[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, 70 kg male patient presented in emergency department with complaints of acute onset vertigo, headache and ataxia and was diagnosed to have a posterior fossa tumour on contrast enhanced computed tomography scan (head). He was subsequently worked up for elective craniotomy and excision of tumour the next morning. His routine investigations and vital parameters were found to be within normal limits. As part of pre-operative monitoring, a subclavian vein central venous cannulation by infraclavicular route was planned. A central venous catheter (16-18-18Ga, 7 Fr, 20 cm, triple lumen; certofix, B Braun) was inserted via right subclavian vein by Seldinger technique under aseptic precautions by the anaesthesia registrar in the operating theatre with HR, NIBP, SPO2 and ECG monitoring. Passage of the catheter was smooth and unimpeded. There was a good central venous pressure (CVP) waveform and good back flow of blood on aspiration from all the three lumens. The rest of the general anaesthesia and surgery were uneventful. CVP readings were taken 30 min apart and each time a good waveform was noted. As part of routine protocol, a portable chest X-ray was performed before shifting the patient to the neuro-intensive care unit for further monitoring and observation. On reviewing the chest X-ray by the anaesthesiologist, the CVP catheter was found to be internally rotated inside the right proximal internal jugular vein. However, it followed the normal path of right brachiocephalic vein to superior vena cava.
Since blood could be aspirated from all the three lumen ports, central venous pressure was measured with a normal CVP waveform and IV fluids/drugs could be infused via the same catheter, we intended to continue with the same central line for the further management of patient. Further course of the patient in the hospital was uneventful. CVC was removed from its site in the neurosurgery-ward when the patient was planned

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


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

[User]
RADIOLOGY NOTE:
A 38-years-old female reported to the Department of Conservative Dentistry and Endodontics with the chief complaint of pain in mandibular left first molar tooth. On clinical examination, mandibular left first molar was found carious. On radiographic evaluation caries with mandibular, left first molar was seen involving pulp, so routine root canal treatment was undertaken. Access opening was done under rubber dam application. Patient was having extreme salivation, coughing and gagging reflex. While taking the radiograph for working length, frame was removed as it was rigid metallic frame. The patient suddenly got gagging reflex and then coughed and moved. During coughing the 15-number K file which was snugly fitting in the root canal slipped on the floor of mouth and was swallowed by patient unknowingly. The patient complained of excessive gagging with the sensation of something sticking in her throat. Patient was instructed to cough forcefully, but file could not be retrieved. Thorough examination was done using tongue depressor but was not productive. There was no evidence of airway compromise, respiratory distress, or abdominal tenderness. Patient was informed about the accident and was assured.
Patient was taken to Radiology Department, a chest and an abdominal radiographs were taken. Chest radiograph was clear (). The file was detected in abdominal radiograph (), suggesting its presence in lower gastrointestinal tract at lumbosacral level, which was confirmed by a radiologist. The patient was informed and reassured. A diet high in roughage was prescribed to aid in the passage of instrument through intestinal tract. She was warned of the possible symptoms, that might indicate a perforation of the intestine and was told to examine her stools for file at every bowel movement. Patient was kept under close observation. Her progress was followed by abdominal radiograph on the 3rd day. Meanwhile, patient had no symptoms like blood in stools, and abdominal tenderness. T

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


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

[User]
RADIOLOGY NOTE:
A 21-years-old Caucasian woman presented to a private dental clinic with a chief complaint of asymptomatic swelling in the gingiva observed four years prior. A gradual increase in size and no history of previous treatment were also reported during the anamnesis. The patient signed the informed consent, which represents the ethical approval of the faculty committee. Her medical and socio-economic histories were not contributory. The extra-oral evaluation did not reveal changes. The intraoral examination revealed a sessile nodule with a color similar to that of the mucosa and a focal erythematous area with a fibro-elastic consistency measuring 1.5 cm in the largest diameter extending from the inferior right lateral incisor to the inferior right first premolar. The lesion involved the vestibular and lingual gingiva, causing displacement of the inferior right canine (Fig. ).
Panoramic reconstruction and parasagittal slices of the Cone Beam Computed Tomography (CBCT) showed a slightly superficial hypodense area between the inferior right lateral incisor and inferior right canine with reabsorption of the alveolar crest (Fig. ). Based on the clinical and immunological aspects, the main diagnosis hypotheses included peripheral ossifying fibroma, peripheral giant cell lesion, and ancient pyogenic granuloma. The peripheral odontogenic tumors were also included as a differential diagnosis. An excisional biopsy was performed and a clear separation was noted between the lesion and mandible bone during the trans-surgical approach. The histopathological analysis revealed a well-circumscribed proliferation comprising numerous islands and strands of epithelial polyhedral cells with well-defined borders and marked round nucleus in the connective tissue under the mucosal epithelium. Numerous nests, cords, and small islands of polyhedral cells with clear and vacuolated abundant cytoplasm were observed interspersed with the amorphous eosinophilic deposits (Fig. ). Immunohistochemistry w

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


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

[User]
RADIOLOGY NOTE:
In May 2011, a 34-year-old male was treated for an ACL rupture using a hamstring graft fixation associated with a partial internal meniscectomy. The hamstring grafts were fixated using a transfixation system in the femur and a biodegradable screw in the proximal tibia. The patient’s post-operative course was uneventful, and he returned to sports without further difficulties. In July 2014 (3 years and 6 months following the initial operation), a tibial cyst suddenly presented and was first treated conservatively, including physical therapy and non- steroidal anti-inflammatory drugs, until it became symptomatic. There were no signs of clinical or laboratory infection. Magnetic resonance imaging (MRI) showed a 10 mm x 25 mm cyst lesion filled with liquid (). In November 2014, an open excisional biopsy and primary closure surgery were performed at a different medical center. The material was sent to a pathology laboratory and resulted in a “ganglion cyst.” 2 months after surgery, a painful mass recurred over the anteromedial proximal tibia measuring approximately 10 mm x 25 mm. A gelatinous substance was suctioned from the mass, in a sterile environment, consistent with a recurrent ganglion cyst. 40 days following this event, the cyst had reappeared and measured approximately 50 mm χ 40 mm (). At that time, the patient was referred to our hospital.
The physical examination revealed a stable knee and a complete range of motion. An approximately 50 mm χ 40 mm palpable mass was evident at the anteromedial proximal tibia. MRI images were consistent with a homogeneous, fluid-filled cyst with a connection toward the tibial tunnel ().
On April 2015, a second open resection and an exploratory arthroscopy were performed. The cyst was approached through the previous skin incision. The mass was meticulously dissected, with care not to injure the cyst or its stalk. After the cyst was isolated from the surrounding soft tissue, it was brought back to its original placing at the tibia

[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 11-year-old boy presented to the outpatient clinic with complaints of pain, deformity and shortening of the left arm (Fig. ). Physical examination revealed pathologic motion at the proximal part of the left arm and 8 cm shortening of the left upper extremity compared to the opposite side. According to his past medical history, he had admitted to another institution 4 years before due to pain, swelling and deformity on his left shoulder and upper arm. An expansile, lobulated lytic lesion in the proximal metaphysis of the humerus had been detected on radiographic evaluation (Fig. ). He had been initially treated by en bloc resection and reconstruction with cortical strut allograft in this center (Fig. a). The histopathological results of the tissue samples had been found to be consistent with ABC. Serial follow-up radiographs showed failure of the fixation with nonunion of the proximal humerus (Fig. b). Second surgical intervention including excision of the graft material and implants had been applied in the same center, 1 year after the index operation. The defect area had been filled with calcium phosphate allografts, and patient’s arm had been immobilized in a sling. However, union of the humerus could not be achieved.
Radiographs at the presentation to the author’s institution revealed evidence of proximal humerus nonunion with a large defect (Fig. a). His shoulder range of motion was completely restricted with unlimited elbow motion. His neurovascular examination was normal.
Surgery was performed under general anesthesia. The patient was positioned at beach chair position, and deltopectoral exposure over the old scar tissues was used to reach the humerus. Curettage of the dead space, which included the previously inserted allografts, was performed carefully. However, it could not be possible to remove all allograft materials completely due to their adhesions to the surrounding tissues. Then, reconstruction of the defective area with fibular autograft was planne

