[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 fifty-seven-year-old male was treated with THA for primary osteoarthritis of right hip. The bearing surface used in cementless THA was ceramic on metal. He made a good recovery without any complications and remained well for 10 years. In July 2011, he presented to us with the complaint of weakness in his right lower limb for the last one month, and an inability to lift limb for the last two weeks. There was no history of trauma, fever or weight loss. Hip examination revealed no significant findings with a normal range of movements. The patient on neurological assessment, was found to have femoral nerve palsy with weakness of hip flexion and knee extension without any sensory deficit. Distal pulses were normal on both the sides.
Plain radiographs of the hip (Fig. ) showed no signs of loosening or osteolysis. Lateral inclination and anteversion of acetabular cup were 45° and 25 ° respectively. Thefemoral stem was in neutral alignment. Blood investigation revealed that complete blood count, ESR and CRP were within normal limits. Serum metal ions were within normal limits. Electromyography and nerve conduction study of right lower limb revealed femoral nerve palsy. Ultrasound examination of the groin demonstrated a large intrapelvic cystic lesion between THA prosthesis and femoral vessels and nerve. Fascicular swelling overlying the femoral nerve was also noted, probably due to mass effect. Fluid-fluid level was also seen within the cystic lesion. There was no definite evidence of intra-articular extension of the lesion to the adjacent hip joint. Ultrasound-guided aspiration was deferred in view of the large size of the lesion, fear of introducing any infective pathogen and risk of recurrence. Further CT evaluation of the right hip confirmed the presence of a large iliopsoas cystic lesion (Fig. , ) along with an overhang of anterior portion of the acetabular component beyond the margins of the true acetabulum (Fig. ). There were no signs of acetabular cup loosening or

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old woman presented with large varicose veins, CEAP C2s, in the left lower limb. The patient had never been treated before because she was afraid of surgery. She had no history of migraine headaches or cardiac diseases. She had never smoked cigarettes, never had high blood pressure, and never been overweight. Her only medication was 20 mg sinvastatin once a day, and her last lipid profile, and all blood tests were normal. Except for the large varicose veins in her left lower limb, physical examination was normal, including normal peripheral pulses and absence of bruits. The patient was treated in the Trendelenburg position with a total of 10 ml of 3% polidocanol foam via direct punctures, 5 mL into an 8 mm diameter great saphenous vein and 5 mL into large collaterals in the leg. Foam was prepared with a 1:4 ratio of liquid to room air, using the Tessari technique involving 40 passes of agitation through a three-way stopcock using one 5 mL syringe and one 3 mL syringe. With ultrasound guidance, foam was injected immediately after each of three preparations, 5 mL, 2.5 mL, and 2.5 mL. No air boluses occurred. Ultrasound scanning showed no foam in the deep venous system. The patient remained lying down for 10 minutes after the injections, before being discharged wearing compression stockings. Less than 1 hour after leaving hospital, impairment of speech capacity was observed. She encountered difficulties when she tried to talk, with incomplete and incomprehensible words. No other alterations were noted. She was taken to another hospital, where the clinical presentation was misdiagnosed as an allergic reaction. One gram of hydrocortisone IV was infused and 20 mg prednisone was prescribed per day for 5 days. The next morning she came to the office to report the allergic reaction. After detailed history taking and physical examination, including the Wells DVT clinical model, the only alteration detected was aphasia. This was Broc

[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 gentleman admitted 3 months ago because of multiple pulmonary nodules which had been found in health examination. HRCT showed that there were two nodules, including one solid pulmonary nodule (SPN) that was located at the right upper lobe (Fig. a) and one GGO at the right lower lobe (Fig. b). Other preoperative examinations showed no contraindications. A right upper lobectomy and right lower lobe wedge resection by single-port video-assisted thoracic surgery (VATS) were performed, and about 3 h before the operation, a CT-guided hook wire localization of the GGO was performed in radiology department. According to the CT scan, the hook wire was inserted 3 cm deep into the pulmonary parenchyma and the hook-shaped tip was fixed 1.8 cm away from the GGO (Fig. c, d). There was no pneumothorax or hemothorax during this procedure.
General anesthesia was performed and then a 4 cm incision was made at the pivot of the fourth intercostal space and the anterior axillary line. While entering the thorax, the hookwire was found still attached to the right lower lobe and the tail outside the thorax was cut off to avoid bacterial contamination. As we planed before, the first step of the operation was wedge resection of the right lower lobe. After several attempts to search for the GGO by manual palpation, the hookwire was submerged in pulmonary parenchyma and could not be touched. A 1 cm incision at the pivot of the eighth intercostal space and the midaxillary line and a 3 cm incision at the pivot of the eighth intercostal space and the posterior axillary line were added but still helpless. Then the patient was sent to the radiologist department where a CT scan was performed and the hookwire was found in the artery of apical segment of right upper lobe, which was planned to be removed (Fig. a). When the patient was sent back to the theater, the operation

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


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

[User]
RADIOLOGY NOTE:
A 74-year-old postmenopausal woman was referred to the gynecology clinic of the Jeonju Presbyterian Medical Center with complaints of a palpable abdominal mass that she first recognized approximately 2 months prior. The patient had a history of gravida 2 and para 2. She had no other medical history but hypertension. First, during routine physical examination, an approximately 16–18 gestational week-sized mass was palpated. It was movable, painless, and was suspected to be a large ovarian mass based upon transvaginal ultrasonography. The echogenicity of the mass was heterogeneous with irregular contours. Pelvic computed tomography (CT) indicated that the mass was 10×8.5×13 cm in size with cystic and solid-enhancing features. Enhancement of the internal component of the mass was complex, but there was no definite pathologic enlargement of lymph nodes and ascites (). Additionally, there was a unilocular right ovarian simple cyst and a uterine myoma. Two suspicious retroperitoneal lipomas were observed in the para-aortic region and infrarenal portion. According to CT findings, the sigmoid colon bordered the huge left ovarian tumor. A colonoscopy was performed and confirmed the absence of tumor invasion into the bowel mucosa. Laboratory findings showed only mild anemia and other laboratory analyses revealed normal values. Tumor markers, including cancer antigen (CA) 125, CA19-9, carcinoembryonic antigen, α-fetoprotein, and β-human chorionic gonadotrophin were also in normal ranges. A laparotomy was performed to assess the pathological findings of the left ovarian mass. During surgery, the large ovarian mass seemed to adhere tightly to the ovarian wall, and its smooth capsule seemed to be connected to the ovarian germinal epithelium. There was no sign of tumor capsule rupture. The tumor looked benign in nature without any ascites or peritoneal carcinomatosis. There was slight adhesion between the tumor base and the peritoneal surface (). Since the patient was elderly with

[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 weighing 60 kg, a victim of road traffic accident who sustained a head injury (depressed skull fracture) and loss of consciousness, had associated hoarseness of voice and difficulty in breathing. He was posted for emergent tracheostomy under local anaesthesia with monitored anaesthesia care. On examination, the patient was conscious (GCS of 15), in respiratory distress and there was a bruise extending from the left shoulder to right across the neck in the front. On examination of the neck, crepitus and tenderness were present on the anterior part of the neck. Computed tomography (CT) scan of neck revealed a tear on the anterior tracheal wall extending from C6 to T1 vertebrae level with loss of anterior tracheal wall and surgical emphysema into the surroundings []. Routine investigations and surveys of other body parts were grossly normal.
In the operating room, baseline values in the form of a heart rate of 112 bpm, blood pressure of 160/90 mmHg and a respiratory rate of 36–38/min with use of accessory muscles. Significantly the oxygen saturation was only 86–88% on oxygen supplementation by polymask. After administration of the local anaesthetic agent (lignocaine 2%), surgical tracheostomy was commenced with oxygen supplementation (100% oxygen by Bain's circuit). Dissection revealed a tracheal rent on the anterior tracheal wall, measuring 2 × 1 cm was observed at the site where the stoma should have been made []. Initially attempts were made to pass the tracheostomy tube through this tracheal rent. Further, failure of such attempts and an impending cardiorespiratory arrest situation prompted the passage of an endotracheal tube after direct laryngoscopy. Post intubation, the oxygenation of the patient improved, ventilation was partially effective due to leak of air from the tracheal rent. Subsequently, another attempt to negotiate tracheostomy tube through the rent also resulted in the failure in passing the tracheostomy tube into the trach

