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

[User]
RADIOLOGY NOTE:
A 71-year-old woman presented with sudden neck pain and weakness in her right upper and lower limbs while she was having a bath at home. Her symptoms resolved spontaneously within 10 minutes. After half past 4 hours later, she had the same onset of right hemiparesis and had full recovery within 15 minutes, and then was immediately admitted to our emergency department. The patient had a 30 years history of hypertension without well-control. She had no previous history of taking any antiplatelet or anticoagulant drugs. There was no recent history of head and spinal trauma or surgery.
The initial blood pressure was 210/90 mm Hg. On neurological examination, the patient had a normal cranial nervous system and sensory system. Her muscle strength was grade 5/5 in bilateral upper and lower limbs, but the right knee reflex was hyperactive and Hoffman's sign was positive. Laboratory investigations showed that a complete blood cell count, prothrombin time, and partial thromboplastin time were within normal limits. An emergency brain computed tomography and cervical x-ray scans were unremarkable. A clinical diagnosis of TIA was considered. Then the patient was hospitalized in the neurological wards and treated with antiplatelet therapy (100 mg aspirin and 75 mg clopidogrel, once daily). She did not complain any other symptoms except a mild neck pain in the following 2 days after admission.
On the third hospital day, the brain magnetic resonance imaging (MRI) and cervical MRI were performed. The brain MRI showed no signs of acute cerebral infarction. The cervical MRI revealed a spinal epidural hematoma located in the posterior spinal epidural space extending from the C2 to C6 spinal vertebral level. The hematoma was isointense on T1-weighted images and hyperintense on T2-weighted images (Fig. ). Just after returning to the wards, the patient recurred the right hemiplegia (muscle strength was grade 3/5 in right upper and lower limbs), and developed rapidly progressive quadripleg

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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:
Our patient is a 49-year-old, previously healthy, premenopausal female who presented to an outside institution’s emergency department with a chief complaint of new onset, left lower quadrant pain and several weeks of constipation. She underwent her first colonoscopic evaluation which demonstrated a near obstructing mass at the rectosigmoid junction. She was transferred to our institution for comprehensive cancer care.
On admission interview, she reported that her obstructive symptoms had been progressively escalating, with her last bowel movement over a week ago. She denied personal history of cancer. Her family history was significant for a grandmother with gastric cancer in her late 60s. Pathology identified the mass as a moderately differentiated, invasive adenocarcinoma. She underwent a computed tomography (CT) scan of the chest, abdomen, and pelvis for staging. Imaging revealed wall thickening at the rectosigmoid junction and luminal narrowing (Fig. ). Suspicious perirectal lymph nodes were present, but there was no evidence of distant metastasis (Fig. ). Due to her progressive obstructive symptoms and abdominal pain, she was taken to the operating room for a diverting loop ileostomy and a rigid sigmoidoscopy which demonstrated the distal border of the lesion at approximately 9 cm from the anal verge.
During her initial admission, she was evaluated by our hematology/oncology and our radiation oncology department for outpatient neoadjuvant therapy. She underwent an MRI of the pelvis to further assist in staging which displayed a 4.6 cm mass located in the upper rectum that extended into the muscularis propria, classifying it as a T3b lesion. Enlarged superior rectal lymph nodes suspicious for malignancy were also noted (Fig. ). Given her clinical diagnosis of stage III adenocarcinoma of the rectum, she was deemed a candidate for chemotherapy with 5-fluorouracil continuous infusion and concurrent radiation followed by definitive surgical resection.
Ten weeks afte

[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 collegiate football lineman was blocking during practice, when he was forced from his left side over an extended right leg, creating an internal rotation and adduction moment of the hip. He felt a ‘sliding and crunching sensation’ as he was driven over his right hip. He fell to the ground, and immediately had pain in his right hip. Initial evaluation on the field by the training staff and physician revealed that the hip had full motion, but there was pain with rotation of hip and inability of the athlete to bear weight. The patient was transferred to the emergency room for radiographs and further evaluation.
In the emergency room, the athlete complained of further pain in the hip which was increased with hip rotation. Initial radiographs consisted of pelvis anteroposterior view and lateral view of right hip []. The radiographs did not reveal any fracture or dislocation. With his persistent symptoms and continued pain with rotation, magnetic resonance imaging (MRI) was obtained to rule out an occult fracture within three hours of the initial injury. The MRI revealed a small hemarthrosis and a posterior labral tear, but there was no iliofemoral ligament tear or bone edema in the acetabulum or femoral head []. The patient was discharged with instructions to not bear weight on the right hip, and use crutches.
The athlete was re-evaluated the next day and found to have continued tenderness with internal rotation and with stressing of the posterior capsule and labrum. He continued to feel a ‘sliding sensation as if (his) hip was popping out,’ although this was not reproducible on examination. A diagnosis of traumatic hip subluxation was made based on his original injury, continued feelings of slipping, and his examination findings. The athlete was placed on hip precautions (patient was instructed to limit internal rotation of the hip, limit adduction of hip, sleeping on back with pillows between the leg) and continued on non-weight bearing,

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


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

[User]
RADIOLOGY NOTE:
A 10-year-old male patient presented with the complaints of decreased vision in the left eye for the last 4 days. On examination, the best corrected visual acuity (BCVA) in the right eye was 20/40, N6 and in the left eye 20/100, N9. Anterior segment examination was normal and the fundus examination of both eyes showed myopic discs with a posterior staphyloma and an extensive orangish-yellow flat lesion in the macular area of the right eye and in the peripapillary and macular area with submacular hemorrhage in the left eye [Figure and ].
Ultrasound B-Scan of both eyes showed a high reflective echo with shadowing at the posterior pole of both eyes. Patient underwent fundus fluorescein angiography (FFA) for both eyes which showed early hypofluorescence with late hyperfluorescence in the macular area of both eyes along with the peripapillary area in the left eye suggestive of the choroidal osteoma. There was an area of early hyperfluorescence which increased in size and intensity in the macular area of the left eye suggestive of an active CNV []. The indocyanine green angiography showed macular choroidal hypofluorescence in both eyes with an ill-defined hyperfluorescence plaque seen in the delayed frames of the left eye suggestive of a CNV []. Spectral domain optical coherence tomography of the left eye showed a steep curvature of the retinal layers due to posterior staphyloma along with a subfoveal CNV [].
He was diagnosed to have bilateral choroidal osteoma with an active subfoveal CNV in the left eye. He underwent a loading dose of three intravitreal injections of 1.25 mg/0.05 ml bevacizumab (off-label use) delivered to the inferotemporal quadrant of the left eye under strict aseptic precautions and short general anesthesia after an informed consent was signed by the parents.
At 1 year follow-up after the last injection showed a BCVA of 20/60, N6 in the left eye. Fundus examination of the left

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


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

[User]
RADIOLOGY NOTE:
The patient was a healthy, 42-year-old male [] who had suffered a roadside accident 2 h before and after initial examination and soft tissue management, he was referred to the conservative Dentistry PG Clinics of Dr. R. Ahmed Dental College and Hospital by Oral Surgery Department of the same college Clinical examination revealed that the injury had resulted in 5–6 mm intrusion [] and uncomplicated crown fracture of maxillary permanent central incisors and left lateral incisor [].
Subluxation of both maxillary canines was also noted. There was additional injury to alveolar bone, teeth and surrounding soft tissues with minor lacerations on both upper and lower lips. Lower central incisors were also mobile due to trauma.
Because of the severity of intrusion and completed root development, immediate surgical repositioning of intruded incisors was planned. Prior to surgical operation, the patient was given doxycycline (100 mg, oral). After the administration of local anesthesia, the intruded tooth was initially luxated. An artery forcep was used for this purpose []. The tooth was brought into a position by applying careful and very gentle force incisally. The teeth were repositioned to a level such that the cementoenamel junction (CEJ) was in plane with the free gingival margin. Following repositioning of the teeth, space was found to be present between the upper and lower teeth. Patient′s history of pre-existing open-bite justified the relative positions []. After bringing the upper lateral incisor and central incisors into their respective positions, these teeth were splinted using Erich's arch bar technique []. The lower incisors with slight mobility were splinted using 22 gauge wire and light-cured composite resin. Arch bar was used in the upper teeth because of the associated alveolar fractures and extreme mobility of the teeth involved in intrusion and mobility of both the canines as well. Another reason for avoiding composite splint in upper teeth was the continue