[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 male patient presented with a large swelling on the left side of neck along with the complaints of difficulty in breathing and swallowing. The patient was a previously diagnosed case of congenital cystic hygroma [], who had undergone surgical excision twice at the age of 6 months and 8 years, only to gradually develop recurrent swellings at the same site. These swellings were treated with bleomycin sclerotherapy every 3 years. However, patient had an apparent “non-response” to sclerotherapeutic agent such as bleomycin since past 4 years, and hence was referred to us for a contrast-enhanced computed tomography (CECT) to ascertain the cause of increasing size of swelling and worsening of symptoms. The clinical provisional diagnosis was a recurrence of cystic hygroma in the patient.
CECT of neck and thorax revealed a large non-encapsulated mass located in the left lateral aspect of neck and chest wall and left axilla []. The mass was a predominantly fat attenuation and contained few areas of coarsely calcified tubular soft tissue structures in the posterior aspect of neck and chest wall []. Few linear enhancing soft tissue components were also seen within the lesion.
The lesion was diffusely infiltrative, and was seen extending from subcutaneous planes into inter- and intramuscular plane without respecting soft tissue planes, with subsequent fatty replacement of left sternocleidomastoid, trapezius, posterior paravertebral, and scalene muscles []. The lesion extended from scalp in left occipital region to D7 vertebral level along the posterior thoracic wall. No bony erosion was observed. Anteriorly, it reached up to the subcutaneous plane in neck and left anterior chest wall, abutting and narrowing left external jugular vein. Left axillary vessels were narrowed. Superomedially, lesion infiltrated into the floor of mouth, left supraglottis, and glottis, causing deviation of airway toward right side along with significant narrowing of airway and obliteration

[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 15-year-old female slipped down during gymnastics practice and had a right knee pain localizing to the lateral side. She went to a hospital 5 days after the injury and was diagnosed with OCD of the LFC and anterior defect with posterocentral shift of the discoid lateral meniscus. The patient underwent arthroscopic partial meniscectomy with repair of the lateral meniscus and multiple drilling at the LFC 2 weeks after the injury at the hospital. During 3 months after the surgery, however, her pain had worsened and she could not walk well.
Eventually, the patient was transferred to our clinic at 4 months after the first surgery. Physical examination revealed tenderness on the lateral joint line of the right knee and positive McMurray test on internal rotation of the tibia. Plain radiographs of the right knee showed an obvious OCD lesion with a large bony defect in the LFC and narrowing of the lateral joint space (). Standing alignment of the lower legs demonstrated about 2 degrees of slight valgus of the right knee compared to the left knee (). Magnetic resonance imaging (MRI; Intera Achieva, Philips, Amsterdam, The Netherlands) of the right knee revealed a 2.5 cm×3 cm sized lesion mainly in the posterolateral area of the LFC (). The lesion progressed more compared with the preoperative initial MRI obtained 5 months ago (). The MRI also demonstrated a complex tear of the lateral meniscus where flaps adhered to the OCD lesion of the LFC (). The patient underwent arthroscopic total meniscectomy of the lateral meniscus and debridement of the OCD lesion first. At that time, since the torn lateral meniscus showed severe plastic deformation, we considered there was no regrowth potential of the remnant lateral meniscus. The OCD lesion treated with multiple drilling at another hospital showed a large osteochondral defect without any regeneration (). Therefore, we planned to perform simultaneous osteoperiosteal autologous iliac crest graft implantation for the massive OCD les

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


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

[User]
RADIOLOGY NOTE:
We reported a 32-year-old female patient who came to the hospital after being referred from another hospital to have further treatment for a soft tissue tumor of her right thigh. She complained of a slowly enlarging lump on her right proximal thigh in the last 4 months, with intermittent sub febrile temperature and mild but slowly progressing pain. She was unable to walk unsupported. Physical examination showed a large fusiform soft tissue mass in the right thigh with a diameter of 84 cm, limited range of motion, moderately firm in palpation, and tenderness of the right hip (). In the previous hospital, the patient underwent a hip radiograph which showed a large soft tissue mass on the right hip and was assessed as a soft tissue tumor. Written informed consent was obtained from the patient for publication of this case report and the patient's identity was being kept anonymous.
An AP radiograph of the right femur was obtained, showed a large lobulated soft tissue mass on the lateral side of the proximal femoral region and was assessed as a soft tissue tumor (). However, there was also central erosion and destruction of the femoral head as well as the acetabular roof. Contrast-enhanced MR showed a large rim-enhancing complex cystic mass with multiple septations and thin walls at the lateral side of the proximal femoral region, superficial to the bone, measuring 18,3 cm x 10,6 cm x 8,7 cm. The lesion was extending to the right gluteal region. However, there was also a small fluid collection with a similar pattern noted at the anteromedial part of the right hip. Enhancing bone marrow edema with an erosion of the right hip joint was also identified. Based on the enhancement pattern, there was a connection between the large cystic mass with the right hip lesion ().
Laboratory test showed microcytic hypochromic anemia, increased white blood cells (WBC) count, (15.150/μl, normal range: 5.000–10.000/μl),

[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 21-year-old female involved in a high speed, helmeted motorcycle accident. After initial evaluation at a community hospital she was transferred emergently to a Level 1 care center. On arrival she was evaluated by the orthopedic and trauma surgery teams, and noted to have a severely deformed left lower extremity with a significant soft tissue injury and active proximal bleeding. She was taken to the operating room where bleeding was isolated to small branches of the femoral artery at the level of an inguinal crease laceration. Hemostasis was obtained by the trauma surgery team. Concurrently, the orthopedic surgery team placed a spanning external fixator across her comminuted, Type IIIB open femur fracture. Proximal fixation was within the proximal femur and distal fixation in the tibia, spanning the knee joint (Figure ). Of the pins within the femur, the proximal pin was placed using standard percutaneous technique and the distal pin placed under direct visualization through the large soft tissue defect (Figure ). Prophylactic four compartment leg fasciotomies were performed as well.
At the time of her index procedure distal pulses were absent and an on-table angiogram was performed. Initially, this showed limited flow below the level of the trifurcation, which improved with application of local vasodilatory agents. Over the preceding 12 hours her dorsalis pedis pulse was lost and a CT angiogram performed. This study suggested the SFA was lying lateral to the distal of the two femoral ex-fix pins, becoming kinked as the anatomic course of the vessel is medial to the femur. The altered path of the SFA was also recognized on retrospective review of the initial angiogram (Figure ). We emergently returned to the operating room and confirmed the findings of the CT angiogram, with a palpable SFA pulse noted to the level of the pin then no distal pulse. The pin was removed after retraction of the vessel, then replaced through the same location in the bone 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 37-year-old male presented with a mass on the right side of the face, which had persisted for five years, with accelerated growth for one year, causing serious facial deformity and difficulty in eating. The painless mass was ~16×16 cm and occupied the right maxilla and the nose, extending superoinferiorly from the right orbit and infraorbital rim to the bilateral alveolar bone and hard palate. Part of the mass displaced the teeth and protruded outward from the mouth, with a rough surface that released a purulent discharge upon palpation. No superficial ulceration, sinuses or fistulas were observed on the overlying skin, which did not adhere to the mass. The patient had bilateral nasal obstruction with effluvial secretion and normal vision, even though the infraorbital rim disappeared, as the mass displaced the optic nerve ().
Enhanced computed tomography revealed that an irregular and low-density shadow without obvious enhancement was displaced in the maxillae, and that a high-density shadow was interspersed in it. Magnetic resonance imaging identified that the well-circumscribed tumor had already obliterated the maxillae, the maxillary process of the right zygomatic bone, part of the left maxilla, the ethmoidal sinuses, the sphenoid sinus and the nasal cavity. The nasopharyngeal cavity and the left maxillary sinus were observed to be narrow, and the turbinate bones and the nasal septum had been resorbed due to the tumor pressure. Although the large mass grew into the intracranial cavity through a bone defect in the sphenoid wing caused by tumor pressure-induced resorption, the tumor was present with well-defined borders under the dura mater (). According to the clinical and imaging examinations, it was hypothesized that the tumor may be a mesenchymal benign tumor with malignant transformation.
Following a tracheostomy, the patient underwent right radical maxillectomy and left partial maxillectomy, which included the partial right zygomatic bone and zygomatic alve