[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 79-year-old, active Caucasian woman with left groin pain was referred to the orthopaedic clinic by her general practitioner to undergo THA. She complained about progressive left groin pain for 12 months that was worst in the morning and exacerbated by physical activity and prolonged sitting. Clinical examination revealed left-sided antalgic gait and tenderness in her left groin. Left hip internal rotation was limited to 10°. Anteroposterior pelvic and true lateral hip radiographs revealed typical signs of osteoarthritis (Figure ). In addition, there was a 25-mm-diameter calcification in the lesser pelvis, which was reported by the radiologist to be a calcified uterine myoma. Finally, the patient was scheduled for elective left THA. At the preadmission clinic, a routine urine dipstick test revealed 3 to 20 erythrocytes and no leucocytes or nitrites. On the basis of the urine dipstick stick, a diagnosis of urinary tract infection (UTI) was made, although the patient was asymptomatic and urine was sent for culture. The patient was empirically treated with oral antibiotics, and the surgery was postponed. Urine cultures showed no bacterial growth, and no further tests or referral to other specialties were done. Four weeks later she underwent a THA with satisfactory recovery. At the first follow-up six weeks postoperatively, the patient was almost pain-free and was using two crutches for stability. Her examination was unremarkable at that time. Standard radiographs showed an acceptable implant position (Figure ). The orthopaedic surgeon and the radiologist did not report any other abnormality. Further physiotherapy was recommended, and routine follow-up was recommended six months from the time of surgery. Unexpectedly, the patient presented to us four months after surgery complaining of worsening left hip pain. Because she was still on crutches, she noted weakness, loss of appetite and weight loss of 5 kg. Further examination revealed generalized tenderness of the left

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


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

[User]
RADIOLOGY NOTE:
A 27-year-old woman presented with a nodule at the lower abdominal caesarean section scar. She had undergone surgery 4 years before. The tumor appeared over the caesarean section scar 4 years after surgery, which gradually increased in size. The patient described cyclical pain at the site of the mass, which coincided with her normal menstrual cycle. She had no previous history of endometriosis. On physical examination, the patient had a firm mass with restricted mobility along the right upper lateral aspect of the caesarean section scar with a black appearance. The mass measured about 5 cm × 5 cm in size and was clinically diagnosed as a tumor on the abdominal wall. It was clinically diagnosed as either metastatic deposit or skin appendage tumor. The patient was found physically fit otherwise.
FNAC was performed and the aspirate was obtained using a disposable 10 mL syringe and 22 gauge needle. The material was collected on glass slides and was wet fixed and then stained by the Papanicolaou method, while the remaining aspirate was allowed to clot. To facilitate clotting, few drops of blood from the finger prick of the patient was added on the aspirate and the clot was transferred to a formalin vial. This method of cell block preparation has been practiced in our institute since long.[]
A cell block was made from formalin-fixed sediment. Sections were cut and stained with the hematoxylin – eosin stain.
Smear preparation of the FNAC sample showed extensive areas of hemorrhage and scattered small cells with compact nuclei and scanty cytoplasm, resembling stromal cells and columnar epithelial cells, which represented the endometrial glands. Hemosiderin pigment-laden macrophages were also seen []. The diagnosis given on FNAC was suggestive of scar endometriosis.
The cell block findings were confirmatory of endometriosis as they revealed endometrial lining columnar epithelium with subepithelial dense and compact endometrial stroma along with extensive areas of hemorrhage

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


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

[User]
RADIOLOGY NOTE:
A 10-year-old boy was referred to a local hospital with hoarseness for 1 year in July 2009. Clinicians saw a tumor of the vocal cord, which subsequently was resected by using direct microlaryngoscopy with a carbon dioxide (CO2) laser. Respiratory papilloma was diagnosed after pathologic analysis. After the procedure, the symptom of hoarseness actually worsened and the patient also gradually developed a foreign body sensation. He then presented to our hospital in May 2010. Fibrolaryngoscopy demonstrated exophytic masses involving the whole length of the right vocal cord and extending to the anterior commissure and anterior third of the left vocal cord (Figure ). The cords were mobile, and no cervical lymphadenopathy was appreciated on palpation. In addition, there was no recent history of fever or weight loss, and laboratory findings were normal. The tumor was resected by using direct microlaryngoscopy with a CO2 laser, and histological examination was performed (see below).
Six months after the second operation, the patient was referred again for hoarseness in addition to shortness of breath. Via laryngoscopy, similar exophytic masses were observed at the same location, and these masses were then resected. However, the lesion returned 5 months later and was removed again, only to reappear a fourth time after 2 months. The tumor from the fourth operation showed a proliferation of spindle cells in the subepithelial stroma. A diagnosis of IMT was made after reviewing the histopathology, combined with the results of immunohistochemical staining and testing for human papillomavirus (HPV) and ALK. During a clinical and pathological discussion, it was proposed that incomplete resection was the cause of tumor relapse. A fifth operation was performed, and frozen sections of the surgical margins sent at the time of the procedure were all negative for IMT. The child’s voice improved after 3 months, and the tumor failed to recur during 2 years of regular follow-up. This report

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old male patient, a retired banker by profession, is a known case of diabetes mellitus, hypertension, locally advanced rectal cancer. He presented to the clinic after being treated earlier at another hospital for rectal cancer. The patient initially had complaints of swelling near the anal region since the last 8-10 months, which was gradual in onset, not associated with pain or per rectal bleeding. He underwent local surgery. His perianal tissue biopsy revealed moderately differentiated adenocarcinoma with cytokeratin 7 patchy positive and CDX 2 as positive. His CT scan of the chest/abdomen/pelvis done in March 2017 revealed diffuse thickening of the anal canal more on its anterior aspect with mild fat stranding in the left ischioanal fossa. Findings were suggestive of a neoplastic lesion along with some post-surgical changes. No regional lymphadenopathy or ascites were seen.
At another hospital, the patient underwent neoadjuvant chemoradiation therapy with 5-fluorouracil till May 2017. The patient was also advised about the surgery but was lost to follow-up secondary to financial constraints. His post-treatment scans done in June 2017 showed thickening in the anal verge, likely suggestive of post-surgical changes. No residual disease seen. In October 2017, he again developed pain in the perianal region along with a foul-smelling discharge. His colonoscopy done in November 2017 revealed rectal growth up to 5 cm from the anal verge. His histopathology revealed moderately differentiated adenocarcinoma. MRI pelvis showed minimal bowel wall thickening involving the anal canal with perilesional edema involving the perianal region, suggestive of post-surgical changes, versus the possibility of residual disease.
He then presented to us, in the clinic in December 2017. His local examination showed ulceration over the anal canal, fixed growth with erythema, and no per rectal bleeding. His positron emission tomography (PET) CT scan was repeated, which showed hyperm

[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 female patient was admitted to the Galactophore Department, Bao Ji Central Hospital with a huge lump in the left breast. The patient stated that they had identified a thumb-sized lump two years earlier, but that they had ignored it. From July 2011, the patient observed that the lump was growing rapidly; in February 2012 the lump had become so large that the patient’s left chest was entirely covered with a solid, irregularly-shaped, somewhat moveable mass of tremendous size and the patient was barely able to lie in the prone position. Family members then finally convinced the patient to seek medical attention. Upon physical examination, the patient presented with an elastic hard mass in the left breast that was 45 cm in diameter, with a circumference of 97 cm (). Rapid growth had resulted in shiny stretched skin that was translucent, showing underlying extremely enlarged veins with sections of the circuitous veins about to undergo ulceration, although no bleeding or discharge was noted. The lymph nodes in the axillary and other superficial areas were not palpable. The patient’s previous medical history revealed that they had high blood pressure, diabetes and atrial fibrillation. Moreover, the patient had suffered from a cerebral infarction; the patient’s right side was paralyzed and communicative disorders had appeared two years previously. The patient was unable to care for herself due to the cerebral infarction. The patient’s medical history was negative for allergies, smoking, drinking, contagions and serious addiction. Furthermore, there was no family history of breast cancer on either side of the patient’s family.
Due to the non-compressible nature of the mass and the size of the tumor, regular breast examinations, including mammography and ultrasound studies, could not be used, while a computed tomography (CT) scan of the chest revealed a solid mass. Total body scintigraphy was negative. Comprehensive examinations and detailed assessments were add

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


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

[User]
RADIOLOGY NOTE:
A 65-year-old male patient presented to the Department of Oral Surgery of Clinical Hospital Centre Zagreb after resection of the mandible due to OPC that was surgically treated in April 2015 (Figures and ). He was referred by a prosthodontist due to an inability to function with a full denture. He had no history of tobacco smoking and only drank socially and did not have any other usual predisposition factors for carcinogenesis in this area. Until this disease, his medical status was remarkable. The patient's medical history revealed radical neck dissection, commando surgery, and reconstruction using an anterolateral thigh (ALT) flap due to a squamous cell carcinoma localised in the anterior palate arch with expansion into the retromolar trigonum area and lateral oropharyngeal walls (T3N0M0). The patient had received postoperative chemotherapy (cisplatin i.v.) for a total of three cycles in conjunction with radiotherapy. Three-dimensional conformal radiotherapy was performed in the region of the tumour, with a total of 32 fractions using a total dose of 64 Gy. In the region of the neck lymph node bilaterally 25 fractions in a total dose of 50 Gy were performed. The patient handled the therapy well (ECOG 0), with no major side effects. The only symptom he had was the expected local side effect of mucositis. Replacement hormone therapy with 50 μg levothyroxine had also been introduced.
On initial examination, an edentulous mandible was found with a narrow zone of attached mucosa, preventing the fabrication of a satisfactory full denture (). Three months before, the patient extracted all remained teeth, upper right molar, four mandibular incisors, and lower right canine because of impossibility of restoration due to deep caries or periapical lesions. A cone beam computed tomography (CBCT) was performed, where adequate residual alveolar ridge height and width for the insertion of dental implants were observed. After consultation with a prosthodontist, we decided to plac