[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 gentleman, ex-smoker, presented to our hospital complaining of mild epigastric pain, regurgitation, and heartburn. On top of that, he has a long-standing history of gastroesophageal reflux disease (GERD), which was managed by proton pump inhibitors. His past medical history was significant for hypertension. He was previously diagnosed with a liver hemangioma based on abdominal ultrasound two years before the presentation. He had no relevant family history. Physical examination revealed mild epigastric tenderness with no palpable abdominal mass. Laboratory data showed no anemia but positive stool occult blood test. Tumor markers including AFP, CEA, and CA 19-9 were all within normal range. Upper GI endoscopy revealed mild esophagitis, Los Angles grade A along with Barrett's esophagus without dysplasia and a 1 cm polyp at the GEJ. A sample was sent for histopathology; the rest of the stomach and duodenum were normal. The patient did not have a previous endoscopy prior to this one.
Infused computed tomography (CT) of the abdomen and chest showed mild GEJ thickness with no evidence of mediastinal or celiac lymphadenopathy and no signs of metastasis. It also demonstrated a large heterogeneously enhancing mass about 6 × 9.5 cm with central necrosis in the upper abdomen that appears to be originating from the gastric antrum (greater curve). The mass was highly suggestive of GIST based on CT; it was the same mass that was previously misdiagnosed as a liver hemangioma (). Endoscopic ultrasound confirmed the previous findings. However, no biopsy was attempted due to the risk of bleeding.
Histopathological examination of the GEJ polyp revealed tubulovillous adenoma with elements of adenocarcinoma in situ. The patient was admitted with a provisional diagnosis of early-stage adenocarcinoma of GEJ along with the incidental finding of enlarging gastric GIST. A trial of endoscopic mucosal resection of GEJ polyp was attempted but failed because of the polyp location th

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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 26-year old male presented with an increasing breathlessness over the previous 15 days accompanied by an episode of hemoptysis. On examination, he was moderately built, had low grade fever and absent breath sounds in the right lower chest. On investigation, hemoglobin and the blood counts were in normal range. Chest radiograph revealed features suggestive of a mass lesion with well-defined margins within the right lower lobe. This was followed by a high resolution computerized tomogram, which further confirmed the presence of the mass and showed it to be pulmonary and not pleural in nature. A lobectomy resection was carried out as he was determined to have no other primary site of tumor.
Gross examination revealed a heavy boggy right lower lobe with a congested pleural surface. On sectioning, a well-defined fleshy mass (13 × 12 × 5 cm) with areas of necrosis and hemorrhage involving almost the entire lower lobe was present. The mass seemed to involve the medial aspect of the lobe including the hilar area with some residual remnant of parent lung in the periphery [].
Microscopy revealed a cellular unencapsulated neoplasm with tumor cells in vague lobulated sheets with pushing margins []. The compact spindle cells most characteristic of synovial sarcoma were largely absent. In most areas, the cells appeared small and round with round to ovoid nuclei and a small amount of eosinophilic cytoplasm []. In only a few areas was their some degree of spindling with cells growing in fascicular arrays []. In places, the cells were in nests separated by fine branching staghorn or hemangiopericytomatous type blood vessels []. Mitosis was brisk (10-14 mitosis/10 HPF). Large areas of geographic necrosis were also present. The differential diagnosis considered based on an initial histology included a neuroendocrine tumor, Ewing's sarcoma, peripheral neuroectodermal tumor (PNET), solitary fibrous tumor, and poorly differentiated synovial sarcoma.
Immunoperoxidase studies on paraffin

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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 42-year-old female presented to us with a primary complaint of pain in the left side of her face for 3 yrs. The pain was spontaneous and oppressive in nature. She had a history of burning, a pricking type of dysesthesia (pins and needles feeling), intermittent in nature and radiated to the left temporal and orbital region. The unremitting nature of pain often made her feel anxious and agitated with lack of sleep. No trigger factors and aggravating or relieving factors were disclosed in the history. She narrated a history of uneventful extraction of a decayed upper third molar and a restoration of carious tooth citing as a possible source of pain by her dentist.
Her medical history was unremarkable except the ingestion of a cocktail of medicines alternating from analgesics, antibiotics, steroids, and antidepressants prescribed by multiple physicians for the unremitting chronic pain she was experiencing. An array of investigations was performed ranging from MRI brain, OPG, and cephalograms that turned out to be inconclusive. Vascular decompression, central pontine dysfunction, skull base, and metastatic tumor were ruled out following the normal slices seen in MRI and CT. Routine chair side diagnostic tests were done to rule out odontogenic pain.
On clinical examination, a sharp localized pain in the hamular region was evident on palpation due to the elongated hamular process that had a knife-edge bony projection (). The overlying palatal mucosa had no change in color or texture. A local anesthetic (1 ml of 2% lidocaine) infiltration was injected with subsequent impermanent relief of symptoms in a localized area. Her oral examination was nonremarkable on the affected left side with deep dentinal caries with respect to 18 () and pulp stones with respect to 16 on the right side (). Blood investigations carry less significance except in the possible diagnosis of cranial arteritis and for autoimmune disorders such as Sjogren's syndrome.
Following a failure of conservativ

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


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

[User]
RADIOLOGY NOTE:
A 31 years old male patient attended the Accident and Emergency department after he had fallen directly onto both knees the day before. He was allegedly assaulted and tripped when he was running to safety. The patient had no past medical history. He was a keen bodybuilder who competed at a semi-professional level. His drug history included current use of anabolic steroids. He complained of pain in both knees and examination revealed effusion and pain over bilateral quadriceps tendons. There was a tender palpable suprapatellar gap on the left and to a lesser extent on the right side. There were bilateral lack of active extension and the patient was not able to straight leg raise bilaterally. Plain radiographs of both knees did not show any bony injury. ( and )
The clinical diagnosis of bilateral quadriceps tendon rupture was confirmed by urgent ultrasonography and the patient was admitted for surgical repair the next day. ( and ) The patient did not complain of any other symptoms at the time. Intraoperative findings consisted of a musculo-tendinous junction tear on the right and an insertional tear of the quadriceps tendon on the left which were surgically repaired with sutures and suture anchors respectively. The patient was discharged the following day after an uneventful postoperative recovery. Both knees were immobilised in extension splints and the patient was allowed to fully weight bear with the support of crutches.
At the first follow up appointment the patient admitted to non compliance to the post operative plan of strict immobilisation and he had taken the splints off to see whether he could move his knees on numerous occasions over the last two weeks. Furthermore he mentioned pain in his left calf, which he apparently recognised on the day of discharge from Hospital. He left this unreported to any member of the medical staff for two weeks. Calf squeeze test as described by Simmonds revealed no plantar flexion of the foot on compressing the calf muscles.[]

[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 13-year-old Caucasian female student reported to the oral and maxillofacial surgery clinic with the chief complaint of purulent discharge oozing just distal to the upper right second molar, with a bad taste and foul odour, that started two weeks before seeking treatment. Upon clinical examination, the patient had no intraoral or extraoral swelling, and there was a full complement of teeth on that arch except for teeth #18 and #28. All teeth were firm, vital and non-carious. A panoramic radiograph revealed ectopic eruption of the right maxillary third molar in the maxillary sinus with hyperdense lesion surrounding its crown and obliterating the sinus cavity (
).
Further radiographic investigation using cone beam computed tomography (CBCT) determined the exact location of the maxillary molar and the lesion extension since the molar was seen in close proximity to the infraorbital rim. CBCT showed the ectopic third molar with incompletely formed roots located in the posterosuperior aspect of the right maxillary sinus with a close approximation to the orbital floor superiorly and pterygoid plates posteriorly (
). The third molar was surrounded by a well-defined corticated hyperdense lesion measuring 23×36×35mm, occupying almost the whole cavity of the right maxillary sinus and causing mediolateral expansion of the alveolar ridge. The CBCT also revealed the destructive effect of the associated pericoronal lesion on the right maxillary sinus floor and buccal cortical plate, distal to tooth #17, causing oroantral communication, which explains the reason for the purulent discharge, the chief complaint of the patient (
). Differential diagnosis of the detected lesion was dentigerous cyst, odontogenic keratocyst or Gorlin cyst. Based on the clinical and radiographical examination, the surgical removal of the ectopic third molar along with cyst enucleation was planned through an intraoral approach under general anaesthesia induced via nasopharyngeal intubation. Induction of a

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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 Twenty-two years old male pedestrian was involved in a road traffic accident and sustained closed fracture of the femur on the right side. He was a known case of homocysteinurea. He was fully awake and conscious at the time of admission. There were no other injuries; He had normal vital signs and was admitted to the orthopedic ward.
On the third day following admission he became tachypnoeic, tachycardic, irritable and started to desaturate and was put on supplemental oxygen. He continued to deteriorate; showed decreased level of consciousness hence was intubated and was shifted to ICU put on ventilatory support, started on remifentanil and midazolam infusions. He was found having petichea all over his upper trunk including axillae. Fundoscopy showed retinal hemorrhages. Blood workup showed drop in platelet counts and hemoglobin level, with increased coagulation profile. He received blood and blood products accordingly. Septic work-up done for his persistent fever was found to be negative.
X-ray chest showed diffuse scattered infiltrates. He was diagnosed as fat embolism syndrome by Gurd's criteria.
CT examination of head showed subtle hypodense changes in centrum semiovale and periventricular region and CT chest showed bilateral basal consolidation []. MRI was done on the sixth day of admission, showed multiple hyperintense areas in the cerebral white matter and basal ganglia, in diffusion weighted images (DWI) and T2 weighted images (T2WI), consistent with the impression of Fat Embolism []. He started to improve after good hydration, and good intensive care management and other supportive measures. He had fixation of the femur done on day15 and subsequently improved further and was extubated on day 19.
He remained in the ICU for two more days. He became fully awake, started to obey commands, was started on normal diet and was transferred to the ward on the 21st day with stable vitals signs and was subsequently discharged from the hospital after two days.

