious. At that time, he had normal motor, sensory, bladder, and bowel functions, and he did not show upper motor neuron sign. Conservative cares were carried out with prescriptions of pain medications and anti-inflammatory analgesic medications.
However, with the lapse of time, the patient's symptoms continued and became severe. The pain now measured 5 to 6 on visual analog scale and lasted for half an hour to a few hours, which was unlinked to position, movement, food intake, or defecation. He eventually consulted a surgeon in the general surgery department and was admitted to our hospital for more evaluation of those symptoms. There was no history of sweating, nausea, vomiting, diarrhea, constipation, fever, chills, or weight loss. On physical examination, there were no gastrointestinal signs on the abdomen, except for mild tenderness on epigastrium. Laboratory test data including complete blood count, urinalysis, erythrocyte sedimentation rate (ESR), C-reactive protein, serum electrolytes, liver enzyme, and amylase were all within the normal ranges. Electrocardiography monitoring showed no abnormalities and the follow-up computed tomography revealed no apparent gastroenterological pathology or musculoskeletal problems.
To rule out neurologic origins, the patient was referred to our rehabilitative medicine department. We first asked him detailed questions about his n

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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 79-year-old male presented to a district emergency department having been sent in by his GP for review of a left leg ulcer. His history included type 2 diabetes mellitus. In spite of living independently at home, he was noted to have dementia with significant cognitive impairment.
The patient was a vague historian and was unable to give sufficient details regarding the genesis or duration of the wound. He stated the ulcer might have been present for two weeks and had occurred subsequent to a fall. No further information regarding the cause of the ulcer could be elicited. His GP had treated the ulcer unsuccessfully with a one-week course of antibiotics prior to presentation. On examination, the patient was noted to be malnourished and cachectic with significant lower limb oedema. Mini Mental State Examination on review was 12/30. Circumferential ulceration of the left lower leg was noted (). The wound was approximately 2 cm wide and extended through the fascia throughout the wound. There was a large burden of tenacious slough, obscuring the base of the wound. The presence of larval infestation was identified. The wound was dressed, antibiotics were commenced, and the patient was transferred to a tertiary referral hospital for review and management by the vascular surgery and geriatric medicine teams.
The patient was reviewed in the emergency department of the tertiary hospital where the wound was inspected before transfer to the ward. A plain radiograph of the area of concern noted a soft tissue defect with no bony abnormality. On review of the wound by the admitting team, the peculiar morphology of the ulcer was noted. The uniform circumferential nature of the wound resembled that of a ligature type injury. Additional questioning however revealed no further clues to elucidate the causative mechanism. The patient denied any process that could adequately explain the circular nature of the lesion. A management plan of elevation, compression, antibiotics, and a dressi

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 57-year-old man with right hemiparesis and epilepsy secondary to a stroke.
The patient presented pain and impossibility at the elevation and extrarotation of his left shoulder soon after a convulsive crisis during his first hospitalization in the Department of Neurology of our hospital.
An X-ray was immediately made (). It shows humeral head fractures with some very little fragments and internal rotation of the humerus.
In order to confirm the posterior dislocation and to discover the associated fractures and the dimension of the reverse Hill-Sachs lesion, we requested a CT scan (). It shows posterior dislocation and a damage of the cartilaginous surface of humeral head with loss of the bone that amounts between 20 and 30% of the articular surface. There are also a posterior glenoid rim fracture and a lesser tuberosity fracture.
In order to prevent instability and to obtain an anatomical restoration that allows early mobilization and complete range of movement, we reduced the dislocation through a deltoid-pectoral incision, we stabilized the lesser tuberosity with a cancellous bone screw, and then we filled the reverse Hill Sachs with crioconserved femoral head contoured in the right shape to reconstruct the patient's humeral head, maintaining his original bending radius. The allograft was fixed by using 2 Herbert screws (). Finally, we reduced and stabilized the posterior glenoid rim fracture with a Herbert screw, through a posterior miniapproach.
This treatment allowed the patient an early mobilization, and so he obtained a range of motion very similar to his previous condition.
At 8-month followup, there are no signs of avascular necrosis (Figures and ) and the patient is satisfied with our operation. We did not perform the Constant score because of the right hemiparesis. However, the patient is able to keep his left arm above his head and to rotate internally till sacral bone (Figures and ). He has no pain.