[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 presented with hematuria and urinary obstruction symptoms. He came to the hospital four times each with presence of gross hematuria. Moreover, the patient suffered from frequency and nocturia at least for six months. Physical examination revealed enlargement of prostate, but there was no palpable nodule on the digital rectal examination. PSA was normal and there was also no evidence of hepatomegaly or splenomegaly.
The first transurethral resection of the prostate (TURP) and biopsy was done for him, but pathologic results showed the evidence of BPH. After 28 days, the patient was admitted again due to gross hematuria. Rectal examination was normal. Pelvic CT-scan revealed a big clot in bladder without any lymphadenopathy. There was a significant heterogeneity in prostate. In second TURP, clot evacuation and biopsy were performed on more than 15 different areas of prostate. During the next 2 weeks, the patient underwent 3 other trans-urethral coagulation and clot evacuations due to hematuria.
However, laboratory tests such as prothrombin time (PT) , partial thromboplastin time (PTT), clotting time (CT), bleeding time (BT) and platelet count were normal. After 15 days hematuria was stopped and was not repeated. Sections from prostate show foci of hemorrhage, and ).
The first transfusion was 2 units of PC during the second surgery. The second transfusion was 2 units of PC and 2 FFP, two days later. The consecutive third and fourth transfusions were done two days later during which the patient received 3 units of FFP, and 3 units of whole blood.
Immunohistochemistry studies demonstrate CD20-positive in 90% of lymphoid cells and in the lymphoepithelial lesions (), CD5-positive in background lymphocytes, CD43-positive in 90% of lymphoid cells, CD3-positive in background lymphocytes, CK and PSA markers are negative in neoplastic cells. Further evaluation and examination such as bone marrow biopsy, abdominal and pelvic CT-scan did not show other involvemen

[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 44-yr-old female with tinnitus in the form of a high-pitched, 'whooshing' sound in the left ear visited our tinnitus clinic on April 11, 2012. The patient had a 6-month history of ear-ringing synchronous with the heart beat during physically stressful conditions such as fatigue, exhaustion, and emotional upset. It was heard about 50% of the time during the day and became louder when she experienced fatigue at her job in accounting. The patient described attenuation of tinnitus by manual compression of the left posterior auricular area. The patient did not complain of hearing impairment, fullness in the ear, hyperacusis, dizziness, or headache. She had no past head or neck trauma, no exposure to ototoxic drugs or extremely loud noise, chronic medical illness, or neuropsychiatric condition. The tinnitus was not audible even with a stethoscope around the left ear and mastoid area. The patient described that the Valsalva maneuver, or manual compression of the left internal jugular vein, reduced the loudness of the tinnitus, but it was unaffected by head position or compression of the right neck. The otoscopic examination and pure-tone audiogram were normal.
An axial temporal bone computed tomography with contrast enhancement revealed that the left MEV had a prominent opening to the sigmoid sinus and the large canal of the vein crossing the mastoid bone to the soft tissue, without other accessory MEVs (). The outer foramen of the MEV was located on the posterior-superior mastoid region. The diameter of the inner foramen (at the sinus side) of the left MEV was approximately 4.5 mm whereas that of the right MEV was 1.3 mm. The magnetic resonance image (MRI, Gyroscan, Philips, the Netherlands) of the posterior fossa with contrast enhancement showed an outstanding figure of the MEV enhanced together with the sigmoid sinus, also demonstrated on an MR-venogram where no other significant abnormality was found

[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:
The patient was a 40-year-old Asian male with a four-month history of a dry cough, dyspnea and hemoptysis. The patient was a heavy smoker with an unremarkable medical history. A chest computed tomography (CT) scan revealed the presence of multiple nodules scattered in both lungs without hilar and mediastinal lymphadenopathy or pleural effusion (). Initially, a bronchofibroscope examination failed to reveal any abnormalities. In order to obtain a definitive diagnosis, the tissue specimens were taken by diagnostic right thoracoscopic lung biopsy.
The histological diagnosis of PEH was based on the pathological examination. The pathological examination of the biopsied specimen revealed that the center of the pulmonary nodule was sclerotic and hypocellular, with hyalinization and calcification. The tumor cells were round with abundant eosinophilic cytoplasm, intracytoplasmic vacuolization and a signet ring-like appearance (). Immunohistochemical analysis revealed that the tumor cells were positive for the endothelial markers, factor-VIII-related antigen and CD34 ().
PEH disease progressed rapidly in this patient one month after pulmonary surgery. The T1-weighted magnetic resonance imaging (MRI) section examination revealed a nodular lesion in the brain, which was strongly suggestive of brain metastasis (). The CT revealed a spreading of the nodules throughout both lungs three months after surgery (). At this point, the patient began treatment with one cycle of chemotherapy with cisplatin, paclitaxel and endostar (15 mg/day for 14 consecutive days). The patient demonstrated improvements in dyspnea and a dramatic improvement in their clinical status. However, no change in the size of the pulmonary nodules over the period of chemotherapy was observed. The patient subsequently received another two cycles (two, bi-weekly) of chemotherapy treatment with carboplatin, paclitaxel and endostar. No significant reduction was observed in the tumor size and number, and the disease pro

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


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

[User]
RADIOLOGY NOTE:
A 9-year-old male presented to our clinics with his parents complaining of swelling and asymmetry in the left side of his mandible.
The questionnaires revealed that the expansion of the swelling was slow, gradually increasing during the past year with no pain reported.
Extraoral examination showed a mild facial asymmetry associated with a well-defined swelling on the left side of the mandible measuring 3 to 4 cm (). No cutaneous pigmentations on the face, no limitations of mouth opening, and no enlarged submandibular lymph nodes were noticed.
Intraoral examination displayed expansion of the buccal cortical plate, extending from the mandibular left incisal to the first molar, and the first deciduous molar was absent (). On palpation, it was hard in constancy, fixed, with no signs of mucosal inflammation observed and no signs of paresthesia.
A panoramic radiograph exposed the loss of trabecular structure and a radiopaque image showing a “ground-glass” feature was observed on the left side of the mandible englobing the dental germ of the permanent second premolar ().
The cone-beam computed tomography (CBCT) axial images revealed a radiopacity lesion with an expansion and thinning of the buccal bone cortical with well-defined borders (). The dental germ was in the middle of the lesion (), and the para-axial images showed the mandibular canal displaced buccally and toward the lower border of the mandible ().
Based on the evaluation of the clinical and radiological data, a provisional diagnosis of FD was made, and differential diagnoses of MAS, MS, and hyperparathyroidism were considered.
As the germ needed to be removed, we discussed with the parents the surgical procedure required to extract the germ along with the need for an osteoplasty to remove the excess bone and a biopsy to be taken during the procedure.
Under locoregional analgesia, a conservative surgical excision of the buccal bone was proceeded, with extraction of the dental germ and remodeling of the region d

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


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

[User]
RADIOLOGY NOTE:
A 64-year-old male presented to the emergency department with a 5-day history of right lower quadrant abdominal pain and distention. He had nausea, vomiting, obstipation, and anorexia. He denied fevers and chills. His past medical history was significant for benign prostate hyperplasia and a two-month history of urinary retention for which he had been followed up by the urology service. He denied previous abdominal surgeries. Examination revealed a distended tympanic abdomen with bilateral lower abdominal quadrant tenderness without rebound or guarding. Laboratory values revealed a white blood cell count of 15,100 cells/mcL with 89% neutrophilia. A urinalysis contained 182 white blood cells, 3+ leukocytes, and 4+ bacteria with a subsequent urine culture growing Escherichia coli.
A computed tomography (CT) scan was performed which demonstrated fat stranding in the right inferior abdominal cavity with an adjacent fluid collection, distended small bowel loops with fecalization, and a clear transition point at the proximal ileum. The preliminary radiologic interpretation was that of an intra-abdominal abscess secondary to a ruptured appendicitis with associated high-grade small bowel obstruction. Following the insertion of a nasogastric tube and the administration of antibiotics, the patient was taken to the operating room. Prior to incision, the CT scan was reexamined and a fluid collection with surrounding fat stranding was noted extending from the bladder to the umbilicus with a transition point at the phlegmon (). Moreover, a normal appendix was visualized ().
Upon entry into the peritoneal cavity, a 4 × 5 centimeter cystic mass was encountered inferiorly and to the right of the umbilicus which was adherent and in continuity with the bladder (). The proximal ileum was adherent to this process and was identified as the transition point. The small bowel in its entirety was examined and there was no evidence of any further pathology. The urology service was consulted i