[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 girl, known to have homozygous sickle cell disease (HBSS) presented to the SCU after having vomited twice that day. This was non-bilious and there was no history of haematemisis. However she reported 5 episodes of watery stool, which was said to be normal in color but there was no associated abdominal pain. She also complained of frontal headache associated with nasal congestion with a bloody nasal discharge. She had experienced one episode of nosebleed and but there was no history of fever or cough. Of note, she had not yet attained menarche.
In her past medical history it was noted that she had defaulted from follow up at the Sickle Cell Clinic for 13 years and had only one visit the month prior to this presentation. She had been diagnosed at 21 months of age following an episode of dactylitis. There were no recorded admissions to the day hospital at the SCU, neither was there a history of serious life threatening complications such as acute chest syndrome and stroke. She reported no recent admissions to hospital the last being 15 years prior. However she experienced pain mainly to lower back and knees and ankles once every 4 months and had not had any episodes in the previous 4 months.
She was treated at the SCU with codeine 40 mg orally and maintained nil by mouth. She was started on intravenous fluids at 100 mL/hour, and then referred to the Accident and Emergency Unit of the University Hospital of the West Indies. While at the emergency room she reported having pain to the left shin. Of note this patient has had no previous history of thrombosis neither is there is a family history of thrombosis.
On physical examination she had a normal mental state. Her pulse was regular and apex was not displaced. A systolic murmur was auscultated at the apex. Her chest was clear with adequate air entry on auscultation. Abdominal examination revealed hepatomegaly with 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 57 year old female patient visited the Department of Surgery, Incheon St. Mary's Hospital complaining of postprandial epigastric discomfort. An esophagogastroduodenoscopy (EGD) and abdominal computed tomography (CT) scan were performed. On EGD finding, a submucosal tumor was found at the posterior wall of the gastric antrum (), and it was revealed by CT scan to be a 10 ×8 cm sized heterogeneously enhanced, well circumscribed solid mass arising from the posterior wall of the gastric antrum (). There was no metastatic lesion in other organs. She was recommended an open resection, but insisted on laparoscopic resection. Therefore, she underwent laparoscopic resection after providing informed consent. Under general anesthesia, the patient was placed in the reverse Trendelenburg position with her legs apart. The operator was positioned on the right side, and the first assistant was positioned on the left side of the patient. The camera operator was positioned between the legs of the patient. A 10 mm trocar was inserted through the umbilicus for the camera. A 5 mm trocar and a 12 mm trocar on the right upper abdomen were used as working channels for the operator. Another 5 mm trocar and a 12 mm trocar on left upper abdomen were used for the first assistant. The greater omentum was opened with ultrasonic shears and the mass was identified. Great care was taken to avoid touching the mass directly with the laparoscopic instruments. There was no direct invasion to the pancreas (). The right gastroepiploic vessels were identified and doubly ligated with clips and the duodenum was resected with a laparoscopic linear stapler. The right gastric vessels and descending branches of the left gastric artery were identified and doubly ligated. The stomach was transected at 4 cm proximal from the upper border of the mass with a laparoscopic linear stapler. The specimen was placed into a plastic bag and retrieved through the umbilical port site which was extended to a 4 cm length (). 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 71-year-old woman was diagnosed with metastatic ovarian cancer in October 2010. She had been experiencing symptoms of vaginal dryness, dyspareunia, and abdominal and lower back pain. Magnetic resonance imaging (MRI) of the pelvis demonstrated a complex adnexal mass and computed tomography (CT) imaging studies demonstrated a lesion in the upper lobe of the left lung, and an adenoma of the left adrenal gland. Transvaginal ultrasonography confirmed a multilocular mass (6.0 × 5.0 × 5.6 cm) centered in the right adnexal region. The mass had multiple irregular thick septa and a soft tissue component with definite vascular flow in the regions of echogenic soft tissue and was highly suggestive of cystadenocarcinoma. The patient underwent a laparoscopic bilateral salpingo-oophorectomy, and the surgical pathology report demonstrated ovarian high-grade serous carcinoma with extension to the fallopian tube surface and fimbrial end in the right ovary and tube, and metastatic to the omentum. In November 2010, the patient was treated with six cycles of carboplatin and paclitaxel followed by 11 cycles of paclitaxel consolidation therapy. CT imaging studies demonstrated no evidence of disease at 5 months after treatment and annually for 3 years. Three years after treatment, she presented to the clinic with increasing pain and pressure in the lower abdomen, including pain with urination. CT scans demonstrated diffuse peritoneal carcinomatosis, evidenced by multiple nodular masses noted within the peritoneum and the supracolic omentum, and small volume ascites. She was retreated with six cycles of carboplatin and paclitaxel, and restaging scans demonstrated improvement in the peritoneal carcinomatosis and no gross CT evidence of residual disease. She had no evidence of disease for 17 months, and then CT scans showed interval development of a heterogeneous soft tissue lesion in the pelvis compatible with recurrent disease. She underwent tumor reductive surgery followed by six cycles

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


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

[User]
RADIOLOGY NOTE:
Our report concerns a 51-year-old Caucasian man who was admitted to our clinic with severe abdominal pain. Two weeks prior, he had undergone an emergency operation in another hospital due to an IDSMA. Colleagues resected the dissection membrane and the SMA was reconstructed with a Dacron® patch. According to their medical history, the patient suffered from hypertension and non-insulin dependent diabetes mellitus (NIDDM). The patient was discharged free of symptoms two weeks prior to presentation in our department. Following admission to our emergency room, an immediate CT-scan and a blood test were performed, as the patient showed signs of an initiating peritonitis.The CT scan showed an isolated re-dissection in the proximal part of the SMA with embolization of a distal branch causing an almost complete decline of right hand side intestinal perfusion. Aggravating, the right hepatic artery originated from the proximal part of the SMA as an anatomical variant. The origin was located directly in the region of the dissection entry. Figure shows the major findings of the CT scan on admission. As endovascular therapy had a high risk of post interventional liver failure, the decision for open surgery was taken at an interdisciplinary level. Blood test results showed a normal serum lactate level, while C-reactive protein (CRP) and leukocytes (WBC) were raised. Thus, the patient had to be transferred urgently to the operating theatre.We resected the dissection membrane from the origin of the SMA and a selective embolectomy of the arcade arteries was performed. The SMA was re-constructed using a venous interponate. Thus, for the interposition the saphenous vein from the right upper leg was used. The patient was admitted to the intensive care unit (ICU) with an abdomen apertum. As hypercoagulability occurred during the operation and we suspected a heparin induced thrombopenia (HIT), anticoagulation was managed using Argatroban with an activated partial thromboplastin time (aPT

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


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

[User]
RADIOLOGY NOTE:
A 70-year-old man presented one year following a right TKA performed for knee osteoarthritis. His surgery had taken place at another hospital, and he had made an initially uneventful recovery with a good clinical range of motion and satisfactory postoperative radiographs. At 9 months, however, he began to develop medial and lateral retinacular and deep knee pain, without associated knee swelling, warmth, or wound disturbance. His symptoms steadily worsened, particularly with load-bearing activity and flexion past 80 degrees.
On examination there was no effusion or warmth present in the knee, and the wound was quiescent. There was generalised medial and lateral retinacular and joint-line tenderness. The knee was stable in flexion and extension with an active range of motion of 0–80 degrees. Passive range of motion was 0–105 degrees. Motion was limited by medial and posterior pain. Other lower limb examination was normal. Blood inflammatory markers were all within the normal limits, repeat radiographs revealed no evidence of component loosening, and a three-phase bone scan found no increased activity in either the dynamic or blood pool images. A TC 99m leucocyte cell scan was also negative. The patient underwent exploratory knee arthroscopy. There was no effusion present or evidence of synovitis, and there was no significant capsular scarring/contracture. The components were intact, without evidence of particulate matter or surface scratching, and there was no evident osteolysis at the bone/implant interfaces. Interposed in both the medial and lateral compartments and extending posteriorly between the femoral component and the polyethylene spacer were ridges of meniscus-like tissue (Figures , , , and ). These were resected using a chondrotome and samples sent for analysis.
Histopathology revealed meniscus-like tissue with fibr-ocartilaginous cells in a scanty matrix surrounded by collagen wavy bundles without significant polyethylene particulate debris. Microbiologica

[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 4-month-old girl is referred for a brownish-black lesion on the posterior trunk present at birth []. A diagnosis of GCMN was made; brain and whole spine MRI was normal.
The patient received follow-up every 6 months, with progressive loss of pigment. There is no halo phenomenon, atrophy, or any other significant change []. Several biopsies showed persistence of CMN on the dermis without cellular destruction, inflammation, or fibrosis.
Spontaneous regression rarely occurs in pigmented lesions and is mostly associated with the development of a depigmented halo; however, there are reports of CMN that show regression without a peripheral halo or vitiligo.[] Current literature suggests that there is a decrease in melanin production rather than an immunologic reaction, since biopsy specimens show amelanotic cells without an inflammatory infiltrate.[] We were able to find only one report that showed inflammation, the one by Gass et al.,[] where a neonatal biopsy exhibits an inflammatory infiltrate that was no longer present when the nevus had regressed. However, the CMN in this report had a large ulceration and healed with a desmoplastic reaction; as these features were not present in either one of our cases, we cannot hypothesize as to this mechanism of involution of GCMN.
A report by Zack et al.[] shows hyperpigmentation as a residual sign after the involution of a GCMN. A biopsy when pigmentary regression had not yet occurred showed no inflammation. The authors present several theories as to why the dermal nevus cells lose their ability to produce pigment, including aging and a hormonal factor; however, an early autoimmune response cannot be ruled out.
The biopsy samples in both our cases were taken when clinical involution had occurred, and the persistence of nevus cells without an inflammatory infiltrate was seen. Therefore, the evidence in our report supports the hypothesis that there is a decrease in melanin production rather than an autoimmune reaction that destro