[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 55-year-old woman presented with recurrent invasive lobular carcinoma of the right breast following previous lumpectomy and partial irradiation for invasive lobular carcinoma. Ductal carcinoma in situ of the opposite left breast also had been treated in the past with lumpectomy. Given the patient history and the recurrence of disease in the right breast, bilateral skin- and nipple-sparing mastectomies with right axillary sentinel lymph node biopsy were planned. These would be followed by immediate bilateral autologous DIEP flap-based breast reconstructions.
Preoperatively, a computerized tomography angiogram was obtained to evaluate the perforator vascular anatomy of the anterior abdominal wall. This study showed a 2.5–3.0-cm left adrenal mass. Subsequent work-up diagnosed a pheochromocytoma. The patient was offered a laparoscopic adrenalectomy after alpha-blockade in addition to a genetic evaluation for hereditary causes of pheochromocytoma. She was advised to undergo an adrenalectomy first before moving forward with oncologic and reconstructive breast surgery. However, given her concern for breast cancer progression, the patient preferred to proceed first with the breast cancer surgery and reconstruction to be followed with later surgery to address the adrenal tumor.
Under consultation with the patient’s Endocrinologist, alpha-blockade (phenoxybenzamine) was initiated 2 weeks before surgery to prevent pheochromocytoma crisis and beta blockage (propanolol) was started 1 week later for heart rate control. Subsequently, bilateral skin- and nipple-sparing mastectomies were initiated with simultaneous abdominal tissue harvest for the reconstruction. Figure a Doppler probe was used to identify the dominant perforators of the abdominal wall on each side of the midline. As the skin and soft tissue flap was developed, dissection on the right side in the suprafascial plane showed the perforating vessels to be small, measuring less than 1.0-mm in diameter. To avoid injury

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


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

[User]
RADIOLOGY NOTE:
A 29-year-old female patient was admitted to Shandong Tumor Hospital and Institute (Jinan, China) on July 17, 2012, due to coughing that had lasted for one month and a fever that had been present for seven days. The patient had no history of any remarkable asbestos exposure. No abnormalities were noted upon physical examination and the patient exhibited no heart-involved symptoms. Furthermore, no heart abnormalities were detected by electrocardiogram and color ultrasonography studies. Laboratory tests showed that the leukocyte level was 7.8×109/l and the level of carcinoembryonic antigen (CEA) was 1.7 ng/ml. A chest radiograph revealed a projecting abnormal giant upper mediastinal shadow (). A contrast-enhanced computed tomography (CT) scan revealed an upper mediastinal tumor, 9.0×10.0 cm in size, adjacent to the aortic arch, trachea, superior vena cava and left pulmonary artery. The vessels in the mediastinum were compressed and shifted to the lower right. The trachea became stenotic, but there was no evidence of invasion. Although a small amount of bilateral pleural effusion was observed, there was no pericardial effusion. The mass was relatively well encapsulated. There was no pleural thickening or clearly swollen lymph nodes in the mediastinum. Heterogeneous and weak enhancement was observed during the arterial and delayed phases ().
A detailed general examination showed no other metastatic or primary lesions. A CT-guided puncture biopsy of the mediastinal mass failed to provide a pathological diagnosis. Based on the suspicion of a mediastinal tumor, thoracoscopic surgery and surgical biopsies of the mass were performed. During surgery, it was observed that the mass was located in the upper mediastinum under the normal mediastinal pleura and convex to the left chest cavity. The surface of the tumor was smooth and uneven, and the tumor was an elastic-hard mass, measuring 8.0×9.0 cm. Furthermore, the tumor was in a frozen state with the mediastinal tissue, with no

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


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

[User]
RADIOLOGY NOTE:
A 49-year-old Caucasian woman was referred to our center. She was known for years to have fibrous dysplasia in the left femur and tibia.
When she was 49 years old, an attempt was made to excise the fibrous dysplasia from the proximal femur. Extreme hemorrhaging complicated the operation. The attending orthopedic surgeon decided to refer the patient to our specialized center. At the time of her visit to our center, she complained about progressive pain in her left thigh and lower leg. Her clinical physical examination revealed soft swelling in the left quadriceps region.
Conventional X-rays of the left leg showed typical features of fibrous dysplasia in the proximal femur (Figure ) and the proximal tibia (Figure ) with ground glass appearance and a shepherd's crook deformity.
Magnetic resonance imaging (MRI) of her left leg showed extensive fibrous dysplasia in the entire femur with expansive growth in the greater trochanter. The left proximal tibia also showed signs of fibrous dysplasia extending 20 cm distally from the tibial plateau. Four well-delineated, cyst-like, intra-muscular soft-tissue lesions were seen in the quadriceps region. Surgery was planned in two sessions. Prior to both operations, angiography and embolization of the pathologic vascularization in both the femur and the tibia were performed.
During the first operation, intra-lesional excision of the tumor of the left proximal femur was performed, followed by cryosurgery. A correctional osteotomy of the left hip was performed, followed by homologous bone transplantation and fixation with a proximal femoral nail. Because of a weakened femoral head, the femoral neck screw had to be stabilized with bone cement. Allograft bone chips were impacted to induce bone matrix. During the procedure, an incisional biopsy of the soft-tissue lesions in the quadriceps muscle was performed.
Three weeks later an intra-lesional excision of the fibrous dysplasia of the left tibia was performed, followed by cryosurgery an

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


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

[User]
RADIOLOGY NOTE:
A 60-year-old Japanese woman was brought to the emergency department of our hospital, complaining of left flank pain. The pain had started the previous day and had gradually increased in severity. On examination, she was found to be alert, with a blood pressure of 173/101 mmHg, heart rate of 110 beats/minute, oxygen saturation of 95% (on room air), and respiratory rate of 20/minute. Her past medical history included myelodysplastic syndrome (MDS), hypertension, and cerebral infarction, leading to left hemiplegia. She had no history of pancreatitis and abdominal surgery. She was taking antihypertensive and acid-reducing medications, but no antiplatelet or anticoagulant medication. Her abdomen was flat, but there was moderate tenderness in her left flank. Her laboratory findings included hemoglobin level of 7 g/dL, hematocrit level of 20.8%, platelet count of 118,000/microL, prothrombin time of 13.3 seconds, activated prothrombin time of 31.9 seconds, and fibrinogen level of 209.4 mg/dL. Her normal hemoglobin level was approximately 8 g/dL. Blood chemistry findings were almost within normal limits. A computed tomography (CT) scan of her abdomen with intravenously administered contrast agent showed a solid mass of 5 × 5 × 8 cm in the left middle abdominal quadrant (Fig. ). The mass was found to be fed by a branch of the superior mesenteric artery (SMA). The contrast agent leaked in the mass. An orally administered contrast agent was not used because she had nausea. On completion of CT, the working diagnosis was an impending rupture of an aneurysm located in a branch of SMA. We decided to perform a transcatheter arterial embolization (TAE); however, angiography of SMA and inferior mesenteric artery (IMA) did not indicate extravasation of the contrast agent. Her blood pressure remained stable, but her pulse rate was still fast. We decided to perform surgery in line with the diagnosis of an impending rupture of the visceral artery aneurysm. Her peritoneal cavity was enter

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


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

[User]
RADIOLOGY NOTE:
The patient is a 65-year-old female who was previously diagnosed with moderately differentiated, invasive adenocarcinoma after a right upper lobectomy in 2013. The tumor was positive for EGFR mutation, KRAS wild type, ALK negative, CK7 positive, CK20 negative, and TTF negative. At that time, no chemotherapy or radiation was required. In 2014, the patient had a recurrence of her disease with a metastasis to mediastinal subcarinal lymph node. Over the next four years due to disease progression or inability to tolerate agents (e.g., development of acute pancreatitis from erlotinib), the patient was treated with multiple antineoplastic agents including bevacizumab, pemetrexed, durvalumab, tremelimumab, erlotinib, and afatinib. These were all discontinued over 6 months prior to this admission to the hospital. She also received palliative radiation to the right mediastinal mass as well as to several metastatic spine lesions in the cervical and thoracic spine during 2017. Follow-up staging imaging did not show any evidence of radiation pneumonitis or fibrosis. In early 2018, she underwent biopsy of metastatic liver lesions, found to be adenocarcinoma of the lung primary with EGFR exon 19 deletion and T790M mutations. In April 2018, she was started on Osimertinib 80 mg daily, which she tolerated well for approximately four months. A staging CT was completed in June of 2018, which showed response to therapy as evidenced by a decrease in size of the right infrahilar mass, adenopathy, pulmonary nodules, and hepatic metastases. In addition, her previously noted brain metastasis was no longer seen on her brain MRI. In August 2018, she required an admission to an outside facility due to symptoms suggestive of congestive heart failure. She was diuresed and diagnosed with nonischemic cardiomyopathy. Her heart failure remained well compensated on goal-directed medical therapy and diuretics. Other past medical history is notable for hypertension, acid reflux, emphysema, and iron defi

