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Extract medical evidence from the following clinical text that supports medical condition coding:
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His PTT was 24.8, INR 1.0, urinalysis negative. He had an electrocardiogram that was done that showed Q waves in 2, 3, F and Qs in V1 through V6 with left bundle branch block and PR prolongation. There was no substantial change from previous electrocardiograms. Chest film was performed, which showed no acute cardiopulmonary disease. HOSPITAL COURSE: 1. Gastrointestinal bleed: The patient's gastrointestinal bleed was felt likely due to radiation proctitis since the presentation was less consistent with diverticular bleed or an AVM. The patient was admitted to the Medical Intensive Care Unit for close hemodynamic monitoring and serial hematocrits.
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Evidence: electrocardiogram that was done that showed Q waves in 2, 3, F and Qs in V1 through V6 with left bundle branch block and PR prolongation.
Condition: Chronic ischemic heart disease, unspecified
HCC: I259
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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MEDICATIONS ON ADMISSION: 1. Atenolol 25 q.d. 2. Sorbitol 30 q.d. 3. Ambien 5 q.d. 4. Hydrocortisone 1% to scalp.
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Evidence: Atenolol 25 q.d.
Condition: Chronic ischemic heart disease, unspecified
HCC: I259
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2191-4-19**] Discharge Date: [**2191-4-21**] Service: [**Doctor Last Name 1181**] HISTORY OF PRESENT ILLNESS: The patient is an 85 year-old male with a history of coronary artery disease and radiation proctitis who presents with bright red blood per rectum on the morning of admission. The patient had a bloody bowel movement in his diaper at his nursing home and needed to be changed four times since that morning. His blood pressure was 110/60 and a heart rate of 70 in the field. The patient was transferred to the [**Hospital1 69**] for further evaluation. In the Emergency Department the patient was given two large bore intravenouses and he was given intravenous fluids.
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Evidence: coronary artery disease
Condition: Chronic ischemic heart disease, unspecified
HCC: I259
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2191-4-19**] Discharge Date: [**2191-4-21**] Service: [**Doctor Last Name 1181**] HISTORY OF PRESENT ILLNESS: The patient is an 85 year-old male with a history of coronary artery disease and radiation proctitis who presents with bright red blood per rectum on the morning of admission. The patient had a bloody bowel movement in his diaper at his nursing home and needed to be changed four times since that morning. His blood pressure was 110/60 and a heart rate of 70 in the field. The patient was transferred to the [**Hospital1 69**] for further evaluation. In the Emergency Department the patient was given two large bore intravenouses and he was given intravenous fluids. Gastrointestinal bleed scan was attempted and there was no clear evidence of a gastrointestinal bleed. Of note during the bleeding scan the patient's blood pressure dropped to the 70s and 80s and the patient was transferred back to the Emergency Department before the scan could be officially completed.
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Evidence: Coronary artery disease
Condition: Chronic ischemic heart disease, unspecified
HCC: I259
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2191-4-19**] Discharge Date: [**2191-4-21**] Service: [**Doctor Last Name 1181**] HISTORY OF PRESENT ILLNESS: The patient is an 85 year-old male with a history of coronary artery disease and radiation proctitis who presents with bright red blood per rectum on the morning of admission. The patient had a bloody bowel movement in his diaper at his nursing home and needed to be changed four times since that morning. His blood pressure was 110/60 and a heart rate of 70 in the field. The patient was transferred to the [**Hospital1 69**] for further evaluation.
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Evidence: coronary artery disease
Condition: Chronic ischemic heart disease, unspecified
HCC: I259
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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His PTT was 24.8, INR 1.0, urinalysis negative. He had an electrocardiogram that was done that showed Q waves in 2, 3, F and Qs in V1 through V6 with left bundle branch block and PR prolongation. There was no substantial change from previous electrocardiograms. Chest film was performed, which showed no acute cardiopulmonary disease. HOSPITAL COURSE: 1. Gastrointestinal bleed: The patient's gastrointestinal bleed was felt likely due to radiation proctitis since the presentation was less consistent with diverticular bleed or an AVM. The patient was admitted to the Medical Intensive Care Unit for close hemodynamic monitoring and serial hematocrits.
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Evidence: electrocardiogram that was done that showed Q waves in 2, 3, F and Qs in V1 through V6
Condition: Old myocardial infarction
HCC: I252
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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MEDICATIONS ON ADMISSION: 1. Atenolol 25 q.d. 2. Sorbitol 30 q.d. 3. Ambien 5 q.d. 4. Hydrocortisone 1% to scalp.
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Evidence: Atenolol 25 q.d.