[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 32-year old gentleman was admitted to our trauma department with a painful, immobile right knee. He sustained the injury externally rotating his knee whilst in “slight flexion” while he was moving from the driver’s seat to the passenger’s seat of his car. He had a history of two previous lateral patellar dislocations on same knee. The first event was 15 years prior, when his knee twisted in flexed position while pushing a car. He was taken to the emergency department where it was successfully reduced under sedation. The second event was four years prior, when he sustained an injury while pushing a van, this time with the right knee fully extended. On this occasion, his patella spontaneously reduced and he did not seek any medical intervention. Our patient had no other significant past medical or surgical history and explained his right knee was completely asymptomatic prior to this current event.
On examination, there was an obvious deformity suggesting lateral displacement of the patella with a sulcus in the skin evident over the femoral groove. Furthermore, the knee was held fixed in 15 degrees of flexion. Due to patient positioning difficulties we were unable to obtain true AP and lateral views on X-ray. The radiographs demonstrated a laterally displaced and a mal-rotated patella in the vertical plane (see Figs. and ). A manipulation under sedation was attempted unsuccessfully. A further attempt of reduction under a femoral nerve block had again been unsuccessful.
Our patient was subsequently taken to theatre where one final attempt of closed reduction was carried out under general anaesthetic and muscle relaxation. Ultimately, this failed and an open reduction was performed. The patient was positioned supine and an anterior midline skin incision was used. Complete rupture of the medial patellofemoral ligament (MPFL) was identified with the patella situated lateral to the lateral femoral condyle, everted by approximately 100 degrees. There were no visible defic

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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 65-year-old gentleman presented to the emergency department (ED) at night with a history of acute-onset atraumatic bilateral knee pain and swelling. His past medical history includes bicuspid aortic valve replacement and subsequent revision of his aortic valve replacement 4 weeks prior to the onset of knee pains. He was diagnosed with sternal surgical wound infection (clinically erythematous skin with possible discharge) 4 days prior to hospital attendance with associated left knee pain and swelling. A diagnosis of wound infection with reactive arthritis was made by his general practitioner (GP), and the patient was commenced on a course of clarithromycin due to penicillin allergy. The wound infection appeared to be responsive to oral antibiotic treatment. However, his left knee symptoms gradually worsened and greatly affected his mobility; 12 hours before ED attendance, he developed acute right knee pain and swelling with associated generalized fatigue. Clinical observation raised concerns of sepsis with a pyrexia of 39°C and tachycardia of 100 beats per minute. Both of his knees were diffusely swollen, warm, and extremely tender to palpate. He did not tolerate any range of movement of his knees. Hip and ankle joints were normal, and there was no appearance of cellulitis. He was also reviewed by the medical team, and other common sources of sepsis including chest or urine infections were ruled out.
On admission, his blood test showed raised inflammatory markers, with white blood cells of 15.9 × 109 L and C-reactive protein (CRP) of 288 mg/L. His knee X-rays revealed no bony pathology otherwise. Aspiration of both knees was performed under sterile technique on the ward prior to commencing antibiotics—cloudy thick pus was drained from both knees (Figures and ). Urgent microscopy and gram stain did not show any organisms.
The patient's initial presentation to his general practice with acute unilateral atraumatic knee pain and swelling raised suspicion of reactive ar

[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 55-year-old male smoker presented with typical anginal chest pain for three days. Upon arrival to the emergency room, pain was slightly improved and found to have NSTEMI with normal electrocardiogram and elevated troponins. The physical examination was unremarkable. The past medical history was significant for hypertension, dyslipidemia, and chronic ITP which responded to steroids and immunoglobulins in the past. Laboratory blood tests revealed a hemoglobin level of 15 mg/dL, platelet count of 42 × 109/L, and normal PTT and PT. He was admitted to the coronary care unit and was started on simvastatin and nitroglycerin and clopidogrel was held. The patient was given one dose of IVIG and was started on prednisone. On the 7th day of hospitalization, the platelet count was 208 × 109/L and the patient underwent cardiac catheterization through the right femoral artery. A drug eluted stent was placed in the obtuse marginal and a therapeutic ACT was reached after heparin administration. On the 8th day of hospitalization, the patient was discharged on aspirin 325 mg, clopidogrel 75 mg, and prednisone. Patient tolerated these medications well and remained in remission.
After six years, he presented again to the hospital with NSTEMI. The episode occurred one day after receiving dexamethasone and rituximab for ITP relapse. The physical exam was unremarkable and the platelet count was 23 × 109/L. He received in the emergency room nitroglycerin and morphine as well as aspirin 81 mg and the patient was started on IV dexamethasone and IVIG. On the fifth day, the platelet count was 180 × 109/L and the patient underwent cardiac catheterization through the femoral artery. Ostial triple vessel disease was treated with off pump bypass surgery with heparin to maintain an ACT > 300 through the procedure. The platelet count was 149 × 109/L after receiving two days of dexamethasone and the patient was discharged on aspirin 325 mg orally daily. Both patients were followed up for two years w