[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 male with past medical history positive only for diverticulitis with a resultant sigmoidectomy presented to a pain management specialist with progressively worsening bilateral low back, buttock, and radicular leg pain, weakness, and numbness for five weeks after falling from an 8 ft. ladder onto concrete. At the time of the fall, no notable injury was sustained and the patient reported only minimal low back pain without radiculopathy. Over the next several days, the patient began to experience numbness and weakness of the bilateral lower extremities. Evaluation in the ER, which included a hip X-ray and MRI of the lumbar spine (seen in ), revealed only mild lumbar facet arthropathy and moderate left neural foraminal stenosis at L3-L4 without any concomitant hip or spine fracture.
Following discharge, the patient reported worsening low back pain and bilateral lower extremity weakness in both L5 and S1 distributions. Several weeks after the initial fall, the patient was referred to pain management where he was evaluated and eventually underwent a radionuclide bone scan. This revealed mildly increased uptake at L5/S1 but was suspected to be a result of facet osteoarthritis. The patient denied any fever at this time, constitutional symptoms, or recent illness. Review of symptoms and physical exam were unremarkable aside from mild paraspinal tenderness and lumbosacral radiculopathy. The rest of the patient's neurologic exam was normal. The patient was instructed to follow up in one week's time. At the return visit, he reported continued worsening of symptoms with no relief. At this point in time, the patient mentioned that he had been experiencing shaking chills at night. Other review of symptoms and physical exam remained unchanged, and the patient was noted to be afebrile. A CT scan () and subsequent MRI of the lumbar spine () were conducted which revealed extensive findings of discitis/osteomyelitis at L5–S1 as well as an epidural abscess result

[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 54-year-old woman complained of finding a lesion in the right liver during her last medical check-up by abdominal B type ultrasound. Further inquiry revealed recurrent right upper abdomen dull pain during the last few months. She was diagnosed of primary biliary cirrhosis 2 months ago in local hospital and had the history of chronic cholecystitis for >20 years. All physical examination findings were normal. No elevation of tumor markers including α-fetoprotein, carcinoembryonic antigen (CEA), cancer antigen 125, and cancer antigen 199 was observed. Hepatitis virus markers were all negative and liver function test was normal. HCC was suspected. Therefore, abdominal contrast-enhanced computed tomography (CT) scan was arranged to confirm the diagnosis.
The CT (Fig. ) revealed a circular and low density lesion in the right posterior lobe of the liver, approximately 22.0 × 18.7 mm in size. The lesion showed relatively low density in arterial phase and faded signal in portal phase and delayed phase. HCC was highly suspected, and hepatic steatosis and cirrhosis were also noted.
The patient was admitted for further examination and treatment. No abnormality was found by blood tests. Abdominal magnetic resonance imaging (MRI) (Fig. ) showed that the lesion was located in right liver measuring about 20 × 18 mm and showed low signal intensity (SI) on T1-weighted images (T1WI) and high SI on T2-weighted images (T2WI). The lesion showed enhancement on arterial phase and faded signal on portal and delayed phases. Hypervascular neoplasm was suspected according to MRI.
The patient received right posterior hepatectomy and cholecystectomy under the impression of HCC. During the operation, a gray firm lesion about 20 mm in size was found in segment VII of the liver (Fig. A). The operation had lasted about 5 hours, and the volume of blood loss was about 200 mL. The pathological examination showed, microscopically, lymphoid cells proliferation and lymphoid follicles formation in lesion

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

[User]
RADIOLOGY NOTE:
A 48-year old man presented with left popliteal pain that had developed 3 months previously. The pain was aggravated when the knee joint was extended in the standing position. He had first visited an orthopedic clinic where a magnetic resonance imaging (MRI) scan showed a cystic lesion around the left popliteal vein with no abnormal findings explaining the pain ().
His previous medical history was unremarkable. There were no deep vein thrombosis-related symptoms like calf swelling or tenderness, and no pulmonary thromboembolic events. Ultrasound (US) Doppler examination done immediately at the time of his visit to our clinic with the patient in a standing position revealed a 2.2×1.6 cm sized saccular aneurysm at the posteromedial aspect of the left popliteal vein at the level of the popliteal crease ().
Preoperative computed tomography (CT) venography was done to evaluate the lesion and adjacent structures. The PVA was confirmed at the same location as seen in the US Doppler. The aneurysm measured 2.0×1.5 cm in the supine position (). A lung perfusion scan was done to rule out pulmonary thromboembolism; no perfusion defect was found.
PVA resection and popliteal vein repair were planned. US mapping was done for accurate surgical incision in the operation room. The patient was placed in the prone position after spinal anesthesia. An S-shaped skin incision was made above the popliteal fossa. Meticulous dissection was performed to isolate the popliteal vein including the aneurysm without the use of electro-cautery, to avoid tibial nerve injury (). The entire aneurysmal sac was isolated and clamped with a side-biting clamp. The aneurysm was resected tangentially while maintaining the venous flow and the remaining vein was repaired with 7-0 polypropylene suture (). After the removal of the clamp, a partial aneurysmal dilatation was remaining. The lesion was repaired using a horizontal mattress suture with 7-0 polypropylene. Grossly, no other dilatation of the popliteal ve

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

[User]
RADIOLOGY NOTE:
A 7-year-old male patient who presented at the Neurology service for a headache in his right temporal region that had evolved during one week, of intermittent nature, mild to moderate intensity, each episode between 3-4 seconds; and with subsequent, complete recovery. No history of trauma; he denies presenting fever or other systemic manifestations. There was no distal coldness, crying, or pallor, no feeling of dizziness, nausea, emesis, photophobia, phonophobia, or autonomic symptoms, no relationship with valsalva, or associated with exercise. Neither the patient nor his parents identified any triggering factors.
The patient reports four episodes of PSH in the week prior to the consultation, without interfering with his sleep hours. There is no history of other neurological symptoms, epileptic seizures or changes in personality. The interrogation did not recognize alterations in neurodevelopment, he presents a good school performance and an adequate sleep pattern. No personal background of relevance. No headaches or other related pathologies are reported in the family history.
On physical examination, he presented normal vital signs, a weight of 22 kg and 1.22 m of height. In the neurological examination, neither alterations nor skin stigmas indicative of neuro-cutaneous syndromes were identified.
The intervention was started with a one-month observation period, in which the child's caregiver was asked to prepare a headache diary that would allow characterizing and quantifying the episodes (date and time, laterality, associated activity, duration and need for medication).
The following month, he was cited for a control, where 21 episodes were quantified with the clinical characteristics described above but without a predominant laterality; no triggering or attenuating factors were identified. A simple and contrasted cerebral magnetic resonance imaging was performed, which showed no alterations of any kind. Based on the characteristics of the episodes, the clinical

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


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

[User]
RADIOLOGY NOTE:
A 39-year-old male presented with a one-year history of pain, swelling of the gingiva and an occasional pus-like discharge in the right mandible. Several teeth had slowly become loose and one tooth had fallen out. The patient was previously prescribed antibiotics by a local dentist who considered the problem to be a bacterial infection. The symptoms were alleviated, yet the problem was never completely resolved. Eight months prior to the current presentation, an initial panoramic radiography of the jaw was taken in a local hospital and the patient was diagnosed with osteomyelitis of the jaw. Although it was suggested that the patient should receive further treatment at a tertiary hospital, since the symptoms were tolerable, this advice was not followed in the eight months previous to the current presentation. At this time, the patient was immediately admitted to the Department of Oral and Maxillofacial Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine (Hangzhou, China) for further investigation.
Clinical palpation of the right mandible revealed that the lateral surface of the mandibular body bulged and that the inferior margin of the body was concave. The first molar was missing and mobility of the neighboring teeth was detected. The second and third molars sloped anteriorly, resulting in immature tooth contact. There was a conspicuous pit in the right mandible, between the first premolar and the second molar, yet no obvious pus-like discharge was found (). The midline of the mandible was shifted to the right by ~2 mm.
The initial panoramic radiograph showed an osteolytic lesion in the right mandible, ranging from the canine to the third molar, and with a moth-eaten margin. The lesion had already invaded the cortices and resulted in a pathological fracture of the mandible (). As the supporting bone was destroyed, the involved teeth appeared to be floating in the osteolytic lesion. The displacement of bone fragments led to immature contact o