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old 66 kg male patient presented to us with h/o fall followed by difficulty in opening the mouth of 10 days duration. He had no history of any prior systemic illness. On clinical examination, he was conscious, afebrile with stable vitals. The patient was an occasional wheezer. He had restricted mouth opening with an inter incisor distance of <0.5 cm. There was no clinical evidence of head, chest and abdominal injuries. Routine laboratory evaluation showed hemoglobin of 9 g%, random blood sugar of 93 mg%, serum creatinine of 0.8 mg%. A routine, electrocardiography, X-ray chest, an echo heart were normal. A computed tomography scan of the face showed bilateral mandibular condylar fracture dislocation. He was posted for reduction of dislocation with internal fixation in the dental chair. A preoperative nebulization with budesonide and levosalbutamol was done half an hour prior. Monitoring included pulse oximetry and noninvasive blood pressure. As the surgery involved reduction, screwing of both maxilla and mandible in both sides, a plan of bilateral maxillary and mandibular nerve blocks by extraoral approach was made. A local anesthetic solution of 20 ml of 0.5% bupivacaine with 0.1 ml of sodium bicarbonate was made. After aseptic precautions, with the patient sitting, the condylar notch was identified. The needle was inserted into the space below the midpoint of the zygomatic process till the needle hits the lateral pterygoid plate. After that, it was slided posterior and superior to get paresthesia of the mandibular region, and 3 ml was deposited. The needle then was withdrawn till subcutaneous plane to go back and hit the pterygoid plate. Then for accessing maxillary nerve, the needle was slided anterior and lower to deposit around 3–4 ml. The procedure was repeated for other side, but the right side had a distorted anatomy, which made identification of condylar notch difficult. Still we managed to elicit paresthesia and administer the block []. Anesthesia

[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 6-year-old male with a medical history of post streptococcal glomerulonephritis presented to the hospital with clinical symptoms of headache and pelvic pain for 2 days.
Haematuria was noted in his urinalysis. The patient’s symptoms persisted over 2 days progressing to fever and suprapubic pain. An ultrasound of the lower renal tracts () revealed a bladder volume of 82.05 millilitres (mL), bladder wall thickening and fine mobile echoes within the bladder. The upper renal tracts demonstrated bilateral hydronephrosis () and bilateral renal enlargement (right kidney 11.61 centimetres [cm], left kidney 10.94 cm). Minimal free fluid was noted in the pelvis; however, no prostatic lesion was appreciated on the transabdominal ultrasound.
The voiding cysto-urethrogram was normal with no features of vesicoureteral reflux or posterior urethral valves. Magnetic resonance imaging (MRI) of the thoracic and lumbar spine () was conducted to exclude a neurological aetiology. This demonstrated no features of spinal dysraphism or spinal cord abnormality; however, bilateral hydronephrosis was evident as documented on ultrasound. Incidentally, the MRI also demonstrated a homogenous cystic lesion within the prostate gland () with mass effect on the bladder base. Only limited sequences through the prostate were obtained and contrast was not administered. Given the background of failure to respond to medical treatment and the progressive symptoms, a PA was considered as the likely aetiology for the obstructive uropathy.
The patient underwent drainage of the abscess. Staphylococcus aureus was cultured and intravenous antibiotics were administered. The blood cultures and nasal swabs excluded haematogenous and distant focus of infection. Improvement in symptoms was noted following drainage of the abscess. On follow-up, the patient demonstrated a clinical response to treatment with resolution of the symptoms. Follow-up sonographic images were not available as they were performed at another in

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


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

[User]
RADIOLOGY NOTE:
An 83-year-old woman suffered from nausea and posterior headache with a history of hypertension, peripheral artery disease, and hemodialysis for 16 years. An emergent magnetic resonance imaging revealed a small infarction in the right cerebellum, and the cardiologist pointed out blood pressure difference between the right upper arm (88/55 mmHg) and the right lower leg (152/76 mmHg). Contrast-enhanced computed tomography (CT) was performed on suspicion of aortic dissection and revealed that the intimal flap was recognized in the distal ascending aorta through the aortic arch but was not found in the mid-ascending aorta (). She was diagnosed as type A aortic dissection with an atypical form and was transferred to our hospital for further treatment. On arrival, she was fully alert, and her hemodynamic state was stable. The CT also revealed an extravasation of contrast medium to the posterior wall of the proximal ascending aorta () with a slight pericardial effusion. At the emergency room, she complained of chest oppression, and her vital status rapidly deteriorated. A repeat transthoracic echocardiography revealed an increasing effusion in the pericardial cavity. She was immediately transferred to the operating room under a diagnosis of rupture of the aortic dissection. A profuse amount of pericardial effusion was bloody, but the ascending aorta was not bluish. After pericardial effusion evacuation and clot removal, excess bleeding was not found. Because the ascending aorta seemed unruptured, we started core cooling through the ascending aorta to bicaval bypass. When we divided the posterior wall of the ascending aorta, fresh bleeding came out. We hurried a cooling under compression around the posterior wall of the ascending aorta, and circulatory arrest was induced at the tympanic temperature of 25°C. A retrograde cerebral perfusion through the superior vena cava was immediately started. The ascending aorta was opened, and we found a circumferential detachment of the

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


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

[User]
RADIOLOGY NOTE:
The patient is a 71-year-old female with a past medical history of paroxysmal atrial fibrillation treated with apixaban, complete heart block status-post permanent pacemaker placement in 2008, hypertension, and congestive heart failure (CHF). She was admitted to the hospital for a CHF exacerbation after presenting with several weeks of lower extremity edema, fatigue, and a dry cough. Just prior to her hospitalization, she had undergone an outpatient computed tomography (CT) heart scan with a total calcium score of zero. This scan incidentally noted a 3.7 × 2.5 cm well-circumscribed, hyperdense lesion at the anteroinferior aspect of the interatrial groove and to the right of the coronary sinus ( and ).
During her hospitalization, she underwent a CT angiogram (CTA) of the chest to further characterize this lesion. This demonstrated a hyperdense, ovoid, circumscribed structure along the inferior surface of the heart with imaging features most suggestive of a cystic tumor of the atrioventricular (AV) node ( and ). A CTA of the chest additionally showed cardiomegaly, a moderate-sized pericardial effusion, and small bilateral pleural effusions.
The patient underwent cardiac magnetic resonance imaging (MRI), which showed findings compatible with hypertrophic cardiomyopathy as well as the interatrial lesion centered within the region of the AV node. This was interpreted to be consistent with an AV node inclusion cyst ( and ). She also underwent a transthoracic echocardiogram (TTE) that demonstrated severely reduced systolic function with a left ventricular ejection fraction (EF) estimated at 20–25%. This was in contrast to a normal EF (60–65%) on a TTE four months prior.
She underwent diagnostic left heart catheterization, which showed normal coronary arteries. She was medically managed for CHF exacerbation with diuresis and was discharged to home after a five-day hospitalization. Repeat TTE one month after discharge showed normal global left ventricular systolic function w

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


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

[User]
RADIOLOGY NOTE:
A 2.8 kg, 4-day-old boy, the second child of non-consanguineous parents, was referred to our institute for the management of respiratory distress and septicemia. He was born by normal vaginal delivery after an uneventful antenatal period, and was mildly depressed at birth with Apgar score of 1 and 6 at 1 and 5 minutes respectively. He was resuscitated with bag and mask to which he responded and then was shifted to the intensive care unit on oxygen hood. His condition improved slowly and he was weaned off oxygen over 72 hours. He was administered expressed breast milk feeds on day four but developed choking, aspiration of feeds and respiratory distress.
On arrival, the baby was floppy, had a weak cry and shallow breathing. The neonate's trachea was intubated with a 3.5 mm endotracheal tube (ETT) and fixed at a length of 9 cm. Lungs were ventilated with help of a pressure controlled ventilator with FiO2 0.7 and moderate pressures. Chest X-ray showed aspiration pneumonitis in the right upper lobe. Patient was started on second line antibiotics, Cefotaxim and Amikacin. Blood culture grew Klebsiella pneumonei and antibiotics were changed to meropenem according to the sensitivity. Patient developed multiple episodes of desaturations associated with dislodgement of ETT to the esophagus. It was observed that when ETT was pushed further in the trachea, the baby ventilated better and there was no ETT dislodgement []. This raised the possibility of a congenital anomaly of the airway.
Further evaluation confirmed a small patent ductus arteriosus and bilateral retinal coloboma. Computerized tomography (CT) scan chest showed evidence of a defect in posterior larynx at the level of vocal cords and inflammatory changes in the left upper lingual and right lower lobe. A diagnostic bronchoscopy was done under general anesthesia to confirm the diagnosis. Patient was given fentanyl 4mcg and atropine 0.4mg intravenous (IV). Anesthesia was induced by