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

[User]
RADIOLOGY NOTE:
A 61-year-old African American female was found unconscious on the road after a suspected pedestrian versus motor vehicle accident. The patient was supposedly walking alongside a busy 4 lane road in the early evening time, when she was struck by a driver. EMS was notified by pedestrians, and she was found in the street unconscious at the time they arrived. There were no witnesses to the accident which came forward to aid police or medical professionals at the scene, and the vehicle involved in the incident fled. Specific details regarding the injury itself are unknown. The patient was intubated by EMS in the field and was brought to the local trauma center.
At the time of presentation to the ED, the blood pressure was 64/50 (posttransfusion and placement of pelvic binder; BP reached 150/110), heart rate of 119, and respiratory rate of 22. The abdomen was soft, nontender and nondistended. No signs of rigidity or acute abdominal trauma were seen at this time. There was an open left lower leg fracture medially with an approximately 15 × 8 cm open wound with “venous oozing.” GCS of 7 quickly deteriorated to GCS of 3. Rectal exam revealed “no” tone. There was no gross blood noted per rectum, but the patient is guaiac positive. There was no vaginal blood or blood in the urethral meatus; however, later the patient was found to have gross bright red blood draining from the catheter.
Hemodynamic instability upon arrival was apparent, and resuscitation through advanced life support (ATLS) protocol was quickly initiated shortly after arrival to the ED. IV fluids and trauma blood were given; 18 units of packed red blood cells, 11 units of FFP, and 1 unit of trauma platelets were been given to this point.
The patient was transported to angiogram for angiography of the vertebral artery and embolization due to pelvic bleeding. Images showed large amounts

[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 deceased donor was a 67-year-old man with a kidney Doppler ultrasound (DUS) that was negative for any nodular lesion. As part of the routine postoperative follow-up management, the recipient underwent DUS to assess the patency of the graft on postoperative day 1. The DUS finding was suspicious for an acute arterial thrombosis but did not reveal any focal irregularities. Consequently, a computed tomography (CT) scan was urgently obtained but it did not show any arterial complications. However, it serendipitously revealed a 2.4-cm lesion on the upper pole of the renal allograft which was not detected during the back-table or ultrasonography monitoring. A biopsy of the lesion was performed, and its histology revealed an epithelial proliferation of large cells with finely granular cytoplasm and medium round nucleus vesicular acidophilus, arranged tubules, and alveoli and cords immersed in a connective tissue stroma. This picture was consistent with oncocytoma. However, because the eosinophilic variant of chromophobe renal cell carcinoma (RCC) may morphologically resemble renal oncocytoma, immunohistochemical staining was performed using Ki-67 antibodies and RCC antigens. The results were negative, ruling out chromophobe RCC. The therapeutic options and potential related outcomes were clearly discussed with the patient. Given the low risk of malignant transformation in an oncocytoma [], we found no reason for resection of the lesion or an allograft nephrectomy. Consequently, we opted for active surveillance of the benign tumor with ultrasonography, every 2 months, for the first year and, then, with magnetic resonance imaging (MRI), every year (Fig. ). The patient received mycophenolate-mofetil, tacrolimus, and prednisone throughout the 5-year follow-up period and the regimen for immunosuppression was not changed despite the presence of the renal mass. After 60 months of active surveillance, we report that radiological studies have shown no growth, regression, or any

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old male presented to the Accident and Emergency Department with inability to pass urine and a painful, foul-smelling, and swollen penis for 3 days. He had no known medical problems and was not diabetic. On admission, the skin of the penis was partially necrotic with progressing gangrene, it was malodourous, and the abdominal wall and scrotum appeared normal.
Ultrasound, retrograde urethrogram, intravenous urogram, and urethroscopy were done within 24 hours. These confirmed a normal upper urinary tract and bladder and showed obstruction of the penile urethra secondary to multiple calculi; however, the calculi were embedded and the tissues were grossly inflamed and ulcerated. He was started on intravenous ampicillin, gentamicin, and metronidazole which were continued for 5 days during his hospital stay followed by amoxicillin/clavulanic acid upon discharge for a further week.
The patient consented for extraction of the urethral stones as well as aggressive debridement of the penile tissues with the risk of amputation. The exploration was done under general anaesthesia and an incision was done on the ventral (urethral) surface of the penis. Through a ventral urethrotomy, three urethral stones were successfully removed and the soft tissues of the penis aggressively debrided. A suprapubic cystostomy was also done and a catheter was inserted at this level (see Figures , , , and ). The ventral penile urethrotomy was closed primarily over a long-term catheter and the penile wounds were dressed and later closed with a scrotal skin advancement flap. Circumcision was not done as the skin though swollen was viable, and having already lost some penile skin to gangrene, all the intact remaining skin was conserved. The preputial oedema settled within 5 days of debridement. The urethral catheter was removed at 4 weeks and the suprapubic catheter was removed at 6 weeks. On a 12-month follow-up he had no evidence of erectile dysfunction or urethral stricture.