Condition: Old myocardial infarction
HCC: I252
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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PAST MEDICAL HISTORY: 1. Coronary artery disease status post anterior myocardial infarction, status post coronary artery bypass graft in [**2182**], status post percutaneous transluminal coronary angioplasty in [**2186**]. 2. Congestive heart failure with an EF of 25% according to a [**2186**] echocardiogram with mild AS and aortic regurgitation and moderate mitral regurgitation. 3. Prostate cancer status post radiation therapy in [**2183**], complicated by radiation proctitis and bleeding. 4.
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Evidence: anterior myocardial
infarction
Condition: Old myocardial infarction
HCC: I252
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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2. Cardiac: The patient has a history of congestive heart failure, but he tolerated the packed red blood cells and fluid boluses well. His Atenolol was held out of concern for hypotension. There were no ill effects from a congestive heart failure standpoint. The patient remained satting well on room air and he did not have any evidence for congestive heart failure. In addition, the patient has a history of coronary artery disease, however, there was no evidence of ischemia on electrocardiogram. 3.
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Evidence: tolerated the packed red blood cells and fluid boluses well
Condition: Heart failure, unspecified
HCC: I509
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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MEDICATIONS ON ADMISSION: 1. Atenolol 25 q.d. 2. Sorbitol 30 q.d. 3. Ambien 5 q.d. 4. Hydrocortisone 1% to scalp.
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Evidence: Atenolol 25 q.d.
Condition: Heart failure, unspecified
HCC: I509
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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2. Congestive heart failure with an EF of 25% according to a [**2186**] echocardiogram with mild AS and aortic regurgitation and moderate mitral regurgitation. 3. Prostate cancer status post radiation therapy in [**2183**], complicated by radiation proctitis and bleeding. 4. Dementia secondary to Alzheimers.
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Evidence: Congestive heart failure
Condition: Heart failure, unspecified
HCC: I509
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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2. Congestive heart failure with an EF of 25% according to a [**2186**] echocardiogram with mild AS and aortic regurgitation and moderate mitral regurgitation. 3. Prostate cancer status post radiation therapy in [**2183**], complicated by radiation proctitis and bleeding. 4. Dementia secondary to Alzheimers. 5. Anemia.
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Evidence: congestive heart
failure
Condition: Heart failure, unspecified
HCC: I509
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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4. Dementia secondary to Alzheimers. 5. Anemia. ALLERGIES: Bee stings.
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Evidence: Dementia secondary to Alzheimers
Condition: Alzheimer's disease, unspecified
HCC: G309
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Satting 97% on room air. In general, he was an elderly man sitting, awake, alert, but not oriented to person, place or time. Head and neck examination extraocular movements intact. Mucous membranes are moist. Conjunctiva were well perfuse with no cervical lymphadenopathy. Cardiac examination he had a 4 out of 6 systolic ejection murmur and a 2 out of 6 diastolic murmur at the left upper sternal border. His lung examination was limited due to lack of cooperation, but it seemed that he had decreased breath sounds at the bases. Abdomen was soft, nontender, nondistended with normoactive bowel sounds. Extremities had no clubbing, cyanosis or edema.
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Evidence: not oriented to person, place
or time
Condition: Dementia in other diseases classified elsewhere without behavioral disturbance
HCC: F0280
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Satting 97% on room air. In general, he was an elderly man sitting, awake, alert, but not oriented to person, place or time. Head and neck examination extraocular movements intact. Mucous membranes are moist. Conjunctiva were well perfuse with no cervical lymphadenopathy. Cardiac examination he had a 4 out of 6 systolic ejection murmur and a 2 out of 6 diastolic murmur at the left upper sternal border. His lung examination was limited due to lack of cooperation, but it seemed that he had decreased breath sounds at the bases. Abdomen was soft, nontender, nondistended with normoactive bowel sounds. Extremities had no clubbing, cyanosis or edema.
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Evidence: not oriented to person, place
or time
Condition: Dementia in other diseases classified elsewhere without behavioral disturbance
HCC: F0280
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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4. Dementia secondary to Alzheimers. 5. Anemia. ALLERGIES: Bee stings.
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Evidence: Dementia secondary to Alzheimers
Condition: Dementia in other diseases classified elsewhere without behavioral disturbance
HCC: F0280
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Abdomen is soft, protuberant, bowel sounds active in all quadrants, no hepatosplenomegaly, no tenderness or masses. G tube in place mid abdomen. G site clean. Rectal examination deferred. Extremities: Light contractures of right upper extremity.
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Evidence: G tube in place mid abdomen.
Condition: Gastrostomy status
HCC: Z930
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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3. GI: Immediately, postoperatively the G tube was placed to gravity. His tube feeds were resumed on [**7-10**], postoperative day one with a Nutrition team following him. He had very low residuals and no problems with aspiration into the oropharynx. 4. Infectious Disease: The patient was afebrile throughout his stay. He was on Ancef and Flagyl after the surgery. He had a urinalysis that was positive and was placed on Cipro throughout the length of his stay.