[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 14-year-old right-handed female fell from a 10th floor apartment, and presented to our emergency department with multiple trauma. She had no history of any previous illness or medication before the injury. She complained of pain in the abdomen, right elbow, pelvic area, and low back area. She underwent iliac artery embolization and exploratory laparotomy to repair the iliac artery and a liver laceration at another hospital, and was subsequently transferred to our emergency center for additional surgical intervention involving the pelvic bone, spine and anterior trans-olecranon fracture dislocation (). Fortunately, computed tomography (CT) confirmed that she had no brain injury and no systematic neurologic symptoms, although there was a chance fracture of the T10 vertebra. She was subjected twice to a closed reduction of the injured elbow joint, once at the first hospital, and then in our emergency room. According to the Mayo classification, the olecranon fracture was diagnosed as type IIIB. Sixteen days after the initial trauma, the anterior trans-olecranon fracture dislocation of the right elbow joint was treated by open reduction and internal fixation by applying a pre-contoured olecranon plate (Zimmer, Warsaw, IN, USA) using the posterior approach incised along the triceps, followed by application of a long arm splint ().
After surgery, the elbow was immobilized in a long arm splint at 90 degrees of flexion and neutral rotation. Starting from the 3rd postoperative day, the patient was allowed gentle exercise of the right elbow joint, but developed aggravated pain during rehabilitation at 2 weeks post-surgery. The HO was first noted in radiographs, at 3 weeks. At 10 weeks post-surgery, she had increased difficulty in moving her right elbow joint, and had reduced range of motion. The size of HO had progressed and was clearly revealed in radiographs. Physical examination revealed total ankylosis of the right elbow at 45 degrees of flexion, at post-operative 6

[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 black African girl was admitted to the emergency room of the Parakou University Hospital Center for altered consciousness and tumor of the left breast. The tumor had been progressing for approximately 6 months before admission, according to her parents. Our patient did not smoke tobacco or drink alcohol. Her medical, surgical, and psychosocial history was unremarkable. She had normal pubertal development. Her parents are of low socio-economic status. The onset of symptoms was marked by the appearance of a small nodule in her left breast, and an evolution marked by a rapid increase in the volume of the tumor, which motivated traditional herbal treatments of unknown nature. No notion of radiotherapy or previous chemotherapy was reported.
Our patient was admitted in a state of apparent death. She had no blood pressure or pulse. Her temperature was 35 °C. She had an estimated Glasgow Coma Scale of 3. She was pronounced dead on clinical examination 10 minutes after admission. Blood samples for laboratory tests of hepatic and renal function and serological tests could not be taken before she died. The parents claimed to have no knowledge of breast cancer in their family. The parents claimed to have consulted two traditional healers and an herbal treatment of unknown nature was administered to the girl, but without improving her health.
A postmortem examination of the body showed cachexia and a bulky, multinodular, exulcerated, blackish red hemorrhagic mass of the left breast, 35 cm in circumference, partially overflowing on the right hemithorax (Fig. ). A biopsy sample of the tumor mass was carried out postmortem. Histopathological examination after staining with hematoxylin and eosin showed tumor proliferation made up of anastomosed vascular networks. The tumor cells were spindle shaped, oval, or rounded in places and were not very cohesive. There was a marked anisokaryosis and numerous foci of tumor necrosis (Fig. ).
The result of a immunohistochemical ana

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


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

[User]
RADIOLOGY NOTE:
The patient’s course is outlined in Fig. .
A 58-year-old, previously healthy, white female presented to her primary care provider (PCP) with the desire to remove a right posterior scalp cyst for cosmesis. This non-inflamed, non-draining, painless, 1–2 cm cyst had been present for close to 10 years without change in size or fluctuance. The cyst was initially drained by the PCP, but, when it recurred 6 months later, the PCP excised the cyst and sent the specimen for routine pathology. The initial read of the tissue sample was high-grade invasive carcinoma with squamous features and arising in association with a PTT. Based on the pathology, the PCP referred the patient to a plastic surgeon for a more definitive excision of the lesion and repair of the defect. The lesion was excised with negative margins and pathology read as invasive high-grade squamous cell carcinoma (SCC). Eight months post resection, the lesion recurred locally along with a palpable right posterior cervical lymph node (LN). A positron emission tomography (PET) scan at that time demonstrated hypermetabolic activity in the posterior occiput and in a posterior neck LN. Fine needle aspiration (FNA) of both the primary scalp lesion and LN were completed, and pathology was reported as SCC, similar to the primary lesion.
With a working diagnosis of locally advanced SCC, the patient’s care was referred to a tertiary care center. There, a dermatopathologist re-evaluated the previous biopsy specimens and altered the diagnosis from SCC to MPTT (Fig. ). Subsequently, the patient was referred to a head and neck surgeon for modified radical posterior neck and lymph node dissection. Intraoperative findings uncovered the presence of nodal metastases to the posterior neck with extranodal extension, extensive perineural invasion of the spinal accessory nerve, and jugular venous invasion of the MPTT. After surgery, the case was discussed at a multi-disciplinary tumor board, and a common

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


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

[User]
RADIOLOGY NOTE:
A 10-month-old male patient presented with a large swelling in front of the neck associated with shortness of breath and stridor for two weeks which was worsening over time. The mother also reported regurgitation of milk from the patient’s nostrils and difficulty in feeding. The parents noticed this swelling soon after birth, prompting them to seek medical advice. The primary care physician diagnosed the swelling as a case of cystic hygroma based on the clinical features. Hence, the patient underwent two sessions of sclerotherapy with bleomycin, four months apart. However, no improvement was seen. So the primary care physician referred him to a tertiary care hospital for further evaluation and management.
In the tertiary care hospital, the patient was re-evaluated through a detailed history and thorough general physical examination, which revealed a fluctuant cystic anterior neck swelling with overlying erythematous skin. It extended from the left temporomandibular joint to the clavicle and encroached towards the angle of the right mandible. Figure depicts these findings.
On palpation, the mass was multilobulated with mixed cystic and solid components and no regional lymphadenopathy. Auscultation revealed wheeze and crackles on both sides of the lung fields. During the preoperative workup, a CT scan of the head and neck was performed which showed a large exophytic mass with solid and cystic components on the left side of the neck. This mass was compressing adjacent structures including the mandible, pharynx, larynx, upper trachea, and esophagus. Figure shows these findings.
These imaging findings were more suggestive of cervical cystic teratoma as compared to cystic hygroma. Hence, after completion of the preoperative workup, the patient was planned for elective surgery to excise the mass. The surgery was complicated by a one-centimeter transverse breach in the cervical esophageal wall which was primarily repaired. Postoperative recovery was uneventful. Histopatholo

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


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

[User]
RADIOLOGY NOTE:
A 54-year-old Caucasian woman was referred to our unit in March 2014 because of a suspected thyroid nodule. The diagnosis was formulated in the emergency department, where the patient was admitted because of headache, as an incidental finding during US of the carotids and vertebral arteries. The US examination was therefore extended to thyroid; the physician described a unique, solid, hypoechoic nodule, with shell calcification, with maximum diameter of 10 mm, located in the posterior part of the left thyroid lobe.
The patient was on levothyroxine replacement therapy to treat hypothyroidism due to thyroiditis. A second thyroid US was performed by an experienced endocrinologist, using a MyLab25Gold scanner and a linear 5–10-MHz probe (Esaote SpA, Genoa, Italy), showing an atrophic thyroid gland, without nodules (). The previously reported thyroid nodule was characterized as an oval, hypoechoic lesion with echogenic foci and peripheral vascularity, measuring 8.9 AP × 15.8 T × 23.4 L mm and located outside of the thyroid capsule, corresponding to an abnormal esophagus (). Therefore the patient was referred for esophagography that showed a 2 cm oval wall irregularity on the back slope of the distal cervical esophagus (). The patient did not complain about symptoms of dysphagia or pain. The endoscopic exploration confirmed a solid lesion at the level of the upper esophageal orifice. A biopsy examination was performed and a squamous cell papilloma was suspected. Magnetic resonance imaging confirmed the localization and the extension of the mass, while positron emission tomography demonstrated the absence of intralesional metabolic activity. Considering the biopsy, the patient was referred to surgery. The pedunculated lesion was excised through an anterior pharyngotomy. Surprisingly, the final histological diagnosis was fibrovascular polyp of the esophagus. Unluckily, the postoperative course was complicated by the formation of a pharyngoesophageal fistula, treated through