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


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

[User]
RADIOLOGY NOTE:
We present the case of a 30-month-old male who was brought to the family medicine clinic with a complaint of abdominal bloating and persistent diarrhea after every feeding for four months. His stools were foul-smelling and occurred more than four times a day. The diarrhea was associated with a failure to gain weight. The parents reported that the child has a normal appetite with no history of vomiting or feeding intolerance. There was no history of fever, night sweats, rash, cough, or joint pain. The child did not have any recent sick contact. The patient was seen by several general practitioners for the same complaint, but no diagnosis was obtained.
The patient had an unremarkable past medical history. He did not have any previous hospital admissions. He had no history of previous surgeries. He does not take any medications and was not known to have any food or drug allergies. Regarding the perinatal history, the child was full term with a birth weight of 3.5 kg. The labor and delivery were unremarkable for any complications. The child was up to date with his vaccination schedule. Regarding the developmental history, the child reached the developmental milestones at the appropriate ages, and there was no parental concern regarding his development. The social history was noncontributory. There was no history of diseases running in the family. The child was not born of a consanguineous marriage.
Upon examination, the child was awake and alert and did not appear sick. No dysmorphic features were noted. The patient was below the second standard deviations for weight and height. He appeared pale, and there was no scleral icterus. His vital signs were as follows: heart rate of 90 bpm, blood pressure of 80/52 mmHg, respiratory rate of 22 bpm, and temperature of 36.8°C. Abdominal examination revealed a soft and non-tender abdomen with no organomegaly and had normal bowel sounds. Neurological examination, including hearing and vision tests

[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-month-old male infant with strong anxiety observed for one day was admitted to our department. Past medical history revealed surgery at the age of 8 months due to a Morgagni-Larrey hernia. In addition, the child was under the care of a cardiology outpatient clinic (ventricular septal defect type 2) and ENT outpatient clinic (bilateral sensorineural hearing loss). There were no abnormalities in complete blood counts and routine biochemical laboratory tests performed two and four months prior to hospitalization. The family history was insignificant. Physical examination revealed pale skin, postoperative scars, Mongolian spot in the sacral region, flat forehead, broad nasal bridge with a tendency to form epicanthal folds, single transverse palmar creases, persistent fetal pads, aphthous stomatitis, umbilical hernia and systolic murmur along the left border of the sternum. Preliminary results of laboratory tests showed agranulocytosis, monocytosis, anemia, and increase in C-reactive protein concentration. The results of laboratory tests are presented in . There were no abnormalities of abdominal organs based on abdominal radiographs and ultrasound examination, except for umbilical hernia.
On the second day of hospitalization, the tender and painful mass about 2 × 2.5 cm, without splashing in the right submandibular area was palpated. Ultrasound examination of this area revealed the features of a forming abscess. An laryngological consultation was performed and initially empiric antibiotic therapy with amoxicillin and clavulanic acid was used, but without improvement. On the seventh day of hospitalization under general anesthesia, a surgical incision and drainage of the abscess were performed. The pus culture indicated methicillin-sensitive Staphylococcus aureus (MSSA) infection. Due to agranulocytosis, immunological, genetic and hematological consultations were carried out to plan diagnostic tests to determine the cause of neutropenia. Epstein-Barr virus and cytome

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


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

[User]
RADIOLOGY NOTE:
An 11-year-old girl presented to our A&E department after a fall on an outstretched arm with immediate pain experienced at the right shoulder. The X-ray demonstrated a nondisplaced fracture of the middle to proximal third of the right clavicle (). There were no other injuries, and neurovascular examination of the upper extremity was normal. The fracture was managed conservatively with sling immobilization for 6 weeks, and on clinical follow-up, it appeared to be healing well. The patient had no pain nor functional limitation, with adequate progression of periosteal reossification and callus formation seen on radiological examination. The patient was an amateur junior javelin thrower and was restricted from all sporting activity for a total of 3 months and until there was radiographic confirmation of callus formation ().
The patient remained completely asymptomatic for 12 months, after which time she presented with new swelling at the callus midline, associated pain, and shoulder function loss, in the absence of additional trauma. The X-ray at 12 months confirmed the clinical suspicion of a pseudoarthrosis ().
Following a multidisciplinary discussion, we decided to investigate the suspected nonunion and need for surgical intervention using CT and MRI (as seen below). The initial topographic examination was important to validate the pseudoarthrosis, which clearly identified two areas of hypertrophy without signs of bridging. The MRI was useful in excluding an entrapment of surrounding articular structures and in evaluating the involvement of the neurovascular bundle with respect to the bone ().
Following a discussion with the patient's parents, we opted for a surgical approach with open reduction and internal fixation and iliac crest bone graft from the ipsilateral hip 3 × 3 × 1 cm. The nonunion was confirmed intraoperatively with debriding of the fracture site, with a loss of bone substance of 2 cm. The bone sample taken from the iliac crest was customised, molded, a