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


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

[User]
RADIOLOGY NOTE:
A 62-year-old woman was hospitalized for the further evaluation of her progressive chest discomfort for 10 days. The patient had undergone total thyroidectomy 20 years earlier, and she has been managed for hypothyroidism since then. Seven years prior to admission, she was diagnosed with and managed for angina pectoris, but was not evaluated properly. A month before presentation, she had experienced worsening chest pain with dyspnea on exertion despite medication. She was diagnosed with severe mitral regurgitation by echocardiography at our cardiovascular clinic. When she was hospitalized, she complained that her chest pain and dyspnea had been aggravated with time. Two weeks of medicinal management did not control the symptoms. After dobutamine stress echocardiography, it was determined that the patient should undergo open heart surgery. Mitral valve replacement was performed under extracorporeal circulation. Immediately after surgery, the patient's general condition and laboratory data were found to be stable except for mild thrombocytopenia. Platelet concentrates were transfused to increase the platelet number and prevent unexpected bleeding. A postoperative echocardiogram showed good mitral valve function without para-valvular regurgitation. Since postoperative day 4, she had a fever over 38℃ and the laboratory data showed signs of disseminated intravascular coagulopathy (DIC). Acinetobacter baumannii was cultured in the blood. She was treated with broad spectrum antibiotics for sepsis as well as plasma and platelet transfusion for pulmonary hemorrhage, which occurred on postoperative day 6. Since the thrombocytopenia did not respond to transfusion, intravenous immunoglobulin G was infused and methylprednisolone was administrated intravenously at a dose of 15 mg three times a day. In spite of vigorous treatment, the platelet count did not increase, and even worse, it decreased to a lower count. The lowest platelet count occurred at postoperative day 9. To identif

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


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

[User]
RADIOLOGY NOTE:
A 51-year-old hypertensive Pakistani male patient was admitted in the cardiac intensive care unit in King Fahd University Hospital on 30 July 2017 complaining of chest and back pain for two weeks prior to the presentation; he took nonsteroidal anti-inflammatory drugs but were not effective. Physical examination was done in the emergency department and revealed stable vital signs; the patient was conscious, moving all his limbs; there were warm palpable pulses of the upper arms.
The CTA of the aorta revealed a large dissection flap from the origin of the left subclavian artery extending down all the way to the level of renal arteries; there was enlargement of the false lumen at the proximal aorta with large aneurysmal dilatation (mural thrombus) and a compression of the true lumen (ascending aorta). Additionally, there was a large entry point seen 2 cm distal to the right subclavian artery. The aberrant right subclavian artery was noted crossing posterior to the trachea and arising as a last branch of the aortic arch distal to the left subclavian artery; also, the left vertebral artery was arising directly from the aortic arch. There was no other evidence of vascular dissection or occlusion below the level of the renal arteries (Figures and ).
The patient underwent general anesthesia for thoracic endovascular repair (TEVAR) two days after his first day of admission; the procedure was done through the right femoral approach; an angiogram was performed intraoperatively (). Stent graft with a size of 34 mm × 15 cm was used and deployed into the descending thoracic aorta; the intimal entry tear was completely covered by the stent, and the false lumen was obliterated. A postdeployment angiogram revealed successful proximal occlusion of the entry point with no perfusion of the false lumen and good flow through both carotid and left vertebral arteries as well as patent right and left subclavian arteries.
The patient was postoperatively moving all his limbs, and the peripher

[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:
O.T, a 20-year old Nigerian female student was seen in July 2007 with history of recurrent breathlessness which had started about 10 years earlier. Her symptoms worsened in the previous three weeks when she became breathless at rest, had paroxysmal nocturnal dyspnoea, bilateral leg swelling and cough productive of whitish, and blood-stained sputum. Past history was significant for recurrent sore throat in childhood and skin rashes. She was not previously diagnosed hypertensive or asthmatic. She was the second child in a monogamous family; both parents are in a very low income group. Her genotype was AS and she was not smoking cigarettes or consuming alcohol. There was no family history of the disease in any of her siblings.
Examination revealed that the woman looked pale, was chronically ill, and had a tinge of jaundice with severe bilateral pitting pedal oedema. A cardiovascular system examination revealed a pulse rate of 120 per minute, irregular and small volume, blood pressure of 90/60mmHg, elevated jugular venous pressure, displaced apex beat which was located at 7th intercostal space anterior axillary line and a fourth, first and second heart sounds. The respiratory rate was 36 cycles per minute and bilateral crepitations. Other examination findings were a tender, pulsatile hepatomegaly of 6 cm below the right coastal margin.
An echocardiography showed densely thickened mitral valves with severe commissural fusion leading to doming of the mitral valve in diastole, markedly dilated left atrium with an intramural clot attached to the posterior left atrial wall, reduced left ventricular ejection fraction, markedly dilated right atrium and right ventricle. Colour flow showed severe tricuspid regurgitation. The calculated mitral valve area is 0.67cm square. Complete blood count showed leucocytosis with a white cell count of 19,700/cubic centimetres and marked neutrophilia. The chest X-ray revealed cardiomegaly with a double cardiac shadow in keeping with the dilate

[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 77-year old lady with a known expansive lesion of the right frontal lobe was admitted to the department due to a rapid deterioration of left-sided hemiparesis. She has been followed up constantly at the neurosurgical outpatient clinic as a result of an expansive lesion, radiologically characterised as meningioma. The lesion has been known for many years, and according to radiological imaging, it had been persistingly unchanged. Until now, the woman was in a good medical condition and did not report of any difficulties in relation to this lesion. However, her neurological condition deteriorated suddenly with weakness of the left limbs. At home, she was walking with progressive difficulty, the gait was unstable and in a few hours, she was not able to stand and walk any more. Additionally, she complained of frontal headache and nausea. Neither loss of consciousness nor seizures were reported by the relatives.
During a neurological examination, no consciousness or cognitive deficits were found. Testing of cranial nerves was normal. There was marked muscle weakness of the left side, equally pronounced in the upper and lower extremity. On the left, the muscle tone was slightly lowered. In comparison with the right side, the reflexes in the left upper and lower extremities were weaker. Walking was not possible.
MRI of the head revealed progression of the tumour, measuring 3 cm in diameter. It was located parasagittally in the right premotor area, surrounded with an extensive oedema, compressing the cortex. After contrast application, it was enhanced homogenously (Fig. ). Following antioedematous therapy with intravenous injections of dexamethasone, the condition briefly improved but worsened again despite further aggressive medicamentous treatment. Surgery was indicated. A right parietal parasagittal craniotomy was performed, nicely exposing the oedematous brain tissue of premotor cortex with the tumour, which was removed completely.
Histologically, the tumour was an ang

[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 patient was referred to a surgeon for extraction of roots of tooth no. 36. Radiographic and clinical examination revealed favorable clinical situation for immediate transplantation of tooth no. 38.
All auto-transplantation procedures were performed following established surgical protocol. Prior to operation sufficient local anesthesia and a mouth-rinse of chlorhexidine 0.02% for at least 1 min were obtained. The tooth at the recipient site is then sectioned with a bur and extracted preserving alveolar bone. Recipient socket is prepared considering measurements of donor tooth germ from panoramic radiograph, — removal of the inter-radicular septum, trimming of neighboring teeth crowns in case of the recipient site narrowing is performed. Next, the donor tooth is carefully removed. In cases of total impaction, flap elevation, bone removal, tooth germ careful removal with the follicle around the crown is performed. When a donor tooth is erupted, careful circumcising around the tooth is made before luxation and gentle extraction preserving as much periodontal ligament (PDL) as possible, as it is imperative for tooth integration at the recipient site.[] Once removed, donor tooth is stored in its original socket until further adjustment of recipient socket are performed. A donor tooth should be handled as little as possible with a minimal delay between extraction and transplantation in order to ensure periodontal membrane vitality.
After transplanted tooth is in its final position, it is stabilized with a criss-cross suture and it is fixed to adjacent teeth with light polymerizing resin and wire splint in slight infra-occlusion. A proper vertical position of the tooth is essential to allow it to erupt and fit into occlusion over the next few months. The transplanted tooth should not contact with opposing teeth during 1st month until it acquires physiological mobility. When donor tooth is positioned in occlusal level during operation (due to root full 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:
Our patient was a 74-year-old Chinese man who had undergone left radical nephrectomy 10 years earlier. Postoperative pathological examination revealed clear cell carcinoma. One year later, he returned for laparoscopic cystectomy due to cholelithiasis, and we found a mass in the subcutaneous tissue protruding by about the size of a thumb into the abdomen. We did not resect the protruding mass, and we decided to see our patient on an annual follow-up basis. Nine years later, he came back to see us because he noticed the protruding mass in the subcutaneous tissue had grown larger within the last year. His physical examination revealed two masses, and enhanced computed tomography (CT) showed a 5 × 6-cm mass in the left side of the anterior abdominal wall and a 5 × 6-cm mass in the back of the right waist (Fig. ). Enhanced CT also revealed a hypervascular lesion in the pancreas (Fig. ). The patient’s tumor marker carcinoembryonic agent concentration was 6.0 ng/ml. Malignant tumors were suspected, and resection of the tumors was performed.
In surgery with the patient under general anesthesia, we first placed the patient in prone position to resect the tumor in the back of the right waist. Then, he was placed in supine position to resect the tumor in the left side of the anterior abdominal wall. Both tumors in the front and back were around 5 × 6 cm in size, and clear cell carcinoma was suspected. Later, we performed distal pancreatectomy with spleen preservation because enhanced CT showed a hypervascular lesion of approximately 3 × 3 cm in the pancreas. The size of the resected tumor in the left side of the anterior abdominal wall was 4 × 2.8 cm; the one in the right waist was 4 × 2.5 cm, and the ones from the pancreas were 1.8 × 1.3 cm and 1.9 × 1.5 cm. All resected tumors were of the clear cell type. Histopathological examination revealed they were