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


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

[User]
RADIOLOGY NOTE:
We report a case of a 40-year-old Hispanic female who was evaluated in the emergency room (ER) for worsening abdominal pain and distension. She had been in her usual state of health until 2 months before this admission. She was initially evaluated by her primary care physician (PCP) for abdominal distension. The initial workup form PCP office showed mild anemia, hepatomegaly secondary to fatty infiltration and ascites on ultrasound of abdomen. She was referred to the outpatient gastroenterology clinic by PCP; however patient presented to ER due to worsening abdominal pain.
On admission to this hospital, she reported that her abdominal pain and distension have been worsening for the past 3 weeks. She described the pain to be sharp, diffuse, non-radiating, rated 10 on a scale of 0 to 10, with 10 indicating the most severe pain. There was no nausea, vomiting, diarrhea, constipation, weight loss or change in appetite. She had regular bowel movements but had noticed several episodes of blood while wiping herself a few weeks ago. Two weeks before this presentation she had dysuria, which had resolved spontaneously in 1 day. However, she did not have flank pain, foul-smelling urine, vaginal discharge or fever during that episode. She had not traveled outside the United States (US) recently and had not contacted any sick person. Her menstrual periods occurred in regular 30-day cycles, and her last menstrual period was 1 week before this presentation.
She had a history of beta thalassemia trait, iron deficiency anemia. She underwent tubal ligation 13 years ago. She had no known drug allergies. She was an active smoker with a 10-pack-year history of smoking. She consumed alcohol socially and reported using marijuana on a regular basis. Her active medications include omeprazole, acetaminophen, naproxen (as needed), and iron supplements. She was born and raised in the US. She lived with her husband and was sexually active. Her father had hypertension, and her 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 11-year-old girl was admitted to our hospital due to abdominal pain and diarrhea of 1 week’s duration. She had no medical history of abdominal trauma or surgery. In addition, she had no travel history and there were no pets at her home. Initial assessment of vital signs showed a blood pressure of 116/70 mmHg, a heart rate of 86 beats per minute, body temperature of 36 °C, respiratory rate of 20 breaths/min, and oxygen saturation of 99%, all of which were within normal range for her age. On physical examination, she had tenderness in the right lower quadrant of the abdomen without rebound tenderness. The spleen and liver were not palpable. Laboratory examinations yielded normal results with a leukocyte count of 6,050 cells/μL, hemoglobin concentration of 13.7 g/dL, platelet count of 318,000 platelets/μL, prothrombin time of 12.3 s, and activated partial thromboplastin time of 30.6 s. Initially, she was diagnosed with acute gastroenteritis, and a contrast-enhanced computed tomography (CT) scan of the abdomen was performed to rule out acute appendicitis. A CT scan of the abdomen revealed an enhancing mass, 61 × 54 × 65 mm in size and several subcentimeter enhancing nodules in the spleen, suggesting possible hemangioma, as well as diffuse edematous wall thickening in the colon (Fig. ). She was diagnosed with acute colitis and a giant splenic hemangioma that was found incidentally, and treated with intravenous hydration and medication for acute colitis. After the symptoms of acute colitis resolved, she received vaccinations for encapsulated bacteria including Haemophilus influenzae type b, Streptococcus pneumoniae, and Neisseria meningitidis.
Two weeks after completion of the vaccinations, the patient underwent splenic embolization at the interventional center by a clinically experienced interventional radiologist. The procedure was performed with the patient under general anesthesia and the electrocardiogram, blood pressure, and oxygen saturation with pulse oximetry

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


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

[User]
RADIOLOGY NOTE:
A 63-year-old man came to the clinical observation because of a rapid onset of dyspnea and dysphonia along with the development of a bulky node in the left side of the neck. He had been working as an interventional cardiologist in an angiographic room for 15 years at the local Hospital. Family history was negative with regard to malignancies and thyroid disease.
The relevant medical history included hypertension treated with valsartan and hydrochlorothiazide and non-insulin-dependent diabetes mellitus treated with metformin. There was no previous history of thyroid disease. Two years before the admission, he was treated with warfarin because of a deep venous thrombosis of the left leg occurred after a short bed rest for prostatitis. He was a heavy smoker.
The iodine status of the patient was not known; however, he was from a non-Alpine region and he was still living in the same area which is considered as a mildly iodine insufficient [].
On physical examination, the patient had a 8 × 10-cm firm left-sided neck mass with a right-sided shift of the larynx. On ultrasound examination, a nodule of the left thyroid lobe was found measuring 5 and 6-cm in its antero-posterior (AP) and transverse (T) diameters, respectively. The nodule was hypoechoic but inhomogeneous, with no vascularization; at the strain elastography, the nodule ranged from a medium elasticity to a hard pattern. The volume of the right thyroid lobe was reduced with a small hypoechoic nodule. No enlarged lymphnodes were found at the neck ultrasound. Computed tomography (CT) of the neck confirmed a 7 × 5 × 13-cm (T × AP × Long diameters) large, inhomogeneous neck mass originating from the left lobe that caused displacement of the trachea, the left common carotid artery and the left internal jugular vein. No evidence of primary malignancies or suspicious for secondary lesions was found at the CT of the head, abdomen, and pelvis. The chest CT showed a 6-mm round-

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


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

[User]
RADIOLOGY NOTE:
Our patient was a 23-year-old Iranian man who complained of diffuse headache and several bursts of vomiting on the day of presentation. He told us that three days before, he had received a traumatic head injury after falling from his bicycle at a low speed due to an obstacle. He had no post-traumatic amnesia, loss of consciousness, seizure or visual blurring. Initially, his headache was mild and focal, but its severity gradually increased. He had been visited by a general practitioner and a skull X-ray had been performed, which did not show any fracture line. The general practitioner had prescribed an acetaminophen tablet every eight hours. After two days, despite the medication, the severity of the headache had increased, become generalized and was not responding to the analgesic. The quality of headache was pulsatile without remission. He also developed nausea and vomiting.
Our patient had no history of seizure. He was uneducated but could cope with his daily life activities alone. He had been married for four years and had a two-year-old son. In a physical examination, macrocrania and asymmetry of his calvarium were evident, with a marked expansion of the left hemicranium. The deformity had been present for many years and our patient had been told that the bulging of his head was due to abnormal fluid accumulation; no neuroradiological investigation had been performed during his childhood.
In a neurological examination, his score on the Glasgow coma scale was 15 and his mental status was normal. In an ophthalmologic exam, he showed grade 2 papilledema. His pupils were normal size and the movements of his eyes were normal bilaterally. Motor and sensory exams were normal and his deep tendon reflexes were normal and symmetric bilaterally. A computerized tomography scan (CT scan) of his brain was performed, which revealed a very large extradural hematoma in the left frontotemporoparietal convexity, but surprisingly we also saw a very large cystic area over the fronto

[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 patient reported to the Oral and Maxillofacial Surgery Department with a complaint of swelling in left lower jaw since 1year []. Patient gave a history of similar asymptomatic hard swelling in the same site 7 years ago. Records revealed an unilocular osteolytic lesion in the left mandible extending from the mandibular canine region to the second molar causing expansion of the jaw involving the lower border of the mandible []. A conservative surgical curettage was listed as having been done under general anesthesia and the pathological diagnosis was reported as a benign fibro-osseous lesion.
Present clinical examination revealed a diffuse extraoral swelling on the left side of the face extending from the midline of the lower lip to tragus of ear anteroposteriorly and extending from ala-tragus line to submandibular region superior-inferiorly. Skin overlying the swelling was normal and tender on palpation. Intraorally it was extending from the lower right lateral incisor to left ramus of the mandible with the obliteration of vestibule. No mobility of teeth was detected and the oral hygiene status appeared to be well maintained. No neurological deficits involving mental or inferior alveolar nerve were elicited.
On radiographic examination, orthopantomograph (OPG) showed a large multilocular radiolucency with well-defined sclerotic borders with the expansion of the cortical plates []. Serum alkaline phosphatase level was elevated with the value of 209 IU/L. Routine preoperative investigations were within normal limits and following a preanesthetic evaluation the patient was posted for resection of the lesion under general anesthesia. Segmental mandibulectomy was done under general anesthesia with the preservation of about 3 mm posterior border of the ramus and it was stabilized using 2.5 mm reconstruction plates []. Adequate stability of the reconstruction plate was ensured and the patient was put in intermaxillary fixation (IMF) immediate postoperativ

[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 male presented to the ED with 1 day of a reported fever, a right temporal headache, and a witnessed tonic-clonic seizure. He arrived confused with left arm weakness noted as well. He had no past history of seizures. For the preceding week, he had complained of sinus congestion and received an antibiotic from his primary care provider several days prior.
His review of systems was negative for rash, emesis or dyspnea. His medical history was unremarkable, and his immunizations were up to date. He lived at home with his family, none of whom were ill, and he took no medications or over-the-counter medications. He denied any allergies. Physical examination revealed a drowsy, but arousable, black male who was only oriented to person. His vital signs included a temperature of 36.6°C, pulse of 108, respiratory rate of 18, blood pressure of 118/54 mmHg, and an oxygen saturation of 100% on room air. His head and neck examination demonstrated only rhinorrhea but no meningismus, sinus tenderness, nystagmus or pupillary irregularity. His neurologic examination revealed isolated 0/5 weakness in the left upper extremity and confusion to time and place. His leg strength and reflexes were normal, but his gait was not tested. The remainder of his examination was normal. Diagnostic testing included an initial computed tomography (CT) that showed a right, frontal subdural hypodensity. His complete blood count was remarkable only for a white blood cell count of 17,300 cells/mm with a left shift. His basic metabolic panel showed normal electrolytes, glucose, and renal function. A magnetic resonance imaging (MRI) was obtained showing right frontal sinusitis with right subdural space extension (). A subsequent lumbar puncture demonstrated no organisms on gram stain and 3 white blood cells per high power field.
He was diagnosed with a subdural empyema and started on intravenous ceftriaxone and vancomycin. He received supportive care and pain control, and he