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


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

[User]
RADIOLOGY NOTE:
A 75-year-old right-handed woman presented to the emergency department with headache and mental confusion 6 hours before admission. She had 5 years of formal education and was able to read and write perfectly. There was no prior medical history other than tobacco use for 50 years. Her family reported that she initially complained of difficulties in handling objects with her right hand and they noticed she was confused.
Initial evaluation revealed a blood pressure of 220 × 120 mmHg and a mild pronator drift of the right upper limb. She was alert and oriented, with no global attention or language abnormalities. Testing was positive for mild right spatial neglect with sensory extinction alone. Her score on the National Institute of Health Stroke Scale (NIHSS) was 1. The patient underwent initial stabilization and a Computed Tomography (CT) scan, which revealed only a residual calcified lesion in the left post-central gyrus. Interestingly, a more detailed cognitive evaluation revealed simultanagnosia (she could not integrate parts of the Boston Cookie Theft Picture or small letters into a global form) and unilateral right optic ataxia (). Moreover, the patient had agraphia, acalculia, digital agnosia and right-left disorientation, consistent with complete Gerstmann's syndrome ().
CT angiography showed diffuse atheromatosis, with moderate stenosis of 50% in the left carotid bulb due to an ulcerated plaque (). Diffusion-Weighted Imaging MRI revealed small hyperintense lesions in the territory of the left middle cerebral artery, predominantly posterior and cortical (). Serial electroencephalogram testing was negative for epileptiform activity, but there was a focal electrical slowing in the left hemisphere. After a complete neurovascular work-up, we concluded the patient had a stroke due to an evident large artery atherosclerosis mechanism.
The patient was treated with dual antiplatelet therapy and a high-potency statin at standard doses for secondary prevention. All cogni

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


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

[User]
RADIOLOGY NOTE:
A 26-year-old woman admitted herself for urological consultation to our hospital. She described a recent history of gross haematuria as well as having recognized a prolapsing vaginal mass. After our first examination we presumed the vaginal mass to be a thrombosed urethral caruncle. The initial sonographic evaluation of both kidneys revealed no pelvic dilatation. While the first try of carefully repositioning our clinical findings () was unsuccessful, we decided to admit the patient to the operating theatre in order to do further examinations and explorations under anesthesia. If the presumed diagnosis of a thrombosed urethral caruncle was correct, deroofing the caruncle would have been possible in the same instance.
During the examination in general anesthesia we found that some clear fluid was secreted from the circular prolapsed vaginal mass when putting pressure on it. Upon further pressure the mass retreated itself spontaneously into the outer urethral meatus. As will be seen in , in the following cystoscopy we found a big ureterocele on the left patient's side, matching the formerly prolapsed mass. The left ureteral ostium was not to be identified.
The right-sided ureteral ostium showed some small protrusion as well, presumably coinciding with another small ureterocele on this side. The further cystoscopy was largely inconspicuous so that we decided to end the procedure due to the now resolved acute situation which, nonetheless, required further investigation.
In order to confirm our intraoperatively newly obtained diagnosis of a prolapsed ureterocele, we did a CT scan of the patient's abdomen the day after the surgical intervention. In the CT scan () the presumed huge ureterocele on the left patient's side was indeed confirmed, accompanied by consecutively dilated left ureter and renal pelvis. There was no incidence for a duplex pelvic system. The right ureter was found to be normal with an inconspicuous ureteral ostium into the bladder.
While being clinicall

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


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

[User]
RADIOLOGY NOTE:
A male, 11 years old, suffered from pain in the left ankle joint after trauma and limitation of motion for 10 years, and the symptoms aggravated with claudication for 1 year. Physical examination showed swelling of the left ankle joint, extensive tenderness, normal skin temperature, and limited range of motion for ankle plantar flexion and dorsi flexion. Venous blood test showed no abnormalities in ESR, CRP, and blood routine. Radiograph and MRI suggested hyperplasia of synovial tissue in the articular cavity and epiphyseal injury of the distal tibia. Ankle arthrocentesis was conducted, and a small amount of turbid liquid was drained. No diagnosis of ankle TB was suggested. Preoperative diagnoses were (1) traumatic ankle synovitis and (2) epiphyseal injury of the left distal tibia. We initially planned to perform articular cavity debridement; however, when we conducted the surgery, we saw obvious hyperplasia of synovial tissue and the cartilage was obviously damaged; TB was highly suspected. Considering that the patient was still a child, ankle arthrodesis was not suitable in this case. Therefore, we only performed articular cavity debridement after obtaining the tissue sample for biopsy. Pathological examination confirmed ankle TB, and the result was also positive for TB-PCR. The patient was prevented from weight bearing for 6 weeks postoperatively; anti-TB treatment of rifampicin, isoniazid, and pyrazinamide were given orally; his nutrition was strengthened. Regular follow-ups were conducted. The swelling of the posterior malleolus was gradually relieved. After the reexamination at 6 months postoperatively, his anti-TB therapy was adjusted and only rifampicin and isoniazid were continued for maintenance treatment of 12 months. At the last follow-up at 5 years postoperatively, the patient’s left ankle swelling and pain disappeared, and the range of motion for ankle plantar flexion and dorsi flexion was basically normal. The AOFAS score improved from 57 points preop