[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 white female initially presented to the emergency department (ED) with a chief complaint of a traumatic severe left lower back pain for three days. The pain was sharp and radiated down her left anterior thigh. The pain worsened with movement and improved with rest, but persisted when lying still. Associated symptoms included dysuria and mild generalized abdominal pain. Past medical and surgical history was significant for genital herpes, iron deficient anemia, and hemorrhoidectomy. She took no prescription medicine. Social history was positive for tobacco use, but she denied alcohol or recreational drug use. Her job was labor intensive and involved heavy lifting. She first noticed the pain with associated stiffness upon waking the morning after a work shift. She denied trauma, fevers, rigors, weight loss, nausea, vomiting, diarrhea, constipation, vaginal bleeding or discharge, weakness or numbness in the lower extremities, and urinary incontinence. On physical examination she was afebrile with normal vital signs. She was in obvious discomfort and unable to sit up straight due to pain. Her gait was antalgic. She had tenderness to palpation and increased tone over her left lumbar paraspinal musculature. Her strength, reflexes and sensation of the lower extremities were normal. The remainder of the physical exam was unremarkable. She was diagnosed with lumbosacral strain and discharged home with a prescription of opiate analgesics.
The patient returned to the ED via ambulance four days later, tearful and writhing in pain. Her vital signs were normal. The physical examination was essentially unchanged from her previous encounter. Specifically, there was no midline spinal tenderness or neurologic deficits in the lower extremities. Straight leg testing was negative with reproduction of the back pain but without radiation. Plain spinal radiographs showed degenerative changes but no acute process. She was treated with intravenous (IV) opiates and antiemetics 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 47-year-old female patient was admitted to our hospital with a few hours history of personality change, cognitive dysfunction, and headache. She also had a 12-year history of abortion and thrombocytopenia. She was drowsy, with a Glasgow coma scale of 14. The platelet count was markedly decreased to 58,000/µL, and physical examination showed splenomegaly. Computed tomography (CT) of the abdomen showed a cirrhotic liver with splenomegaly. However, she had no history of hepatitis. Lumbar puncture was performed after platelet transfusion, and no red blood cells were found in the cerebrospinal fluid.
Magnetic resonance (MR) imaging and CT of the brain were performed for evaluation of suspected intracranial lesions. A T1-weighted axial image showed a target-like thrombosed aneurysm located in the right anterior sylvian fissure (). Ovoid high signal intensity was suggestive of a hematoma surrounding the posterior aspect of the aneurysm. A T2-weighted axial image also showed a thrombosed aneurysm and a posteriorly located hematoma with a surrounding dark line (). Difference in signal intensity was observed between the posteriorly located hematoma and the thrombosed aneurysm on T1- and T2-weighted images, i.e. on T1- and T2-weighted images, the posterior hematoma showed homogeneous high signal intensity, whereas the thrombosed portion of the aneurysm showed intermediate and inhomogeneous high signal intensity (). A gadolinium-enhanced axial image showed no definite enhancement of the lesions (). On precontrast CT scan (), the thrombosed aneurysm showed a highly attenuating wall. This high attenuation on CT images presented as high signal intensity on T1- and T2-weighted images. The posteriorly located hematoma abutted the aneurysmal sac. The hematoma also differed in density from the highly attenuating aneurysm wall. No evidence of subarachnoid hemorrhage was observed on MR or CT images. Digital subtraction angiography was performed, and 2 unruptured aneurysms were detecte

[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 current disease story of our 68-year-old Caucasian male started two years ago, when this patient observed a hard lesion in the anal canal, which, in the first months since he observed it, was neither officially diagnosed nor treated. Ten months after that, he underwent cholecystectomy due to cholelithiasis, and the perioperative diagnostic examination revealed some suspicious lesions in the anal canal and some enlarged pelvic lymph nodes. His comorbidities included only gout, and his Karnofsky performance status was 90. He has never been treated with radiotherapy, and he had a second-degree family history for malignancies. At that time, a digital rectal examination identified mild prostatomegaly, with a palpable suspicious nodule in the left prostate lobe, without any signs of the extracapsular extension. Also, a large ulcerated mass was palpable at the dorsal anal canal wall, without lymphadenopathies in the inguinal region. Subsequent colonoscopy confirmed the presence of a suspicious lesion on the posterior anal canal, extending above up to the anorectic junction. A magnetic resonance imaging (MRI) for the regional staging confirmed an infiltrative lesion of the anal canal with a maximum diameter of 3.2 cm, with a high-grade suspicion of sphincter infiltration, and two enlarged lymphadenopathies in the mesorectum and in the right internal iliac region, respectively, both with a maximal diameter of 2 cm, which is suspicious of tumour metastases. Further, an area with a maximal diameter of 2 cm within the left prostate basis having a restricted diffusion with a lower apparent diffusion coefficient (ADC) than that in the surrounding healthy prostate tissue, which appeared hypointense on ADC maps but hyperintense on the diffusion-weighted maps, was also described. Afterwards, biopsies confirmed a poorly differentiated squamous cell carcinoma of the anal canal, as well as a moderately differentiated prostate adenocarcinoma, with a Gleason score of 7 (3 + 4) in bot

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


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

[User]
RADIOLOGY NOTE:
A 71-year-old female with a pulmonary metastasis from primary sigmoid colon cancer presented for video-assisted thoracoscopic LUL lobectomy. She underwent resection of sigmoid colon cancer (StageIIA T3N0M0) five years previously. She did not receive adjuvant chemotherapy. Recent computed tomography scan revealed a mass in the left upper lobe of the lung, and she was admitted to undergo video-assisted thoracoscopic LUL lobectomy. She had a history of hypertension and osteoporosis, treated with raloxifen, alfacalcidol, fexofenadine hydrochloride, pseudoephedrine and esomeprazole magnesium hydrate. She smoked two packs of cigarettes per day for 45 years. Physical examination on admission was unremarkable. Preoperative electrocardiogram showed sinus rhythm with an incomplete right bundle branch block. After placement of an epidural catheter between the fifth and sixth vertebrae, general anesthesia was induced with remifentanil and propofol. Tracheal intubation was accomplished using rocuronium bromide. Combined epidural and general anesthesia was maintained with remifentanil, desflurane and ropivacaine. The LUL lobectomy proceeded without difficulty with an operating time of 157 min. No arrhythmias or severe hypotension were detected during the surgery. She was transferred to a general ward after extubation in the operating room.
The postoperative course was uncomplicated with no episodes of atrial fibrillation on the first postoperative day. On the evening of the second postoperative day, she was seen to lean suddenly to the left after urinating. She developed left hemiparesis, right conjugate deviation and dysarthria. She underwent emergency magnetic resonance imaging after immediate removal of the epidural catheter. Cerebral magnetic resonance angiography revealed cessation of blood flow in the right internal carotid artery (Fig. ). An acute cerebral infarction was diagnosed and she was transferred to another hospital to receive intravascular therapy. Initially, 4000

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


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

[User]
RADIOLOGY NOTE:
A 16-year-old Japanese girl with no past medical history or previous injuries presented to a nearby clinic complaining of chronic anterior left ankle pain for the past 2 years. She was diagnosed with anterior ankle impingement syndrome by ultrasonographic findings of synovial hyperplasia in the anterior aspect of the ankle joint and referred to our hospital for further treatment. A physical examination revealed tenderness and swelling across the anterior aspect of the left ankle but no local heat or redness of the overlying skin. She played badminton three times a week and complained of increasing pain with sports activities. Careful interviewing revealed that she also had pain at rest which increased with motion in the morning which was strong especially immediately after awakening.
The range of motion of the left ankle was normal, and marked pain was observed with forced dorsiflexion. There were no signs of ankle instability. A blood test showed that her white blood cell count, C-reactive protein level, and matrix metalloproteinase-3 level were within normal limits. Rheumatoid factor and anticyclic citrullinated peptide antibody tests were negative. Plain radiographs showed a small exostotic bony bulge on the talar neck which resembled a traction spur and a recess on the talar neck (). Computed tomography (CT) showed an 8 mm radiolucent lesion with marginal sclerosis and central calcification in the talar neck (). Magnetic resonance imaging (MRI) revealed a bone lesion in the talar neck with surrounding bone marrow edema, synovial thickening in front of the bone lesion, and joint effusion ().
We initially considered two pathologies as differential diagnoses: one was anterior ankle impingement syndrome considering the bone lesion as a recess, flake, and spur caused by impaction of the distal tibia against the talar neck; and the other was OO in the talar neck considering the bone lesion in CT and MRI as a nidus with secondary synovitis in the ankle joint. Activity