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


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

[User]
RADIOLOGY NOTE:
In early 2014, a 61-year-old woman experienced numbness and pain on the right side of her face, accompanied with impaired vision in the right eye. Magnetic resonance imaging (MRI) revealed a soft tissue mass measuring 5.0 × 4.3 × 6.1 cm spreading both sides of the sphenoid sinus, with extension to the ethmoid sinus, cranial base, base of the middle cranial fossa, and the adjacent right temporal lobe parenchyma (Fig. ). Incisional exploration and biopsy were performed under local anesthesia for an accurate diagnosis. Biopsy results indicated that the mass was a poorly differentiated adenocarcinoma (Fig. ).
The review of medical history found that the patient was diagnosed with a 35 mm intraductal carcinoma in the left breast in 2009 and treated with radical mastectomy and axillary node clearance. Eleven axillary lymph nodes were removed, and none of them was positive for breast carcinoma. The carcinoma was classified as histological grade 3 and staged as pT2N0M0 according to the Tumor, nodes and metastasis staing system. Further analysis revealed the cancer specimen was negative for estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER-2), indicating that the malignancy was triple-negative breast cancer. Following primary mastectomy, the patient underwent chemotherapy with the FAC regimen (fluorouracil, doxorubicin, and cyclophosphamide) for 4 cycles. The patient remained asymptomatic and was free of recurrence during routine follow-up care for 4 years.
The sphenoid sinus specimen was processed for immunohistochemical staining. The results showed the lesion was positive for CK7 and negative for CDX2, CK20, TTF–1, villin, ER, PR, and HER-2. The histology sections of the primary breast lesion of this patient were obtained from the hospital where the patient underwent mastectomy and compared with the sphenoid sinus sections. The specimen from the sphenoid sinus demonstrated similar morphological and immunophenotypic featur

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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 woman presented in July 2017 with extensive bleeding from her ileostomy site. Her history included locally advanced bladder cancer for which she had undergone pelvic exenteration and ileal conduit formation in November 2015. At that time, she had a known primary lung adenocarcinoma as well, but had no known liver metastases or other liver disease. Intravenous contrast-enhanced CT of the abdomen and pelvis performed in January 2016 raised the possibility of cirrhosis; however this was not biopsy-proven. In April 2016, she began to notice intermittent bleeding from her stoma which was initially thought to be mechanical tissue breakdown from the stomal flange. Concern for hepatic encephalopathy was raised when she had her first episode of confusion in December 2016. At that time CT of the abdomen and pelvis demonstrated strong radiographic suspicion for cirrhosis together with prominent vessels surrounding the urinary diversion site suspicious for portal hypertension. Despite not having a tissue biopsy, she was diagnosed clinically with cryptogenic cirrhosis in May 2017 during a hospitalization for fatigue, anasarca, and altered mental status. An upper endoscopy performed in June 2017 demonstrated portal hypertensive gastropathy but no esophageal varices.
Upon presentation to the Emergency Department in July 2017 she had significant hemorrhage from her stoma resulting in hemodynamic instability. She was anemic with a hemoglobin of 8.3 g/dL that improved to 9.4 g/dL after blood transfusion, but gradually fell to 8.2 g/dL by the time of the procedure. Her MELD score was retrospectively calculated to be 19 at presentation, with an INR of 1.5 and total bilirubin of 4.3 mg/dl. She was emergently taken to the interventional suite for embolization with or without portal venous decompression via portosystemic shunt formation. A review of intravenous contrast-enhanced CT imaging showed extensive venous varices around the stoma involving the abdominal wall with a l

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


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

[User]
RADIOLOGY NOTE:
An 18-year-old male patient was born through a normal vaginal delivery at 40 weeks of gestational age; he did not cry at birth, and was recognized as hypotonic at birth, and after vomiting due to breast feeding, the patient began to be fed on formula. However, he continued to vomit in spite of the change to formula feeding. He was admitted to the hospital 1 week after birth with high bilirubin level and jaundice. The patient's condition improved in almost 1 week and was discharged with formula feeding. A short time after the discharge, he was admitted to the hospital again with complaints of abdominal swelling. A liver biopsy was performed and thereafter he was followed-up with the diagnosis of “cirrhosis.” He was admitted to the hospital frequently due to fever, pneumonia, and diarrhea and finally had a diagnosis of galactosemia with the identification of galactose-1-phosphate uridyl transferase deficiency in the serum and urine at the age of 8 months. Diet regulations were made. The first cranial magnetic resonance imaging of the patient was unremarkable at that time. The patient, whose motor development was delayed, held his head up at the age of 3 years, started sitting up, and later crawling and speaking at the age of 4 years. Sphincter control started at the age of 5 years.
He had a febrile convulsion when he was 3 months old. The mother and father were cousins, and three siblings of the patient were healthy. No history of epilepsy was present in the family. The family history revealed that a cousin of the patients’ mother had hydrocephalus, and a child of the patient's uncle had died during childhood with unknown cause. He was admitted to the hospital again at the age of 9 years due to agitation and staring during playing. The neurological examination of the right-handed patient revealed mental retardation (IQ: 36), convergent strabismus, bilateral Babinski, and hypoactivity of the deep

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


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

[User]
RADIOLOGY NOTE:
The patient was a 72-year-old man who was followed up for persistent pain in the left side of the waist for 2 years, radiating to the left hip. The history of schistosomiasis was 40 years, and with hypertension 1 year. On physical examination, he had pain on movement of the spine with bilateral Grade IV motor strength in both lower extremities. There was not numbness in both feet and ankles with normal ankle reflexes bilaterally. There was a normal knee reflex bilaterally. There was no obvious bulge in the bilateral kidney region, and the left lateral kidney region knocks out to be positive for pain. The neurological symptoms were ascribed to the compression of the spinal cord and nerve roots by an expanding mass partly protruding into the vertebral canal.
Magnetic resonance imaging (MRI) was performed that the left side of the vertebral body and the left peritoneum showed an elliptical abnormal signal shadow, which showed a dumbbell growth. The MRI scan showed an area of increased signal intensity on T2-weighted images in the T12-L4 paravertebral region. At discovery, on the left side of the L1 vertebral body, there was a slightly longer T1/T2 signal, with a size of 8.6 × 8.4 × 12.4 cm (Fig. ). The boundary was clear, and the enhanced scan showed an uneven separation. The lesion protruding into the erector spinae muscles and behind the retroperitoneum are connected to the lesion in the vertebral canal through the intervertebral foramen, and the spinal cord was compressed and the boundary was clear. And the computed tomography (CT) showed that bone destruction can be seen on left lateral transverse process of L2, and the left kidney was significantly compressed (Fig. ).
The patient was treated with surgical resection of the total tumor, followed by the spinal internal fixation of L1 to L2 with pedicle screws. A posterior approach was selected for decompression. Intraoperatively, 2 lumps

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


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

[User]
RADIOLOGY NOTE:
A 75-year-old woman (virgo, gravida 0, para 0, body mass index (BMI) = 21) presented with diffuse abdominal pain and enterorrhagia. She entered menopause at the age of 55 and she had regular menstrual cycles with no dysmenorrhea. Her medical history includes hypertension treatment with angiotensin II receptor blocker. She had undergone knee arthroplasty bilaterally and had never complained of bowel or reproductive system symptoms before, while there is no family history of colorectal or endometrial neoplasms.
The patient underwent colonoscopy, which was not completed due to bowel intussusception, 28 cm from the anus. It was assumed that intussusception was the result of external pressure. Blind biopsies were performed and the relevant histopathological examination revealed intestinal mucosa with tubular adenoma of low-grade dysplasia. Computed tomography (CT) of the upper and lower abdomen demonstrated a midline pelvic lesion with a transverse diameter of 6.1 cm ( and ). Additionally, two more nodal lesions with a transverse diameter of 2.8 cm each were found in a cephalad and caudal direction (). The caudal lesion was found to be in contact with the anterior surface of the fundus of the uterus. Thus, local expansion of the intestinal tumor to the uterus was hypothesized. Small (diameter <5 mm) local lymph nodes were also revealed. Small cystic lesions were found in both ovaries. The rest of the organs appeared normal (). The lower abdomen ultrasound revealed an atrophic uterus (51 mm × 22 mm × 35 mm) with a thin endometrium (3 mm). The ovaries could not be visualized. No pathological findings were observed in the pouch of Douglas. A thorax CT scan was negative for pericardial or pleural effusion and for any other parenchymal diseases. The preoperative blood test results were normal.
The patient underwent sigmoidectomy, with excision of the intestinal mass found preoperatively in CT and colonoscopy, and end-to-end anastomosis with the use of a stapler. Intraoperativ