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


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

[User]
RADIOLOGY NOTE:
A previously healthy, 52-year-old Caucasian man presented to his family physician a week after having a tonic-clonic seizure. A magnetic resonance imaging (MRI) scan showed a 10 cm left frontal tumor, which was confirmed as an atypical meningioma following craniotomy and resection (Figure ).
Postoperatively, he took 400 mg of phenytoin PO once a day. He had no seizures postoperatively or afterward. The patient uneventfully received 60 Gy of adjuvant radiation therapy to the postoperative bed in 30 fractions. Three months after the resection of the tumor, the patient began a trial of phenytoin but nine days later, he developed symptoms consistent with a generalized seizure. He resumed his daily phenytoin prophylaxis with good effect.
Two months later, he complained of blood in the stool and after an evaluation was diagnosed with a locally advanced nonmetastatic adenocarcinoma of the low rectum (Figure ). A curative-intent dose of 50.4 Gy in 28 fractions of neoadjuvant radiation therapy was prescribed, with 2000 mg PO BID of concurrent radiosensitizing capecitabine []. After 20 of the planned 28 fractions, he began to feel unwell and experienced new, right-sided upper and lower limb dysfunction and an unsteady gait. A contrast-enhanced computed tomography (CT) scan of the brain showed no suspicious findings but his phenytoin level was dramatically elevated at 138 µmol/L, compared to 49 µmol/L just prior to neoadjuvant therapy (normal range: 40-80 µmol/L). His albumin level from a few weeks prior to these symptoms had also been normal at 39 g/L (normal range: 34-46 g/L), and he was taking no other medications other than an occasional stimulant laxative. Capecitabine was discontinued, and the patient was treated with charcoal and admitted for observation. Phenytoin was temporarily discontinued and then reintroduced at the previous dose of 400 mg PO per day once levels began to normalize. His symptoms quickly resolved and he showed no further

[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 Danish woman was referred with constant pain in the right proximal thigh that had progressed for 8 years. She had no other known medical conditions. Menarche was at age 13. There was no family history of sclerosing bone diseases. The limb pain was aggravated at night and was moderately relieved during physical activity and by cold baths. She was on daily analgesic medication with nonsteroidal anti-inflammatory drugs, paracetamol, and weak opioid agonists, and she was on sick leave from her university studies at the time of referral due to her symptoms. She was using shoe inserts because of leg length discrepancy.
At age 11 she had consulted a rheumatologist because of hip joint pain. Guided by ultrasound a hip joint puncture was performed due to fluid gathering; serology was negative. After the puncture, the joint pain ceased.
Six months prior to referral to our clinic, she was involved in a traffic accident and hit by a car from the right at knee level. She was discharged from an emergency room (ER) with no suspected fracture and a radiological examination was not performed. She reported that there was significant worsening of the femoral pain after the traffic accident.
A clinical examination revealed no skin lesions, café au lait spots, or redness; there was no increased temperature or swelling in her right thigh. Leg length was unequal but within normality.
She was instructed to fill out a diary with daily registration of pain on an analog scale from zero to 10, where increasing values were equivalent to more intensive pain. Orally administered analgesics were required when the pain exceeded a score of 6 or more, and the score 10 was reserved for symptoms that kept our patient from falling asleep and that did not respond adequately to orally administered analgesics.
Magnetic resonance (MR) and positron emission tomography-computed tomography (PET-CT) scans revealed significant increased cortical thickness in the right femoral diaphysis that partial

[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 5-year-old female child was brought to us with a right sessile and dense membrane on the right upper eyelid since 1 month after birth. The membrane had previously been removed, and she had received long-term topical steroid treatment in another clinic. Upon examination, we found that she had right mechanical ptosis, esotropia, corneal leukoma, and complicated cataract, possibly steroid induced. The membrane had a firm, fibrous consistency with elevated edges and measured 20 × 14 mm in the right upper eyelid []. There was minimal inflammation in the lower eyelid. Her visual acuity was motion hand-20/20 in her right and left eyes, respectively. The membrane was excised from the upper eyelid. Histopathological analysis of the removed pseudomembrane showed eroded epithelium with massive subepithelial deposits of amorphous hyaline-like eosinophilic material and granulation tissue together with inflammatory cell which consisted of plasma cells and lymphocytes []. The eosinophilic materials were negative for Congo red stain. After surgery, she was treated with CsA 2% drops in olive oil, four times daily. Recurrence of the conjunctival lesion was noted at the site of excision 2 months later. The lesion was again excised. The child did not come back for follow-up. The patient returned 2 years later with the same lesion. The lesion was excised and the AM epithelium was secured up to the conjunctival edge at the mucocutaneous junction and the fornices with 8-0 polyglactin sutures in the right upper eyelid []. The right eye was treated with topical CsA four times daily and tobramycin eye drops six times daily.
Four months after AM transplantation (AMT), the patient showed new recurrence at the same site. The new pseudomembranous lesion was much smaller and softer; it was removed and the AM was used to cover the excision site. Treatment with topical CsA four times daily was continued for 6 months postoperatively. There was no recurrence of the membranes at the end of 28-months