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old woman was hospitalized in November 2001 in our department for surgical coronary revascularization. In 1998, she had an anterior acute myocardial infarction, and in January 1999, complaining exertion induced angina, she underwent coronary angiography and subsequently percutaneous transluminal coronary angioplasty of the left anterior descending (LAD) coronary artery. A year and a half later, she complained again exertional angina, and a repeated angiography showed a LAD occlusion and 90% stenosis of the first diagonal, while right and circumflex arteries showed a normal caliber; left ventricle ejection fraction measured by ventriculography was 50% and echocardiography showed only a mild mitral regurgitation. At that time, the lady underwent LAD grafting via a left anterior thoracotomy, with the left internal mammary artery (LIMA) as conduit. Two weeks later, she presented with recurrent exertional angina and coronary angiography showed occlusion of the LIMA graft. Reoperation was performed again via left anterior thoracotomy, and LAD bypass grafting was obtained using a tract of the saphenous vein. The cause of acute LIMA occlusion was due to technical issues at the level of the anastomosis. Postoperative course this time was uneventful, and the patient was transferred to rehabilitation department. Here, in January 2002, transthoracic echocardiography showed a small mobile mass on the right coronary cusp. The mass on the aortic valve was later confirmed by transesophageal echocardiography (TEE): a mobile, pedunculated, 0.8 cm round mass on the aortic side of the right coronary cusp of a trileaflet aortic valve, with an appearance most consistent with a PFE. She was afebrile and blood cultures were negative, ruling out endocarditis. Considering that we routinely use perioperative transesophageal echocardiography (TEE) during cardiac surgery, we may believe that PFE formed after the revascularization procedure.
Although the patient was adequately informed

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


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

[User]
RADIOLOGY NOTE:
This case involved a 17-year-old, left-handed, male, high school baseball pitcher. He trained six times a week at a top regional level. Six months before the season started, he experienced occasional mild discomfort in the right lower back, but continued to train, including throwing. Two months after the season started, he complained of acute-onset, right unilateral, severe and sharp low back pain during a game and stopped further play. He experienced aggravation of the pain on right lateral bending, bilateral rotation, and extension of the trunk; coughing and sneezing were also painful. He was referred to a local hospital on suspicion of acute onset stress fracture of the pars interarticularis or lumbar disc herniation. However, lumbar x-ray, computed tomography (CT), and magnetic resonance imaging (MRI) ruled out these injuries, and a tentative diagnosis of lumbar facet pain syndrome combined with back muscle strain was made. Five days after onset, he was referred to our institution for a second opinion.
On physical examination, the patient presented with pain on palpation of the lower edge of the right 12th rib in the lower back (). Right lateral flexion, right and left rotation, and extension of the trunk reproduced the pain, as did eccentric-phase trunk rotation exercises and muscle contractions against resistance maneuvers. Low back pain originated at the point of tenderness and spread to the right side of the lower back from almost the L1 to the L4 level, along with the lateral edge of the iliocostal muscle. Neurological examinations all yielded normal results. Oblique muscle injury was thus suspected. This suspicion was confirmed by review of the previous MRI, focusing on the affected site, revealing internal oblique muscle injury at the junction of the thoracolumbar fascia and the costal cartilage interface of the right 12th rib on axial- and coronal-section short tau inversion recovery (STIR) sequences (). Hematoma was thus identified tracking along muscle

[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 63-year-old female never-smoker was admitted to our department for the first time on December 23, 2015, due to cough and dyspnea for over 20 days. Her chest computed tomography (CT) showed space-occupying lesions in the right hilum and enlarged lymph nodes in the mediastinum, atelectasis of the right lung, massive pleural effusion in the right side, and multiple nodules in both lungs (). Magnetic resonance imaging (MRI) showed gadolinium-enhanced multiple abnormal intensification foci in the brain which were considered to be multiple metastatic tumors (). The serum concentration of the carcinoembryonic antigen (CEA) was 18.75 ng/mL. Right thoracic closed drainage and pleural biopsy were performed, resulting in a total of 1,500 mL yellow pleural fluid drained out () and a pleural fluid CEA of 17.55 ng/mL.
The histology of the pathological changes confirmed by both pleural biopsy () and fiberoptic bronchofiberscopy biopsy () was adenocarcinoma of the lung. Then the EGFR mutation status was investigated and the result showed a point mutation at exon 21 (L858R). One month later, the patient underwent a systemic bone imaging examination, which revealed abnormal bone metabolism in the middle of the left femur (). Bilateral femoral MRI showed bilateral femoral shaft metastatic tumor.
The patient received gefitinib and intermittent zoledronic acid for bone metastases until 20 months, and then MRI showed that BMs which had disappeared and shrunk () after gefitinib were progressing again. The cancer lesions in lungs of the patient were significantly reduced () after gefitinib and did not progress during the treatment period. Systemic bone imaging showed that the metabolic activity of hypermetabolic lesions in the middle part of the left femur was significantly decreased after gefitinib treatment () and the patient had never been affected by lower limb discomfort.
The patient received osimertinib for 38 months which was recommended after T790M acquisition confirmed by liqu

[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 24-year-old Haitian female with no known past medical history or smoking history was in her usual state of health until three weeks prior to presentation when she started to experience right arm pain, numbness, and tingling sensation. She did not report a history of cancer in her family. She initially presented to an urgent care facility where she was prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants without any improvement of her symptoms. She also had two episodes of pre-syncope over the past two months which she attributed to poor diet; she did not seek any medical attention. On the day of presentation to the emergency department (ED), the patient was returning from the Bahamas via airplane when she felt progressively worsening right-sided chest discomfort radiating to the right flank and back. She reported right upper extremity pain and numbness. She did not report cough, fever, shortness of breath, cold symptoms or recent changes in the weight and appetite. Her vitals in ED were a heart rate of 120 beats per minute, oxygen saturation of 98% on room air, blood pressure of 110/78 mm Hg, and temperature of 98.2 F. Her physical examination was unremarkable. Initial laboratory investigation was normal including complete blood count (CBC) and comprehensive metabolic panel (CMP). A preliminary chest X-ray was done (Figure ).
Due to tachycardia and positive travel history, a computed tomography angiogram (CTA) was performed which was negative for a pulmonary embolism. However, CTA revealed a heterogeneous superior right mediastinal mass, measuring about 10 cm. The trachea was noted to be severely deviated to the left and markedly stenosed. Multiple pleural-based lung masses and nodules were also present on imaging, which are classical imaging signs of adenocarcinoma (Figure ).
The patient underwent a mediastinal biopsy and was diagnosed with metastatic poorly differentiated non-small cell adenocarcinoma (Figure ). She later underwent 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:
An 88-year-old Caucasian woman was referred to our orthopedic unit following a simple trip on the stairs leading to a locked knee at an 80° angle. In the fall, the quadriceps muscles were forcefully contracted on her bent knee. Prior to the incident, she was independently mobile with the use of a stick. Her medical history included osteoarthritis affecting both knees and mild, generalized, right-sided weakness following a subdural hemorrhage secondary to an RTA. The physical examination of her right knee revealed a closed injury with minimal swelling. We noted a tender, inferiorly displaced patella. Her range of movement of the knee was 80°to 115° with a definite block to extension.
The initial plain radiographs of her flexed knee revealed inferior displacement of the patella (Figure ).
Under patient sedation, the patient¹s patellar swelling was reduced by hyperflexing the knee, placing downward pressure on the inferior pole of the patella, and then slowly extending her leg. Her knee was then placed in a camp splint and allowed to mobilize. The following day the patient was able to raise and straighten her leg with a relatively pain-free range of movement of the knee and was able to mobilize independently on the ward. While in the hospital, she was unable to tolerate the splint and abandoned it. Her knee then locked again following flexion past 90°. A computed tomography scan of her right knee was performed, which showed a superior patellar osteophyte embedded in the lateral femoral condyle (Figure ).
The patient's knee was examined while she was under general anesthesia. When her knee was flexed past 90°, the patella locked into the lateral femoral condyle. The knee could be unlocked by slightly increasing flexion and applying pressure inferomedially while slowly extending the knee. Arthroscopy was performed using standard lateral and medial portals. This confirmed the presence of a deep ridge where the patellar osteophyte had become embedded into the arthritic lat