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Evidence: G tube was placed to gravity.
Condition: Gastrostomy status
HCC: Z930
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Abdomen is soft, protuberant, bowel sounds active in all quadrants, no hepatosplenomegaly, no tenderness or masses. G tube in place mid abdomen. G site clean. Rectal examination deferred. Extremities: Light contractures of right upper extremity. Significant contractures of the left upper extremity with left hand flexed. No skin breakdown. All four limbs can be extended left greater than right. Neurologic: Mental status: Alert, minimally verbal, follows simple requests.
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Evidence: G tube in place mid abdomen.
Condition: Gastrostomy status
HCC: Z930
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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3. GI: Immediately, postoperatively the G tube was placed to gravity. His tube feeds were resumed on [**7-10**], postoperative day one with a Nutrition team following him. He had very low residuals and no problems with aspiration into the oropharynx. 4. Infectious Disease: The patient was afebrile throughout his stay. He was on Ancef and Flagyl after the surgery. He had a urinalysis that was positive and was placed on Cipro throughout the length of his stay. 5.
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Evidence: G tube was placed to gravity.
Condition: Gastrostomy status
HCC: Z930
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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GI: Immediately, postoperatively the G tube was placed to gravity. His tube feeds were resumed on [**7-10**], postoperative day one with a Nutrition team following him. He had very low residuals and no problems with aspiration into the oropharynx. 4. Infectious Disease: The patient was afebrile throughout his stay. He was on Ancef and Flagyl after the surgery. He had a urinalysis that was positive and was placed on Cipro throughout the length of his stay. 5. Respiratory: He continued to have thick secretions requiring frequent suctioning and chest PT.
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Evidence: His tube feeds were resumed on [**7-10**], postoperative day one with a Nutrition team following him.
Condition: Gastrostomy status
HCC: Z930
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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GI: Immediately, postoperatively the G tube was placed to gravity. His tube feeds were resumed on [**7-10**], postoperative day one with a Nutrition team following him. He had very low residuals and no problems with aspiration into the oropharynx. 4. Infectious Disease: The patient was afebrile throughout his stay. He was on Ancef and Flagyl after the surgery. He had a urinalysis that was positive and was placed on Cipro throughout the length of his stay. 5. Respiratory: He continued to have thick secretions requiring frequent suctioning and chest PT.
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Evidence: His tube feeds were resumed on [**7-10**]
Condition: Gastrostomy status
HCC: Z930
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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This problem was first noticed around eight years ago. He had a gastrostomy tube placed in [**2150**]. He continued to have reflux, however, with aspiration and recurrent pneumonia. In [**2159-6-12**], he developed right pleural effusion. He had a thoracoscopy and chest tube placement.
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Evidence: gastrostomy tube
Condition: Gastrostomy status
HCC: Z930
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Fleet's enemas q2-3 days prn. DIET: His diet includes 3/4 strength 2-cal HN 70 cc/G tube q hour with 1/4 strength Jevity Plus x12 hours q day along with two tablespoons of ProMod [**Hospital1 **]. FAMILY HISTORY: Maternal parents colon cancer. Paternal parents significant cardiac disease. Father died of transient ischemic attack and stroke.
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Evidence: G tube
Condition: Gastrostomy status
HCC: Z930
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Abdomen is soft, protuberant, bowel sounds active in all quadrants, no hepatosplenomegaly, no tenderness or masses. G tube in place mid abdomen. G site clean. Rectal examination deferred. Extremities: Light contractures of right upper extremity.
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Evidence: G tube in place
Condition: Gastrostomy status
HCC: Z930
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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3. GI: Immediately, postoperatively the G tube was placed to gravity. His tube feeds were resumed on [**7-10**], postoperative day one with a Nutrition team following him. He had very low residuals and no problems with aspiration into the oropharynx. 4. Infectious Disease: The patient was afebrile throughout his stay. He was on Ancef and Flagyl after the surgery.
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Evidence: G tube was placed to gravity
Condition: Gastrostomy status
HCC: Z930
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Cyst noted at base of the skull. Lungs: Occasional rhonchi, decreased breath sounds at bases. Heart: Normal sinus rhythm, no audible murmurs. Abdomen is soft, protuberant, bowel sounds active in all quadrants, no hepatosplenomegaly, no tenderness or masses. G tube in place mid abdomen. G site clean. Rectal examination deferred. Extremities: Light contractures of right upper extremity. Significant contractures of the left upper extremity with left hand flexed.
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Evidence: Occasional rhonchi, decreased breath sounds at bases.