[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 thirty-eight-year-old male with a history of vape use was admitted for massive hemoptysis of about 500 ml on two episodes. Nebulized and intravenous tranexamic acid was given. Bedside bronchoscopy localized the lesion on the left lung with polyp-like lesion versus an abnormal vessel on the left main bronchus about 2 cm from the carina (). Blood clots were also noted proximal to the polyp-like lesion suggestive of the primary site of active bleeding (). Endobronchial blocker was placed on the left main bronchus followed by the instillation of endobronchial epinephrine. Bronchial artery angiography showed collateral flow from the right bronchial artery to the left bronchial artery supplying the presumed bronchial polyp or abnormal blood vessel (Figures and ). Gelfoam slurry embolization was performed on the right bronchial artery with follow-up angiography demonstrating occlusion of the collateral vessels from the right bronchial artery. Procedures on the left bronchial artery were aborted due to acute upward angulation of the vessel and the risk of embolizing the anterior spinal artery. Following the successful right bronchial collateral artery embolization, endobronchial bleeding stopped, and the patient was successfully extubated. A week after, repeat chest computed tomography (CT) revealed bilateral pulmonary embolism (PE). The patient had another episode of massive hemoptysis with almost one liter of expectorated blood. Left bronchial artery embolization with Gelfoam slurry was performed via left brachial artery approach. Multiple bleeding ensued which required fourteen (14) bronchoscopic clearings of airway blood clots via forceps extractions (Figures and ). Pulmonary consolidations on bilateral lungs also developed which were considered to be pulmonary infarctions and/or atelectasis from plugging of airways with blood clots (). The patient's persistent severe hypoxia led to cardiac compromise, and the patient went to pulse electrical activity arrest. Increase

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


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

[User]
RADIOLOGY NOTE:
Our patient is a 62-year-old woman with a history of anemia, deep vein thrombosis, anxiety, and Devic's disease. After an initial misdiagnosis of MS, she was found to have Devic's disease when she tested positive for the NMO-IgG biomarker in her serum. She has required plasmapheresis as her primary treatment for her Devic's disease due to the failure of corticosteroid treatment. She received plasmapheresis via a left arm brachial-axillary PTFE AVG that has been in place for 10 years and used without incident.
In May 2017, the patient developed acute thrombosis of her AVG. Thrombolysis was completed, but the graft clotted off again within 1 week. She was seen and evaluated in our clinic for placement of a new dialysis access in June 2017, and we elected to create a new right arm AVG using an immediately cannulable graft (Acuseal, W.L. Gore & Associates, Flagstaff, AZ, USA) []. This was placed in a brachial-axillary configuration with the brachial artery connected to the axillary vein via a trilayer PTFE graft. There were no issues during the operation, and Doppler ultrasound confirmed a widely patent graft at the conclusion of the case. The patient was able to use this graft for plasmapheresis immediately after surgery.
The patient presented to our clinic 2 weeks after surgery for a routine postoperative visit. During this visit, it was noted that the graft was thrombosed, and there was now an absence of a radial and ulnar pulse. The patient was asymptomatic, and thus elective open thrombectomy of the graft was scheduled. This procedure was completed in late June 2017; during this procedure, we were unable to pass the Fogarty thrombectomy catheter past either the arterial or venous anastomoses. Open exploration of both anastomotic sites was then performed and severe myointimal fibrosis was noted within both the brachial artery and the axillary vein. While the axillary vein was completely

[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:
21-year-old male patient referred to department of oral and maxillofacial surgery with a complaint of drainage from a cutaneous lesion which was approximately 2 cm diameter under his chin (). According to the history of the patient, he had first become aware of the lesion 6 months before contacting with the author. Initially, the lesion was diagnosed as a carbuncle by the physician and had been treated with combine systematic antibiotics (1 gr amoxicillin and clavulanate every 12 hours and 150 mg clindamycin every 6 hours for 7 days). After using these medicines the patient reported that for a while drainage was stopped and the lesion decreased in size. Since there was repeated occurrence (the lesion gradually increased and drainage started) of the lesion, he referred to our dental clinic for an alternative solution.
Extraoral examination revealed that there was a cutaneous lesion on his chin (). Intraorally, although he had class III restorations on his mandibular anterior teeth (mesial sides of 32 and 42 and distal sides of 31 and 41), the teeth and periodontal tissues at anterior region of mandible seemed healthy. Furthermore, there was no pain either palpation or percussion. Dental ethology of sinus tract of odontogenic origin can be confirmed with the use of gutta-percha or similar radiopaque material but since the patient did not accept any extraoral interventions an intraoral periapical radiograph was taken without gutta-percha and it showed radiolucency around lower right central incisor which was the only reason that can cause cutaneous lesion. Radiolucency indicated inflammation of pulp that causes chronic apical periodontitis (). The treatment started with root canal treatment (). 2 days after the filling of the root canal, apical resection was performed and platelet-rich fibrin (PRF) was administered into the bone cavity and a PRF membrane was used to close the site as well. Following soft tissue closure with 3–0 silk sutures (), patient was instructed t