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


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

[User]
RADIOLOGY NOTE:
A 34-year-old woman with no significant past medical history presented with the chief complaint of left facial numbness, left ear pain and decreased hearing in the left ear of three years duration. The patient had also been experiencing sharp and shooting pain in different areas of her left thigh. The pain was not associated with any weakness, tingling or numbness. Besides mild fatigue she denied having any fevers, night sweats or weight loss. Neurological physical examination was grossly intact except for sensory loss in the V2 (maxillary) and V3 (mandibular) distribution of trigeminal nerve (cranial nerve V). Abdominal exam was without evidence of lymphadenopathy and hepatosplenomegaly. Given deficits in the sensory distribution of trigeminal nerve, she was initially evaluated by ear, nose and throat (ENT) and underwent two sequential minimally invasive surgeries for nasal polyps without significant resolution of her symptoms. She was subsequently referred to a neurologist and had magnetic resonance imaging (MRI) of the brain performed. Brain MRI revealed a soft tissue mass with expansion in the left Meckel’s cave, measuring 22 x 16 x 12 mm (Figure ), raising concerns for a trigeminal schwannoma. She was evaluated by the neurosurgery and underwent an orbital zygomatic craniotomy and left trigeminal schwannoma resection. Pathology revealed deposition of abundant hypocellular eosinophilic material on light microscopy examination (Figure ). Congo red staining demonstrated characteristic 'apple-green birefringence' upon polarization (Figure ), consistent with diagnosis of trigeminal nerve amyloidoma. Unfortunately, no immune fluorescence or electron microscopy was done on the pathology specimen to determine the amyloid subtype. Postoperatively, the patient was referred to oncology to rule out systemic amyloid deposition. Basic workup including complete blood count was unremarkable except for hemoglobin of 12 g/dL with mean corpuscular volume (MCV) of 76 fL per cell. 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:
An otherwise healthy 23-year-old Caucasian man presented to our Emergency Department reporting a sensation of “bubbles” under the skin of his neck and mild chest pain. He denied any dyspnea, neck pain, dysphagia, odynophagia, or dysphonia. He reported that he had “snorted” a small amount of cocaine two nights prior to his Emergency Department presentation. He did not have a history of chronic or regular drug use. There was no history of any trauma or vigorous physical exercise. He had mild rhinorrhea but no coughing or vomiting. He did not take any regular medication, but reported the occasional use of illicit drugs such as cocaine and ecstasy.
On examination, he was alert and responsive without any airway compromise or respiratory distress. His pulse rate was 96 beats per minute with a blood pressure of 120/73mmHg. He had a respiratory rate of 18 breaths per minute with oxygen saturation of 97% on room air and he was apyrexial. Subcutaneous crepitations were palpable across his neck and the superior part of his chest. The rest of his physical examination was unremarkable.
Results from baseline blood tests, including arterial blood gases, were unremarkable and an electrocardiogram showed a normal sinus rhythm with no arrhythmias or segmental changes. A plain posterioranterior chest radiograph revealed subtle pneumomediastinum and soft tissue emphysema at the base of his neck with no associated pneumothorax (Fig. ). A plain radiograph of his neck demonstrated extensive subcutaneous emphysema (Fig. ). Computed tomography of his neck and chest was performed, and confirmed the above radiographic findings (Figs. and ). No additional sequelae of cocaine use, such as granulomas, emphysema, or bullae, were seen on pulmonary imaging. In order to rule out any esophageal involvement, our patient was transferred to a tertiary center for a barium swallow fluoroscopy study, which was normal (Fig. ).
He was admitted under the care

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

[User]
RADIOLOGY NOTE:
A 68-year-old woman with a history of colon cancer was referred for thoracoscopic resection of a metastatic lesion in the right inferior pulmonary lobe (). Preoperative coronary angiography revealed total occlusion of the left anterior descending artery (LAD) after the origin of the first diagonal branch (). Percutaneous coronary intervention was not performed because of its technical difficulty and contraindication for perioperative anticoagulation. To minimize the operative trauma, we performed simultaneous MIDCAB via a small left thoracotomy and thoracoscopic wedge resection of the lung lesion.
The patient was anesthetized and intubated with a double-lumen endotracheal tube. Single-lung ventilation was used to facilitate exposure for harvesting of the left internal thoracic artery. The patient was positioned supine with 30° rotation toward the right decubitus position by means of a rolled towel. External pads for emergency defibrillation were placed on the right anterior and left posterior sides of the chest wall. A 5-cm left anterior thoracotomy incision was then created along the inframammary line and tunneled into the fourth intercostal space according to the preoperative chest X-ray and coronary angiography images. After harvesting of the left internal thoracic artery, a pericardial incision was made to expose and stabilize the LAD with a specially designed minimally invasive stabilizer. The coronary anastomosis was performed using a continuous running suture technique (8-0 suture) and intracoronary shunting.
After heparin neutralization and switching of the single-lung ventilation to the other side, the patient was positioned supine with 30° rotation toward the left decubitus position. A 4-cm incision in the fifth intercostal space was made along the right anterior axillary line for wedge resection of the dorsal segment of the right inferior pulmonary lobe using a thoracoscopic linear stapler with a blue reload. After the surgery, the patient was transferred

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


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

[User]
RADIOLOGY NOTE:
We report the case of a 58-year-old female patient with a history of acute pancreatitis with conservative treatment 2 years ago, chronic alcohol consumption with affirmative abandoning in the last 12 months, and an admission for a left pleural effusion one month ago, with resolution under antibiotic treatment. Due to the persistent abdominal pain, the patient underwent an abdominal ultrasound and CT scan which showed biliary lithiasis and the presence of 3 distinct large cystic masses in the pancreas and spleen (Figures and ). Surgery was proposed but the patient refused it.
The patient was subsequently admitted for intense abdominal pain with altered general status (blood pressure 90/60, pulse 110) and a drop of the hemoglobin level to 8.2 g/dL. An emergency CT scan showed the same cystic lesions and raised the suspicion of a ruptured splenic artery pseudoaneurysm and splenic hematoma. Due to the obvious signs of important bleeding and the impossibility to perform emergency arteriography, we decided to perform an emergency laparotomy.
Intraoperatively, we found a small amount of intraperitoneal blood and a large pancreatic pseudocyst filled with clots and fresh blood, extending into the retroperitoneum and spleen, corresponding to the 3 cystic lesions identified on the preoperative CT scan (). An active pulsatile bleeding from the splenic artery was identified in the cyst cavity (). Anatomic dissection of the splenic vessels at the level of the upper pancreatic border failed due to fibrosis and adhesions. We performed splenectomy, partial cystectomy with ligation of the splenic artery at the level of the vascular erosion (), cholecystectomy (lithiasis), and multiple drainage.
The immediate postoperative course was favourable, with discharge on postoperative day 19. The patient presented 2 postoperative complications: an elevated level of platelets which required prolonged anticoagulation (low molecular weight heparin followed by oral warfarin treatment) and a pancr

[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 woman presented in our vascular clinic due to an asymptomatic juxtarenal 10 cm AAA identified as an incidental finding in a recent computed tomography (CT) scan (
). Her medical history included mild hypertension under drug medication. At physical examination of the abdomen, a large pulsating mass was present with normal pulsation of femoral and tibial vessels. There were no complaints of previous intermittent claudication.
The woman was planned for open repair. She was very anxious about the result and the possible complications of the surgical procedure. The woman had intense stress, phobia for surgery, and was consulted by a psychiatrist.
To better define the aneurysm anatomy (with 1mm imaging slices), we performed a new CT angiography (CTA) 48 hours after admission, which surprisingly revealed complete thrombosis of the AAA just below both renal arteries without any signs of acute renal insufficiency, mesenteric ischemia, or limb ischemia (
). The most impressive element of the CTA was the rich collateralization between the thoracic aorta and the common femoral arteries through the superficial epigastric and other arteries of thoracic and abdominal wall. This collateralization was not evident in the first CT 2 days earlier.
The following physical examination revealed the absence of the previous pulsating mass and absence of femoral and distal leg pulses. Both legs were warm with normal skin color. The surgical procedure was postponed and the woman was discharged from the hospital with double antiplatelet therapy and weekly follow-up for the possible signs of limb ischemia.
After a month, the patient presented with severe intermittent claudication in the left lower limb. The following digital subtraction angiogram revealed a thrombosed abdominal aorta with collateral vessels between the aorta and both common femoral arteries (
). The woman underwent a left axillary–femoral bypass with polytetrafluoroethylene No. 8 graft. The patient's postoperative