[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 9-year-old female leucoderma patient presented to the stomatology department of a public hospital in Rio de Janeiro, Brazil. She complained of small nodules in the left parotid region that had developed over the course of 2 years. Her main complaint was of recurring periods of worsened symptoms characterized by the exacerbation and remission of gland volume that was possibly triggered by occasional otolaryngologic infections or unrelated to these infections. These symptoms suggest juvenile recurrent parotitis. Facial panoramic radiography revealed the presence of multiple circular radiopaque masses in the left parotid region (Fig. ). The ultrasound revealed increased volume of the left parotid, with imprecise borders, heterogeneous echotexture with hypoechoic and hyperechoic areas within it. These features were suggestive of an inflammatory process associated with calcifications in the parenchyma of the gland. CT scan revealed a dense mass in the left parotid; it was heterogeneous and included calcifications in its center (Fig. ). Because of the association between the patient’s clinical history, her clinical presentation, and the imaging findings, the possible origin of the calcified materials was questioned. There was evidence of sialoliths or dystrophic calcification associated with recurrent inflammation/infection. Sialoliths are typically symptomatic because of their association with secondary bacterial infections, which are generally treated with systemic antibiotic therapy. Spontaneous remission of bacterial sialadenitis associated with sialoliths is not expected. In addition, sialoliths generally observed as oval-shaped calcified masses or fusiforms on imaging. Because of the pediatric nature of this case, the clinical conduct selected to treat this patient was clinical follow-up and the use of imaging and functional assessments of the gland affected every 6 months or when any signs and/or symptoms appeared. After 48 months, the patient is asymptomatic, wi

[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 46-year-old Javanese woman presented with urinary incontinence following an abdominal hysterectomy with bilateral salpingectomy 3 months earlier. She is a housewife with no history of routine drug use and no prior history of hypertension, diabetes, allergies, or other chronic disease. She does not smoke tobacco and does not consume alcohol.
A physical examination revealed that her general condition was good and her vital signs were: blood pressure 112/74 mmHg, heart rate 89 beats per minute, respiratory rate 18 times per minute, and temperature 36.6 °C. There were no abnormalities in her chest and abdomen, or in musculoskeletal and neurological examinations. In a genitalia examination using a speculum, we identified fistulae above her vagina wall that were 1 cm in size. All laboratory findings (that is, complete blood count, liver functions, renal functions, and urine analysis) were within normal limits.
After discussion with our patient regarding the risks and benefits of an open abdominal procedure and laparoscopic approach, we discussed the similarities and differences between the two procedures were her. We chose surgical management using laparoscopic approach with the considerations that it could facilitate precise dissection, offer good visualization, and be minimally invasive, thereby enabling faster recovery.
Our patient was placed in the lithotomy position and received general anesthesia. A cystoscopy was performed to confirm the fistulae orifice and a stent was inserted into the fistulae tract from her bladder to her vagina. A tamponade was inserted into her vagina up to the vaginal apex, to be able to identify the vagina and prevent loss of pneumoperitoneum. A transperitoneal approach was performed with trocars distributed as follows: The camera was placed through a 12 mm port with 30° down lens located superior to the umbilicus. Two ports for the surgeon were placed on the right side (Fig. ).
She had adhesions; therefore, adhesiolysis was performed, us

[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 13-year-old boy reported to the Department of Pedodontics and Preventive Dentistry with a history of fall from cycle 2 days back. The child complained of sensitivity in the upper anterior teeth. The medical history of the child was found to be insignificant. Proper immunization schedule was followed for the child. Clinical and radiographic examination revealed Ellis class III fracture (involvement of enamel and dentin compromising the pulp) of the maxillary left central incisor []. No significant hard or soft tissue injury other than tooth fracture was observed. An intraoral periapical radiograph was taken, which showed the coronal fracture with no root fracture or any other periapical changes []. The child was carrying the broken tooth fragment that was confirming adequately to the fractured left central incisor []. The tooth fragment was stored in water and did not show any significant change in color.
An immediate endodontic intervention followed by bonding of the fractured segment using the acid etch technique was decided. Single-visit endodontics was performed for the fractured central incisor. An access cavity was prepared and pulp extripation was performed with the help of barbed broaches. After working length determination, biomechanical preparation was carried out with the help of K-files using the crown down technique. Copious irrigation of the root canal was intermittently done with sodium hypochlorite and normal saline. The canal was dried with absorbent point and was obturated with Gutta percha points and Zinc oxide eugenol sealer using the lateral condensation technique []. Now, the pulp chamber was partially filled with restorative Glass Ionomer Cement. Then, the tooth fragment and the remaining tooth structure was prepared for bonding. The tooth fragment was disinfected with sodium hypochlorite solution and then rinsed properly with water. An enamel bevel was prepared all around the remaining tooth structure as well as the fractured margin of the s

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


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

[User]
RADIOLOGY NOTE:
A 30-year-old male with no prior medical history presented with nonradiating upper abdominal pressure and pain associated with early satiety and bloating. This was progressive over approximately 2 months before he sought medical attention. His physical exam demonstrated an easily visualized and palpable firm epigastric mass (). There were no signs of chronic liver disease such as ascites or jaundice.
Standard tumor biomarkers such as CEA, AFP, and CA19-9 were normal, as was serum bloodwork for liver metabolic and synthetic function. Subsequent imaging workup demonstrated a large heterogeneous liver tumor approximately 27 × 13 × 20 cm in size, occupying his entire upper abdomen with mass effect and posterior displacement of the pancreas and stomach.
Multiphase contrast enhanced computed tomography (CT) scan showed the tumor originating from the left liver spanning segments 2, 3, and 4 with no evidence of biliary obstruction. However, the left portal vein was not well-visualized beyond the portal bifurcation suggesting severe compression or occlusion. Similarly, the middle and left hepatic veins were not seen (). There were felt to be reactive ascites and a right pleural effusion but no clear evidence for metastatic disease in the thorax or abdomen.
Percutaneous biopsy showed spindle cells consistent with an undifferentiated sarcoma. After multidisciplinary review, the patient was considered a surgical candidate but preoperative downsizing might help from a technical standpoint. Tumor embolization was thought to be feasible and worth attempting to achieve this. The patient thus underwent bland embolization to the tumor via the left hepatic artery. Approximately two weeks after procedure, CT angiogram showed unfortunately no significant change in size although perhaps with some tumor necrosis related to the procedure.
This mass continued to be highly symptomatic and it was felt that further surveillance would result in being minimal if any shrinkage of the tumor; thus

[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 noted pain and swelling in her proximal right arm. Imaging revealed a mass in the posterior compartment of the arm as well as innumerable lung lesions consistent with metastases. MRI showed no brain lesions. Biopsy revealed ASPS and she began sunitinib at 37.5 mg daily. Toxicity included hand-foot syndrome (ultimately requiring dose reduction to 25 mg daily), but imaging showed both primary tumor and metastases to have decreased in size on imaging 3 months after initiation. She continued on sunitinib for the ensuing 33 months with stable disease on imaging. At 33 months, because of worsening neuropathic arm pain, sunitinib was held and palliative radiation (50 Gy/20 fractions) to the arm was administered, with sunitinib resumed afterwards. Arm pain and swelling initially worsened over several months before finally improving above baseline.
Following the treatment break for radiation, imaging showed lung nodules to have grown slightly. It was hoped that this was due to interruption of treatment, but over the ensuing year, the lung metastases continued to grow despite ongoing sunitinib. Forty-seven months from her initial presentation, sunitinib was discontinued and she began bevacizumab 7.5 mg/m2/14 days. With this, she enjoyed a decrease in swelling in her right arm and consequent improvement in strength; we had not realized that sunitinib had been worsening the edema in her arm. CT of the chest 2 months later confirmed continuing progression and bevacizumab was discontinued. She embarked on cyclophosphamide and sirolimus, but tolerated this for only 2 months before discontinuing for worsened fatigue, anxiety, and shortness of breath.
Imaging confirmed progression of lung nodules, and 53 months after her initial presentation, she began pazopanib at 800 mg daily. This too proved difficult to tolerate. She was admitted to the hospital for hypoxia and found to have a pulmonary embolism, which in retrospect was probably responsible for her earlier cl