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


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

[User]
RADIOLOGY NOTE:
A 61-year-old Caucasian female presented to her general practitioner with painless and palpable right-sided submandibular and thyroid swellings. Her past history revealed left mastectomy and axillary clearance with postoperative chemoradiotherapy for grade 2 lobular breast carcinoma 2 years ago, and left radical nephrectomy for clear cell type RCC (Fuhrman grade 2, stage pT1, completely excised with no renal vein involvement) with no regional or distant metastases 7 years ago. Considering her recent history of invasive breast carcinoma, she was referred onto the breast surgical clinic for further assessment. An ultrasound scan (US) of her neck suggested multinodular thyroid goitre (largest nodule in right lobe) and a well-defined hypoechoic mass in the right submandibular gland. US-guided fine-needle aspiration (FNA) cytology of the right thyroid nodule was nondiagnostic on two separate occasions and of the right submandibular gland suggested a pleomorphic adenoma (PA).
She was then seen in our otolaryngology department where a complete ear, nose, and throat examination was normal except for the obvious right submandibular and thyroid gland swellings. A computed tomography (CT) scan of her neck was performed which revealed a tumour mass in the right submandibular gland with prominent vascularisation unusual for benign lesions such as a PA (). CT scan also showed a large nodule in the right thyroid with similar intense vascular enhancement as the submandibular lesion (). There was no suspicious cervical lymphadenopathy. A bone scan showed no osseous metastases and chest X-ray revealed no pulmonary metastases.
Initially the right submandibular gland was excised revealing an encapsulated tumour within the glandular tissue. A right level I and II neck dissection was also performed with preservation of the marginal mandibular nerve. Histopathological examination of the tumour showed striking similarity to the clear cell RCC of left kidney resected previously (). The diag

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


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

[User]
RADIOLOGY NOTE:
A 28-year-old female patient reported with complaints of generalized swollen gums since last one year, preventing proper speech, articulation, and mastication causing inadequate lip apposition and poor aesthetics. Detailed case history disclosed that in last six years, she has been operated for the same problem four times; once full mouth open flap debridement and three times gingivectomy was performed but again causing the recurrence of gingival enlargement within 4 to 5 months. She did not give any history of drugs intake, fever, anorexia, weight loss, seizures, hearing loss, nor having any physical or mental disorder. Also, family and postnatal history was non-contributory.
Extra oral examination revealed that patient has incompetent averted lips and convex profile.
An intraoral examination revealed generalized diffused, nodular enlargement of gingiva, more on the right side. Gingiva was fiery red in color with soft and spongy consistency and bleeding on slightest of provocation. The teeth were covered with enlarged gingiva till the middle one third, with some teeth showing grade I mobility [Figures –].
Panoramic radiograph revealed generalized bone loss [] and, teeth no. 11, 21, 45, and 46 were root canal treated with crowns on them. Hematological investigations showed all the blood elements to be within normal limits.
On the basis of detailed case analysis and clinical and histological findings, the case was diagnosed as refractory periodontitis with chronic inflammatory gingival enlargement.
On the basis of clinical features and history of the patient, the diagnosis of refractory periodontitis with gingival hypertrophy was made, not responding to various periodontal surgical procedures. Thus, non-surgical periodontal therapy was chosen as the mode of therapy along with systemic administration of minocycline for which a written informed consent was signed from the patient. Minocycline 100 mg one a day was advised to start with for 1 week. At the end of 1 week o

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


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

[User]
RADIOLOGY NOTE:
We had a 65-year-old male who came for the treatment of his patella fracture and deformity of knee. His knee society score was 70 for the left knee and 78 for the right knee. It was known that he was having multiple comorbidities such as hypertension and coronary artery disease. There was a history of percutaneous transluminal coronary angioplasty 1 year back. He had a history of fall from two wheelers 1 month back, and he sustains injury to his left knee. The patient was having pain, swelling, but he had not taken any treatment for it. Patient neglected the injury and was able to walk with the support of walking aid. On examination, the patient was having bilateral knee Varus 20°9 () and fixed flexion deformity of 30°. Active straight leg raising was not possible on the left side. Range of movement of left knee was possible from 30 to 90°. Radiographs revealed a transverse fracture of the patella with Grade 4 osteoarthritic changes on the left side and arthritic changes on right knee also (). Other findings of blood investigations were normal. We decided to go for single-stage procedure with fixation of patella fracture and TKR. Anterior midline incision was taken, and medial parapatellar arthrotomy was done. On extensor side the retinaculum was found intact intraoperatively, so we first proceed with TKR. Calcified medial meniscus was excised, and posteromedial tibial defect was taken care with downsizing of the tibia. After through irrigation with normal saline and debridement of soft tissue from articular side of patella fracture, the fracture ends were approximated. Reduction held with patella pointed reduction clamps and two parallel K wires. An 18 G SS wire was used for tension band wiring of patella. The extens or retinaculum was reinforced with absorbable sutures ( and ). The incision was closed in layers without a suction drain. Post-operative radiographs showed an acceptable reduction of the fracture and an acceptable TKR. In postoperative period patient w

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


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

[User]
RADIOLOGY NOTE:
A 45-year-old Haitian American female with no significant medical history presented with a six-month history of progressive solid food dysphagia and a one-month history of odynophagia. The patient had lost 15 pounds and was only able to tolerate pureed food or liquids. She had experienced no symptomatic relief on omeprazole 40 mg twice daily for the past two months and did not use tobacco, alcohol, or illicit substances. Her initial blood count and metabolic panel were unremarkable. An esophagogastroduodenoscopy (EGD) revealed erythematous and friable mucosa with ulcerations in the proximal esophagus (). There was a stricture encountered at 15 cm from the incisors through which the gastroscope could not be traversed. Biopsies were taken from the inflamed esophageal mucosa and the proximal lumen of the stricture. Brush cytology was collected through the stricture as there was a concern for malignancy. A subsequent barium esophagram and upper GI series demonstrated 2 cm irregular narrowing in the cervical esophagus, but no abnormalities in the rest of the esophagus, the gastroesophageal junction, stomach, duodenum, or proximal jejunum. Contrast-enhanced computed tomography (CT) of the chest showed no acute esophageal, mediastinal, pulmonary, or cardiac pathology. The esophageal biopsy indicated acute and chronic inflammation with filamentous sulfur granules consistent with Actinomyces; rare fungal hyphal elements were additionally identified (Figures , , and ). The cytology was negative for malignant cells and the acid-fast bacilli (AFB) stain was negative, ruling out Nocardia as a potential pathogen. The patient was started on intravenous (IV) Penicillin for a diagnosis of esophageal actinomycosis and oral Fluconazole for a presumed Candida coinfection given concurrent fungal elements. Her human immunodeficiency virus (HIV) status was negative and her fasting blood glucose was within the normal range. She was discharged on Fluconazole 200 mg daily for 2 weeks and IV

[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 80-year-old Japanese female presented with a four-week history of right nasal discharge, nasal obstruction and left neck swelling. The patient was a non-smoker with a history including left traumatic blindness, chronic renal disorder (estimated glomerular filtration rate on admission, 30.3 ml/min), hypertension and diabetes mellitus. Physical examination demonstrated an easy-bleeding tumor in the right nasal cavity () and swelling of the left medial and inferior cervical lymph nodes (diameter, 3 and 2 cm, respectively).
Computed tomography scanning revealed a huge lesion occupying the nasal cavity and paranasal sinus that had destroyed the posterior and medial walls of the maxillary antrum (). There was direct extension into the right ethmoidal air cells, but no extension to the floor of the orbit, skull base or hard palate. Fluorodeoxyglucose-positron emission tomography (FDG-PET) showed high accumulation in the primary tumor, with a maximum standardized uptake value (SUVmax) of 9.63 (). The SUVmax of FDG-PET in the left medial and inferior cervical LNs was also high (6.90 and 4.62, respectively; ), although there was no definitive lesion in the right cervical LNs or distant metastasis.
The tumor in the right nasal cavity was biopsied using forceps, but the pathological examination resulted in necrotic tissue with suppurative granulation. It is unclear whether the biopsy revealed the presence of necrotic tissue or whether the biopsy procedure itself caused the necrotic tissue. An incisional biopsy of the left cervical lymphadenopathy and the right maxillary antral lesion was therefore carried out via the canine fossa. Pathological examination revealed a highly malignant anaplastic tumor. Under hematoxylin-eosin stain, two components could be observed in the lesions: SqCC and small cells containing chromatin-rich nuclei with scanty cytoplasm undergoing apoptosis and mitosis (). To characterise the cells, an immunohistochemical examination was performed. On evalua

[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.