[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 38-year-old Greek woman who presented to our Emergency Department complaining of abdominal pain during the last week without any other symptoms. Her clinical history was clear and she had not noticed the occurrence of the same symptoms before. A clinical examination revealed only focal tenderness in the left part of her abdomen. Laboratory results were within normal limits. During an ultrasound examination of her abdomen, an anechoic lesion in her upper left abdomen was revealed. In a further investigation with computed tomography (CT), a well-defined hypodense cystic 7.08 × 6.05 cm mass with mild enhancement was noted (Fig. ). Surgical approach was decided after a thorough examination and our patient gave her consent for surgery. A cystic lesion sized 7.08 × 6.05 cm appeared between the layers of small bowel mesentery (Fig. ). The cystic lesion was excised within healthy borders and sent for further pathologic examination (Fig. ). On macroscopic examination, the cyst sized 7.08 × 6.05 cm was unilocular and contained a white, milk-like viscous fluid (chylous), which was drained out by incision. Histopathological investigation showed a thick fibrous wall, pervaded by chronic inflammatory cells (lymphocytes and plasma cells) and lymphoid aggregates. Variously sized vessels could also be observed while immunohistochemically CD31 (platelet endothelial cell adhesion molecule) was positive (Fig. ). CD31 is used primarily to demonstrate the presence of endothelial cells and can help to evaluate the degree of tumor angiogenesis. A definitive inner epithelial lining was not found. On the inner surface, multiple aggregates of foamy macrophages as well as focal foreign-body giant cells were present. (Fig. ) The thickness of the wall varied trivially with small parts of mature fat tissue toward the outer surface, indicating the mesentery. The findings were found to be most consistent with a simple lymphatic (chylous) cyst of the mesentery in combination with

[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 4-year old male child was referred to our hospital (St Paul’s Hospital Millennium Medical College located in Addis Ababa, Ethiopia) from a district hospital for further evaluation of recurrent chest infection and wheezing in 2018. He was admitted to the referring hospital eight times for chest infection in the first 2 years of his age. The first admission happened at the age of 2 weeks. Cough, fast breathing, and wheezing were the main presenting symptoms during the exacerbations. At each admission, he was treated with parenteral antibiotics and bronchodilators and was discharged from the hospital after he got improvement. He was apparently healthy in between the episodes of the respiratory illness. He did not have history of chocking episodes. He was delivered in a hospital at term, and pregnancy was uneventful. He had optimal development and was a kindergarten student at the time of writing this report.
On examination, he was not in respiratory distress and SPO2 was 94%–96% with room air. He weighed 14 kg, with a height of 106 cm (his anthropometric indices lie above –2 SD except his weight-for-height which lies between –2 and –3 SD). Chest examination revealed trachea shifting to the right side, decreased air entry over the right lung field, and relative dullness over the same area. Cardiac auscultation revealed normal heart sounds with regular rate and rhythm with no gallop. He was alert and playful, having good interaction during the examination.
Basic laboratory examinations were within normal limits, and HIV status was negative. Chest X-ray showed hyperinflated left lung and reduced right lung volume with decreased vascularity and trachea shifted to the right ().
Echocardiography demonstrated absence of the right pulmonary artery with no other cardiac lesion (). Subsequent computed tomography (CT) scan also showed hypoplastic right lung with absent right pulmonary artery ().
The case was evaluated by a team comprising pediatr

[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 4 year-old girl from Sarlahi district in Nepal was brought to our emergency room with a history of sudden onset of severe headache and generalized tonic clonic seizures. She had a history of a minor fall injury while playing at preschool. At that time there was no loss of consciousness, nausea or vomiting and she remained well for the following two days. Two days later at around 3 a.m., the child screamed out in her sleep and complained of severe headache followed by an episode of generalized tonic clonic seizure. The child was then rushed to the hospital. At presentation, her Glasgow Coma Score was 14/15 (E4/M6/V5). No anisocoria was present. She was hemiparetic on the right side with a power grade of 3/5. Computed tomography (CT) scan of the head showed focal intra cerebral hemorrhage in the medial basifrontal region and subarachnoid hemorrhage (SAH) in the inter-hemispheric and in the left sylvian fissure (
). No significant past medical or surgical illnesses were elicited. She was managed conservatively in the neurosurgical intensive care unit. In repeated serial CT scans, the hematoma was found to be resolving and the child’s motor power in the right side had improved to 4+/5. The child was discharged with advice of regular follow up. The child was again brought to the emergency room one month following the initial hemorrhage with a history of headache and repeated episodes of vomiting. GCS was 15/15 with both pupils equal and reacting to light. CT scan showed re-bleed in the left medial basifrontal region with ventricular extension (Graeb score of 8/12) (
). The child developed acute hydrocephalus with sudden drop in conscious level which was managed with emergent placement of external ventricular drain (EVD) from the right Kocher’s point. Conventional cerebral angiography showed delayed filling of a 9.6 mm × 6.8 mm aneurysm arising from the proximal

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


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

[User]
RADIOLOGY NOTE:
A 22-year-old man who was involved in a car accident sustained a hemorrhagic cerebrovascular accident. His hospital stay extended for several months and was remarkable for prolonged intubation (2.5 months),tracheostomy tube placement, jejunostomy tube placement, and recurrent chest infections. During his hospital stay, the patient did not receive any lower limb physical therapy. Upon discharge, he had right-sided spastic hemiparesis with aphasia and was started on private physiotherapy and rehabilitation. He presented to our outpatient clinic after 1.5 years of physiotherapy with significant resistance and progressive limitation in the range of movement around the right hip joint. At this stage, the patient was bed ridden with the inability to ambulate independently. On physical examination, the patient was continent, the right hip joint was absolutely stiff with flexion deformity and fixed external rotation, and power was 4/5 all over the right lower extremity with intact sensation. His left hip joint had a completely normal range of motion and the rest of the physical examination was unremarkable.
Radiographs of the right hip joint revealed evident ossification(). On 3D-CT, HO surrounding the right hip joint was seen associated with atrophied muscles and partial fusion of the proximal femur and dorsal acetabulum/ischium, causing fixed external rotation of the right femur (). SAP level at presentation was within normal limit. The bone scan initially demonstrated increased blood flow and hyperemia at the involved region, suggesting that the observed HO was immature; however, when repeated after 6 months, the bone scan was normal. The patient was consented for excision and arthrolysis. Intraoperatively, the patient sustained a stable intertrochanteric fracture and a dynamic hip screw (DHS) was inserted ().Postoperatively, there was a significant improvement in the range of motion with physiotherapy and oral indomethacin as the first two cases. Sadly, however, the fol

[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 female was referred with pain involving the upper left incisors region. Patient history revealed endodontic treatment of the maxillary upper left incisors with necrotic pulp and periapical radiolucency six months earlier. A few months after the treatment, she experienced discomfort pain. Extraoral examination revealed an integrate mucosa with normal appearance, whereas, intraorally, the upper left lateral incisor presented chromatic alterations and mobility in the region. A periapical radiograph showed the presence of a defined radiolucency lesion between the upper left incisors of the endodontically treated teeth with a size of 2.5 × 1.0 cm in a high diameter (). An incisional biopsy was made using local anesthesia and sent to the Oral Pathology Laboratory. The specimen was fixed in 10% neutral formalin and routinely prepared for light microscopy; the sections were stained with hematoxylin and eosin. Histological examination showed malignant neoplasm fragments consisting of fusiform cells with comma-shaped nuclei, originating from cell bundles exhibiting one of two forms: a round shape with large nuclei (occasionally palisading) or hyalinized strands and/or islets (Figures and ). Immunohistochemistry analysis was performed using streptavidin-biotin technique with monoclonal antibodies; the cells were positive for both the S-100 protein and the glial fibrillary acidic protein (GFAP) (Figures and ). The immunohistochemical expression of protein S-100 was weak at less than 50% of the tumor cells (), and a diagnosis of MPNST of the maxilla was made. The patient was referred to the Oncology Department and was subjected to surgical excision of the upper left lateral incisor as well as the total removal of the remaining lesion and adjuvant chemotherapy. The examination of the surgical part had not exhibited banks committed and it was staged as low grade of malignancy. The research of metastasis through the exams for images revealed no secondary tumors. The c