[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:
1: A-39-years-old male referred to our General Hospital with sensation of giving away and unable to extend on the right knee after car accident 1.5 years ago. He had history of close fracture of lateral condyle right femur. The patient complain of irreducible patellar dislocation during flexion and extension of the right knee joint. He underwent 4 times surgery of his right knee by other orthopaedic surgeon. The first surgery result still unreduced fragment fracture, and we done open reduction and internal fixation (ORIF) also PCL reconstruction. The right knee became valgus knee after fracture union and instability sensation on the medial knee joint. On physical examination, the right knee had 18° of valgus deformity, moderate instability to valgus stress, complete lateral dislocation of the patellae during extension and flexion, and tenderness at the lateral joint line (). Range of motion was 0–110°.
During radiographic examination, the standing knee radiograph showed mild arthritic changes on the lateral compartment of the right knee that were not observed on the left knee. The long-leg weight-bearing standing radiograph showed 18° valgus on the right knee and 5° valgus on the left knee with depression of the lateral tibia plateau and a mechanical axis passing outside the lateral compartment, and the weight bearing line locates lateral to Fujisawa point. The anatomical lateral distal femoral angles of the right and left knees were 105° and 82° respectively (normal value is 81° and 62°, respectively); the medial proximal tibial angles were 94° and 93° respectively (normal value is 87° and 63°, respectively). This result confirmed valgus deformities of both knees. A skyline view radiograph showed complete lateral dislocation of the patella () [].
2: A-26-years-old obese female came into outpatient clinic with chief complain of left patellar dislocation. She had history of left knee surgery for dislocation at age 5 years old. Her left knee never felt comfortable and

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old female patient was referred for orthodontic consultation. Her chief complaint was the presence of a gap due to a missing tooth in the front region in the upper jaw. She had no relevant family history, no significant prenatal and postnatal history, no medical history, and no history of parafunctional habits. She was very conscious of the space present in the front teeth and her smile ().
On clinical examination, she had a straight profile with a symmetric face and competent lips. Intraoral examination revealed class I molar relationship bilaterally, missing left maxillary lateral incisor, upper right peg lateral incisor, and gap between the teeth in the upper front region.
Both maxillary and mandibular arches were U-shaped, spacing in the maxillary arch, and the lower arch was skewed on the left buccal segment.
The cephalometric analysis indicates skeletal class I relation () with an ANB angle of 2° and nearly normal growth pattern, as shown by an FMA of 22° and SN-GoGn of 29°, nearly normally inclined and normally positioned maxillary incisor and nearly normally inclined and normally positioned mandibular incisors with obtuse nasolabial angle.
The panoramic radiograph revealed a missing upper lateral incisor on the left side and the presence of all third molars. The overall alveolar bone level was within normal limits ().
The treatment objectives were to close the spaces, align irregular teeth in both jaws and replace the missing upper left lateral incisor by lateralization of 23, achieve optimal occlusion, and improve the esthetics.
The patient had a skeletal class I pattern and nearly normal growth pattern; hence, corrective orthodontics was planned.
Two treatment options were presented to the patient.
Option 1: creation of space for missing lateral incisor followed by a prosthesis.
Option 2: closure of missing left lateral incisor space by lateralization of canine followed by reshaping of the canine to resemble the lateral.
Both the treatment

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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 59-year-old female patient presented to her local family doctor with chronic generalized intermittent colicky abdominal pain and altered bowel habit for a few months. She has no other associated symptoms. She previously had laparoscopic adjustable gastric band (LAGB) insertion 8 years prior with good result (BMI pre-procedure was 56 kg/m2, and now 36 kg/m2). Her other comorbidities include hypertension and colonic diverticular disease with previous acute diverticulitis. She was organized to have an elective colonoscopy. Colonoscopy revealed tubular foreign body embedded in the wall of colon, with an entry and exit point, ~55 cm from anal verge (Fig. ). There was also significant sigmoid and descending colon diverticular disease.
CT abdomen with oral and intravenous contrast was organized to further investigate the tubular foreign body. It revealed concurrent gastric band erosion into gastric lumen and connection tubing eroding into the posterior wall of transverse colon and exiting inferiorly (Figs –). There was no evidence of any oral contrast leak from the stomach.
This patient has previously been admitted for acute diverticulitis 4 years prior. Reviewing prior imaging did not reveal any gastric or colonic erosion. The gastric band tubing is noted to be running along the inflamed colon. Since the initial admission for acute diverticulitis, she has had multiple further acute diverticulitis episodes, which were treated with oral antibiotics. We suspect recurrent diverticulitis lead to the erosion of the gastric band into the colon and stomach.
As part of the surgical management, both colorectal and upper GI surgeon were involved in the operation. Patient underwent laparoscopic removal of gastric band and laparoscopic assisted wedge resection of transverse colon. The gastric band was removed following adhesiolysis and the gastric defect was repaired with intracorporeal suturing. The gastric band port was subsequently removed. Gastroscopy was done to ensure the repa

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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 female, Scottish Sheep farmer presented to Aberdeen Royal Infirmary Major Trauma unit with pain and discomfort from a lesion on her non dominant left ring finger distal phalanx. She accidently stabbed her hand when she was shearing a sheep this resulted in a laceration to her left ring finger. She presented 2 weeks following the incident with a soft well circumscribed mass on the ulnar aspect of her distal phalanx bordering the nail plate. The patient has a past medical history of protein c deficiency for which she requires lifelong warfarin. She is a non-smoker, works full time as a farmer and is physically fit able to perform all activities of daily living. She was not aware that any of her sheep were infected with the Orf virus infection and had not seen evidence of lesions around the mouths of her sheep.
Aberdeen Royal Infirmary run a dedicated tertiary hand service. The on-call orthopaedic hand registrar reviewed the patient. After taking a full medical history a through clinical examination was performed. The lesion presented on the left ring finger distal ulnar aspect bordering the nail a 4 mm by 4 mm discrete brown hemispherical lesion was noted (). The surrounding skin was slightly erythematous. The lesion was not warm, nor tender on palpation. The patient did not present any Kanaval’s signs to suggest pyogenic tenosynovitis or evidence of dorsal compartment infection. No fluctuance was noted in the lesion. The patient had a full range of movement in her left ring finger. The distal neurovascular status of the finger was intact. The patient had seen a clear fluid exudate discharge a day before she presented. The lesion was dry on presentation. The patient was prescribed oral antibiotics by her general practitioner which commenced a week before presenting to the hand unit. The antibiotics did not resolve the lesion. Radiographs taken did not show any evidence of foreign body within the

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

[User]
RADIOLOGY NOTE:
A 28-year-old male patient was sitting next to the driver seat in a sports utility vehicle which met with road traffic accident. The sudden deceleration injury caused both the knees of the patient to hit against the dash board. The patient was taken to a level 3 trauma center and later shifted to our level 1 trauma center after 48 h of injury. On presentation, the patient was conscious, oriented and hemodynamically stable. The right thigh was deformed, painful, had abnormal mobility around thigh, and was more shortened compared to the left lower limb which was in an attitude of external rotation, there was contusion over the right gluteal region. The radiographs [] revealed a posterior dislocation of the right hip with a posterior acetabular wall fracture, an ipsilateral fracture of the shaft of the femur, reverse oblique trochanteric fracture on the left side, and a both bones fracture of the right forearm. Being a high-energy injury and in order to study the acetabular fracture morphology in detail, a noncontrast computed tomography (CT) scan with a 3D reconstruction of the pelvis was done which revealed acetabular fracture geometry and a minimally displaced femoral neck fracture on the left side [Figure –]. On a careful review of previous radiographs, a suspicious fracture line was seen on the left side, though it was not very clear.
The patient underwent open reduction and internal fixation of all his fractures in the same sitting having an irreducible dislocation on one side and a femoral neck fracture on the other about 50 h from his time of sustaining injury. First with the patient in left lateral position on the right side, open reduction and internal fixation (ORIF) of the femoral shaft fracture with a locking plate and of the posterior wall acetabular fracture with a reconstruction plate and lag screws was done. A trochanteric osteotomy was also performed on the right side to aid in the fixation of the high posterosuperior acetabular wall fracture and the

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


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

[User]
RADIOLOGY NOTE:
A 79-year-old man was admitted to the intensive care unit on November 2017 for a ruptured penetrating atherosclerotic ulcer of the ascending aorta identified on CT scan (Figure).
He had a significant past medical history: end-stage renal failure undergoing dialysis, and myocardial infarctions with previous stentings (the last infarction dating back 10 months). Earlier in the day, the patient had presented with severe retrosternal chest pain for which a myocardial infarction was initially suspected, but the electrocardiography and the transthoracic echography performed in emergency excluded the diagnosis. A CT scan was realized and showed a local aortic plaque rupture of the ascending aorta with active contrast leakage, the patient was then transferred to our institution.
At admission the patient was haemodynamically stable with good blood pressure, a normal pulmonary auscultation with oxygen saturation at 100%, and no more pain. The patient was considered for open cardiac surgery but was evaluated at a high mortality risk based on his age, his medical history, and significant calcifications on his aorta. Our vascular surgical team decided then to perform an endovascular repair.
In emergency, an off the shelf endovascular stent graft was used. The rupture measured 12 mm and was located at just a few millimetres proximal to the IA. The ascending aorta measured 8 cm from the coronary sinuses to the IA. The largest diameter measured along the length of the ascending aorta was 33 mm (Figure). The shortest available off the shelf thoracic stent graft was the 10 cm length Conformable GORE® TAG® Thoracic Endoprothesis (WL Gore & associates, Flagstaff, AZ, USA).
In a hybrid operative room, first we performed an IA debranching with a left to right common carotid bypass through a cervicotomy using GORETEX vascular graft (8 mm). Via a transfemoral approach, the IA was embolized with a plug emplatzer (16 mm). Then, we considered a femoral approach to place the stent graft