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


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

[User]
RADIOLOGY NOTE:
A 23-year-old female presented to the spine clinic of a tertiary teaching hospital with complaints of low back pain (VAS -– 8/10) for 3 years. The patient had a Deformity in the lower back and difficulty in walking for 3 months duration. Low back pain was insidious in onset, progressive in intensity, more during night time and relieved on taking medication. Deformity in low back was noticed by parents which gradually progressed to the presenting state. There was weakness in bilateral lower limbs with difficulty in walking and sensory disturbances in the form of tingling and numbness over the areas of both lower limbs for three 3 months as described in the clinical examination below. There were no complaints suggestive of of bowel and bladder involvement. On examination, there was visible knuckle deformity in the mid lumbar region which was tender on direct palpation ( ). The neurological evaluation of the patient is as shown in the (Table 1) below.
Knee, ankle, and plantar reflexes were absent bilaterally and graded sensory loss was seen over L3, L4, L5, and S1 dermatomes bilaterally. The patient had had X-rays taken at the interval of three 3 months, before presentation to our OPD which showed the evolution of the involvement of vertebra from a lytic lesion to complete collapse and dislocation ( ). NCCT scan showed destruction of L3 body with only remnants of endplates seen with a point contact between L2-L4 and dislocation of L3-L4 facet joint (). MRI revealed that a homogeneous mass was at the level of L3L4 L3L4 and on either side of the pedicles of L4 with obliteration of bilateral neural foramina. The lesion and mass were hypointense on T1- weighted images and iso to hyperintense on T2 weighted and in contrast images. There was also considerable compression on the thecal sac at the level of L3 (). USG- guided biopsy was

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


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

[User]
RADIOLOGY NOTE:
An 86-year-old man presented with a pulsatile mass in his right leg that had persisted for two months. He had a history of hypertension, diabetes mellitus, hyperuricemia, and atrial fibrillation. He had been hospitalized for acute pancreatitis in the past. However, he did not have a history of relevant episodes of injury or infection. Clinical findings of Behcet, von Recklinghausen, and any other connective tissue diseases were absent.
A physical examination revealed a pulsatile mass, about the size of a hen egg, on the lateral face of his right leg. All peripheral pulses were normal.
Computed tomography (CT) angiography revealed a 3.2×5 cm aneurysm of the anterior tibial artery, another two aneurysmal changes (0.8×0.7 cm) on the distal side of the aneurysm, and patent peripheral arteries (). The aneurysm contained no mural thrombosis, and the posterior tibial and peroneal arteries were patent. No other aneurysms were evident.
Surgery was initiated through a tibialis anterior lateral approach. The incision was made vertically about 10 cm above the aneurysm, and the tibialis anterior muscle and long extensor muscle of the great toe were divided. No adhesions had formed around the aneurysm, and the neurovascular bundle was confirmed. The deep peroneal nerve, located behind the aneurysm, was gently peeled away with careful manipulation. The aneurysm was opened, and the wall was removed. The artery was reconstructed using a reversed greater saphenous vein graft, which was proximally and distally sutured by an end-to-side anastomosis (). Postoperative peripheral pulses were good.
Histological analysis of the aneurysmal wall revealed fibrous thickening of the intima and medial degeneration with calcified atheroma (). Arteritis or dissection was not observed. Thus, the mass was diagnosed as an atherosclerotic, true aneurysm.
The patient was discharged 10 days after surgery with no signs of ischemia or deep peroneal nerve disorder. Six months after surgery, the graft remain

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


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

[User]
RADIOLOGY NOTE:
A 21-year-old Caucasian female gravida two parity one at 28 weeks presented to the dermatology clinic for evaluation of a large mass on her left lateral thigh (Figure ). The patient had an existing diagnosis of NF One, but no other medical conditions. Denied any use of regular medication besides prenatal vitamins. The mass had been present since early childhood and had been stable in size since 11 to 12 years of age.
Per the patient, the mass started to grow early in her first trimester and was noted to be more painful than in the past. The patient reported pain with minor trauma that lasted for days. No change in consistency of the mass was noted. No reported weakness or altered sensation in the leg, night sweats, fevers, chills, or weight loss by the patient. In her past pregnancy, the patient denied any change to the size of the mass or increase in pain like she was currently experiencing.
The physical exam was notable for multiple 2-3 mm hyperpigmented macules in the bilateral axilla. The upper extremities and back had large hyperpigmented tan macules and patches in various sizes consistent with Cafe au lait spots. The left thigh had a large 18 x 9 cm boggy hyperpigmented mass on the lateral side. It was pendulous and had multinodular consistency. The mass was moderately tender on palpation. The patient was noted to be able to ambulate without difficulty and had equal sensation and strength in both lower extremities.
After discussion with the patient, she was prepped for punch biopsy of the mass. Multiple biopsies were taken from different areas of the mass to ensure adequate sampling. The results of the biopsy revealed plexiform neurofibroma without any indications of malignant changes in any of the sites. The patient returned to the clinic a week later for suture removal and was informed that the mass was a plexiform neurofibroma, but did not appear to be malignant at the time of biopsy.
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.