[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, apparently healthy male presented with intermittent leak of clear fluid from his nostrils for the last 2 years. Initially, he had assumed that he had an attack of the common cold; however, when the leak persisted, becoming more frequent and increasing in amount, he sought medical opinion.
He gave no previous history of trauma, hypertension, headache, or meningitis. The leaking fluid was examined and was found to be CSF. Detailed clinical evaluation of the patient did not reveal any other neurological abnormality. There were no features of meningeal irritation.
CT cisternography was performed, which revealed an approximately 3-mm size defect in the left anterolateral wall of the sphenoid sinus, with a soft tissue density mass filling the adjacent part of the sphenoid sinus []. Despite putting the patient in the knee–elbow position for 30 min and applying compression over the jugular veins, we could not demonstrate an active leak at the time of the examination. Another smaller bony defect was also observed laterally involving the greater wing of the left sphenoid []. Remodeling of the greater wing of the left sphenoid was also seen. As compared with the normal right side, it was thinned out and bulged toward the infratemporal fossa.
MRI revealed a tongue of the anteromedial temporal lobe herniating through the bony defect. Abnormal T2 hyperintensity was also demonstrated in the adjacent temporal white matter. No herniation of brain or meninges was seen through the lateral defect in the greater wing of the left sphenoid [Figure and ].
Taking into consideration the history of recurrent CSF rhinorrhea and the imaging findings, the patient was advised surgery. He was operated through the transnasal route. At surgery, the dural and bony defects and the associated prolapse of the anteromedial temporal lobe were confirmed. The herniated tiny lip of tissue was amputated and the dural defect was closed. The patient had complete resolution of CSF rhinorrhea and 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 23 years old Malay lady who was born with a solitary lesion over her right foot dorsum. Initially the size of the lesion was about the size of a pea and gradually increase in size and causing pain. At the age of 1 month old, parents claimed it was excised. Over the years, other cutaneous skin lesion erupted and size gradually increase. The biggest lesion was over the right arm and it was operated at the age of 2 in tertiary hospital by hand surgeon.
Patient had her episodes of recurrent intestinal bleeding which resolves spontaneously since the age of 19 and requires frequent blood transfusions. Later, the patient was referred to surgeon for her chronic anemia with multiple cutaneous bluish lesion. Investigations that was done including OGDS, colonoscopy, capsule endoscopy and CT abdomen. Due to this indwelling problem, patient underwent laser treatment of the gastrointestinal lesion and she was symptom free for about one year. Sclerotherapy for lesions on each foot sole and right hand dorsum had to be done due to pain especially upon ambulation.
Unfortunately a year later, patient had a massive gastrointestinal bleeding which require patient to underwent major surgery. Intraoperative findings were multiple naevi over small and large bowel with contact bleeding which were excised, large naevus at the mesentery at the proximal jejunum which was left in-situ, naevus over the appendix and appendicectomy was done and multiple naevi over the liver surface which was left in-situ. A total of 53 enterotomies and 9 colotomies was done for this patient. On the same setting of the surgery, over 112 cutaneous lesions were excised over suprapubic region and bilateral thighs. Post operatively she was recovered from any intestinal bleeding and does not require any blood transfusion. Clinically she was well and pink, laboratory investigations shows her hemoglobin level maintain at 10 gm/dL.
A year later, patient complaining of bilateral cheek and intraoral lesions which has cause

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


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

[User]
RADIOLOGY NOTE:
A 10-year-old white girl with right-sided SWS was diagnosed with right anisometropic amblyopia at age of 6 years and responded to glasses with a stabilized visual acuity of 20/100 in the right eye. She underwent laser treatment of the cutaneous nevus flammeus of the right side of the face with a good cosmetic result. There was no history of glaucoma. Magnetic resonance imaging of the brain excluded intracranial involvement. She presented with decreased vision in the right eye to over a period of 6 months with a hyperopic shift from 4.00 D to 6.00 D. At presentation, her best-corrected visual acuity (BCVA) was hand motions right eye and 20/20 left eye. Intraocular pressures were normal without evidence of iris neovascularization or abnormal conjunctival or scleral vessels. Ophthalmoscopic evaluation revealed a tomato ketchup red appearance of the right fundus compared with the left and a serous retinal detachment (RD) of the right eye (). The entire inferior retina of the right eye was detached with involvement of the macula. B-scan ultrasound and optical coherence tomography (OCT) () confirmed the presence of a diffuse choroidal hemangioma with thickening of the choroid and associated RD. Fluorescein angiography showed diffuse early hyperfluorescence. The intense early hyperfluorescence persisted through the laminar venous and full venous phases and only faded in the late angiogram phase. There was no fluorescein leakage from the retinal circulation. The patient underwent PDT with parameters typically used in treatment of choroidal neovascularization. Two sessions of PDT where the tumor was thicker were planned: the macula area and the area next to inferotemporal arcade. Verteporfin was infused at a concentration of 6 mg/m2, and an 83-second treatment was conducted with a 689 nm Zeiss laser that was delivered at 50 J/cm2 with an intensity of 600 mW/cm2. Firstly, four spots of 5300 μm were applied to the diffuse choroidal hemangioma in the

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


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

[User]
RADIOLOGY NOTE:
A 17-year-old woman with hypertrophic cardiomyopathy (HCM) was transferred to our hospital after successful resuscitation from ventricular fibrillation (VF). After the patient was diagnosed with HCM based on the echocardiogram and cardiac biopsy 2 years prior, she had been free from any symptoms or arrhythmic events while taking a beta-blocking drug and ACE inhibitor. Both her father and grandfather had HCM, and her father died suddenly at 53 years old. Although she did not complain of anything, her BNP level was constantly high (500–970 pg/ml), so cibenzoline of 200 mg was added 3 months prior for the purpose of improvement of diastolic function caused by attenuation of the LV contraction and prevention of arrhythmic events. Then, she collapsed while walking due to VF.
She arrived at our hospital while undergoing therapeutic hypothermia. Her height was 159 cm and weight 56 kg. Her blood pressure was 158/89 mmHg. Physical examination revealed coarse crackles in her whole chest. Blood tests revealed normal renal function and electrolytes. The plasma cibenzoline concentration was not checked.
An ECG showed ectopic atrial rhythm with heart rate of 63 bpm, complete right bundle branch block, and left ventricular hypertrophy with ST-T changes with QRS width of 148 ms and QTc of 0.514 (Figure ). Those findings were almost like those before the episode. The serial ECGs showed that QRS width gradually prolonged over 2 years from 110 to 147 ms, suggesting that the conduction disturbance from the His–Purkinje system through the ventricular myocardium had been progressing (Figure ). The ECG findings including QRS width did not change after commencement of the administration of cibenzoline.
After she recovered almost fully without severe neurologic sequelae, a subcutaneous implantable cardioverter–defibrillator (S-ICD) was selected for second prevention as she was young and pacing therapy was thought as unnecessary. The surface ECG screening prior to the S-ICD implantation was

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


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

[User]
RADIOLOGY NOTE:
A 46-year-old Javanese female presented in the emergency room with shortness of breath. Since the past month, the dyspnea got worse with physical activity and sleeping in supine or left lateral recumbent position and alleviated with sitting or left right recumbent sleeping position. Full examination of airway, breathing, and circulation revealed pleural effusion in the right hemithorax () and a lump of 8 × 7x3 cm in size with skin ulceration and retracted nipple in the right breast as well as enlargement of right axillary lymph nodes. More detail history taking revealed that the patient recognized a lump around 2 cm in diameter since a year before admission. The lump grew slowly, and skin ulceration appeared since the past month. No previous history of gynecological cancers as well as benign tumor in the breast including fibrocystic, ductal papiloma and atypical ductal hyperplasia. Her personal history included G3P3, menarche at 14 years, breast feeding for 18–24 months of each child, and using of hormonal contraception for 4 years. No family history of breast and gynecological cancers as well as no other important former medical visits were reported. Pleural aspiration was performed resulting in 200 ml serous-hemorrhagic fluid. Cytology analysis of pleural fluid revealed ductal cell carcinoma. Fine-needle aspiration of the lump near the ulceration in the right breast also showed ductal cell carcinoma. Ultrasonography of the breasts revealed diffuse spiculated masses in the right breast with enlargement of multiple lymph nodes in the right axillae (). Mammogram of the right breast could not be performed because of the skin ulceration and mammogram of the left breast showed breast dense of D type with equal density lesion in the retro-papillae suggested a fibrocystic lesion (). The patient was then diagnosed as breast carcinoma T4bN1M1. Metastatic breast cancer was established from the finding of breathless accompanied by pleural effusion in the right hemithorax with

[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.