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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 55-year-old woman was referred to our hospital because of a rectal submucosal tumor detected on a colonoscopic examination. She had undergone a sigmoidectomy for sigmoid colon carcinoma 2 years previously in our hospital. Postoperatively, the final disease stage was T1N0M0 (Stage I) according to the TNM classification. The histological subtype of the sigmoid colon cancer was moderately differentiated adenocarcinoma. There had been no evidence of recurrence or metastasis during 2 years follow-up. The patient showed no signs of tuberous sclerosis complex.
On digital rectal examination, a hard mass was palpated on the posterior wall of the rectum. The results of other physical examinations of the abdomen and other organs were normal. Laboratory data showed no marked abnormalities, including tumor markers such as carcinoembryonic antigen and carbohydrate antigen 19-9. Colonoscopic examination in our hospital revealed a submucosal tumor 3 cm in diameter arising in the posterior rectal wall, 10 cm from the anal verge (Figure a). The submucosal tumor was accompanied by an ulcer and superficial mucosal bleeding at its center. A biopsy was performed, but a histopathological diagnosis could not be established. An endoanal ultrasound scan showed a heterogenous, low echoic, nodular tumor arising in the muscularis of the posterior rectal wall (Figure b). The tumor was suspected to invade the muscularis propria and subserosa. Contrast-enhanced computed tomography of the chest, abdomen, and pelvis detected no lymph node lesions around the rectum or metastasis to other organs.
The patient underwent transanal endoscopic microsurgery for a suspected diagnosis of rectal stromal tumor. We excised the full-thickness of the rectal wall excision with a 1 cm safety margin of normal mucosa around the tumor. The wound in the rectal wall was closed with a running suture. Macroscopically, the resected specimen showed a brown mass 2.5 cm in maximum diameter, with a central ulcer, an ill-defin

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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 9-year-old female patient reported to the Department of Pedodontics and Preventive Dentistry, Yenepoya Dental College, Mangalore, after sustaining an uncomplicated crown fracture to her maxillary left central incisor while playing about 24 hours ago.
The fractured tooth fragment was recovered by the patient at the site of the injury and she had kept it in an empty box. Clinical examination revealed that the teeth had fracture of the incisal angle involving the enamel and dentin []. The fractured part of the tooth was intact, with some crack and craze lines
[]. No abnormal mobility of the injured tooth was recorded and the surrounding tissues were healthy.
A periapical radiograph showed that the root formation was complete and there were no other injuries. The tooth fragment was checked for the fit with the tooth and immediately maintained in normal saline.
The treatment options were presented to the patient and her parents, which included a) no treatment; b) crown build up with composite; c) reattachment of the fractured fragments. After some deliberation about the advantages, disadvantages and prognosis, the patient opted to have tooth fragment reattached.
The tooth fragment was analyzed and tried intraorally to check for proper positioning and fit with the fractured coronal structure. The operating field was isolated with rubber dam; the fractured fragment and the tooth surface was treated with 37% phosphoric acid, followed by rinsing. The adhesive system Excite (Vivadent, Liechtenstein) was applied to the fragment and the tooth, followed by placement of a small increment of flowable composite resin, Tetric flow (Vivadent). The fragment was properly positioned on the fractured tooth surface, excess resin was removed and the area was light cured for 60 seconds while the fragment was held in place under pressure.
Margins were properly finished with diamond finishing burs and polished with a series of soflex disks. The immediate postoperative view [

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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 12-year-old Caucasian boy presented with a history of pain and swelling in his left knee joint for 3 years for which he had received no previous treatment. His physical examination revealed a soft, non-tender, palpable 3 × 4 cm mass on the medial aspect of his left knee. In full flexion the mass appeared more pronounced. He denied any history of trauma and there was no effusion in his knee, with the joint not showing any signs of instability; he also had a full range of knee motion and normal strength in the lower extremities. McMurray and Apley tests were negative. There was no difference in leg length and there were no cutaneous lesions. Laboratory tests, including a complete coagulation profile, were all within normal range and his medical, developmental and family histories were unremarkable.
Plain radiographs and magnetic resonance imaging (MRI) scans were obtained (Figures , and ). The anteroposterior and lateral radiographs of the left knee showed no abnormality, especially no signs of phleboliths but the MRI scan showed a well-defined mass located within the suprapatellar pouch, but infiltrating the vastus medialis muscle. The mass appeared lobulated in contour with internal septae. On T1-weighted images the lesion had a low or intermediate signal and was not clearly distinguishable from adjacent muscles (Figure ). On T2-weighted images the mass had a signal intensity brighter than fat with thin fibrofatty septae of low-signal within the lesion (Figures and ). The differential diagnosis mainly included pigmented villonodular synovitis (PVNS) and synovial sarcoma.
Due to the differential diagnosis, an incisional biopsy was performed first, strictly according to the guidelines of orthopaedic tumour surgery. The biopsy specimen was 4 cm in diameter, measuring synovial tissue. An intraoperative frozen section showed a hemangioma with huge, cavernous spaces but also containing capillary vessels. Because of the diffuse extension of the hemangioma, angiography wa

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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:
This publication of this case was approved by the Ethics Committee of Beijing Friendship Hospital and written consent was obtained from her parents for the purpose of publication of case details and images.
A 47-year-old woman with a known trisomy 21 syndrome was about 155 cm tall and weighed about 80 kg. She was diagnosed with a mental retardation grade 2 and had an intelligence quotient of 23. In this time, she was admitted to hospital due to an esophageal foreign body for 3 days. The foreign body, a Chinese date seed, was stuck at the sternal angle level and was suspected to puncture the esophagus and compress trachea, causing moderate wheezing symptoms. For this reason, an urgent procedure to remove the foreign body was required.
The patient was obese with a body mass index of 33.2, was well unable to obey orders and did not cooperate with the examination due to mental retardation. Her tongue was hypertrophic and prominent in the oral cavity. Due to the deformed jaw, mouth opening was significantly limited, with an approximately 3 cm of inter-dental interval. The neck activity was also limited and the width of the chin was only about 4 to 5 cm. The computed tomography images showed thick neck, small jaw and bad cervical alignment (Fig. ). In the view of these risk factors, difficult airways were predicted.
Because patient did not cooperate, general anesthesia was needed before the airway was established. Given that patient had a high risk of difficult airway managements after anesthesia induction, and a possibility for the occurrence of “can’t intubate, can’t oxygenate (CICO)” situation after failed intubation, according to the current difficult airway management guideline of the American Society of Anesthesiologists,[ it was planned to firstly insert an intubating laryngeal mask airway (LMA) with general anesthesia to quickly establish an effective airway and then perform tracheal intubation through the intubating LMA using the flexible fibers

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


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

[User]
RADIOLOGY NOTE:
A 34-year-old Caucasian female presented to the emergency department with complaints of right hemiparesis, numbness, dysphagia, and ataxia. These complaints began as numbness over her right scapular area two weeks prior, and the numbness later progressed to include the right leg. Additionally, she reported five days of waking up during the night with severe headaches. Although she reported a history of migraines, which were usually accompanied by an aura, she stated that these new headaches were different in nature. She also had no known allergies and no previous surgeries. Her mother had a history of breast cancer, and her father had a history of ischemic heart disease. A review of systems was otherwise negative. After workup in the emergency department and consultation by neurology, she was referred to neurosurgery for management of a high-grade brainstem tumor.
Examination
On initial presentation, the patient was alert and oriented to person, place, and time with a Glasgow Coma Scale (GCS) score of 15. Her pupils were equal, round, and reactive to light. Cranial nerves II-XII were grossly intact. Motor testing revealed that strength was 5/5 in both upper and lower extremities. Pronator drift was noted in the right upper extremity. Dysmetria was noted in the right upper extremity during finger-to-nose testing, and discrimination of fine touch was subjectively diminished on the entire right side from the zygomatic process to the foot. Patellar reflexes were 3+ bilaterally. Over the course of her initial admission, the patient demonstrated a progressive decline, to include mild left facial droop, dysarthria, and a worsening dysphagia. A percutaneous endoscopic gastrostomy (PEG) tube was placed because the patient was unable to swallow without effort. These findings continued until her initial discharge. Upon readmission, the patient displayed similar findings. Left lower quadrant abdominal pain radiating to the shoulder and acute numbness of the left chest and shoul

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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.