Condition: Other drug-induced interstitial pulmonary diseases
HCC: J84114
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Deep tendon reflexes hyperreflexive lower extremities, normal reflexes upper extremities. PREOPERATIVE CHEST X-RAY: Showed pleural thickening with no acute consolidation or change. PREOPERATIVE ELECTROCARDIOGRAM: Within normal limits, rate 80, normal sinus rhythm, no change since previous electrocardiogram in [**2154**]. Patient underwent a total laryngectomy on [**2159-7-9**] with Dr. [**Last Name (STitle) 1837**]. There were no complications. He received 4800 cc of crystalloid. Urine output 425 cc, 200 cc estimated blood loss.
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Evidence: PREOPERATIVE CHEST X-RAY: Showed pleural thickening with no acute consolidation or change.
Condition: Other drug-induced interstitial pulmonary diseases
HCC: J84114
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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He received respiratory care multiple times a day. Wheezing was controlled with albuterol and Atrovent nebulizers. 6. Endocrine: He had a TSH of 0.78 postoperatively. He received his normal dose of Synthroid. No changes were made.
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Evidence: Wheezing was controlled with albuterol and Atrovent nebulizers.
Condition: Other drug-induced interstitial pulmonary diseases
HCC: J84114
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Respiratory: He continued to have thick secretions requiring frequent suctioning and chest PT. He received respiratory care multiple times a day. Wheezing was controlled with albuterol and Atrovent nebulizers. 6. Endocrine: He had a TSH of 0.78 postoperatively. He received his normal dose of Synthroid.
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Evidence: He received respiratory care multiple times a day.
Condition: Other drug-induced interstitial pulmonary diseases
HCC: J84114
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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2. Pulmonary fibrosis secondary to Macrodantin. 3. Chronic constipation. 4. Acne. 5. Pre-procedural anxiety. 6.
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Evidence: Pulmonary fibrosis secondary to Macrodantin
Condition: Other drug-induced interstitial pulmonary diseases
HCC: J84114
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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6. Senna four tablets daily. 7. Levothyroxine 25 mcg q day. 8.
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Evidence: Senna four tablets daily.
Condition: Chronic constipation
HCC: K5652
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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8. Milk of magnesia 60 cc daily. 9. Topamax 250 mg [**Hospital1 **]. 10. Fludrocortisone 0.1 mg q day. 11. Albuterol/ipratropium nebulizers qid. 12.
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Evidence: Milk of magnesia 60 cc daily.
Condition: Chronic constipation
HCC: K5652
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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3. Chronic constipation. 4. Acne. 5. Pre-procedural anxiety.
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Evidence: Chronic constipation
Condition: Chronic constipation
HCC: K5652
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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6. Endocrine: He had a TSH of 0.78 postoperatively. He received his normal dose of Synthroid. No changes were made. He was on an insulin-sliding scale throughout his stay.
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Evidence: He had a TSH of 0.78 postoperatively.
Condition: Hypothyroidism, unspecified
HCC: E039
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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6. Endocrine: He had a TSH of 0.78 postoperatively. He received his normal dose of Synthroid. No changes were made. He was on an insulin-sliding scale throughout his stay. On [**7-16**], staples and drains were discontinued. The patient was in good condition with continuing needs for frequent suctioning. He was discharged to Rentham with antibiotics, pain medication, and instructed to followup with Dr. [**Last Name (STitle) 1837**] in [**12-14**] weeks.
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Evidence: He had a TSH of 0.78 postoperatively.
Condition: Hypothyroidism, unspecified
HCC: E039
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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Endocrine: He had a TSH of 0.78 postoperatively. He received his normal dose of Synthroid. No changes were made. He was on an insulin-sliding scale throughout his stay. On [**7-16**], staples and drains were discontinued. The patient was in good condition with continuing needs for frequent suctioning. He was discharged to Rentham with antibiotics, pain medication, and instructed to followup with Dr. [**Last Name (STitle) 1837**] in [**12-14**] weeks.
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Evidence: He received his normal dose of Synthroid. No changes were made.
Condition: Hypothyroidism, unspecified
HCC: E039
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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7. Levothyroxine 25 mcg q day. 8. Milk of magnesia 60 cc daily. 9. Topamax 250 mg [**Hospital1 **]. 10.
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Evidence: Levothyroxine 25 mcg q day.
Condition: Hypothyroidism, unspecified
HCC: E039
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Endocrine: He had a TSH of 0.78 postoperatively. He received his normal dose of Synthroid. No changes were made. He was on an insulin-sliding scale throughout his stay. On [**7-16**], staples and drains were discontinued. The patient was in good condition with continuing needs for frequent suctioning. He was discharged to Rentham with antibiotics, pain medication, and instructed to followup with Dr.
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Evidence: He received his normal dose of Synthroid.
Condition: Hypothyroidism, unspecified
HCC: E039
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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7. Hypothyroidism. 8. Hypothermia. 9. Atypical psychosis/frontal lobe syndrome.
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Evidence: Hypothyroidism
Condition: Hypothyroidism, unspecified
HCC: E039
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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His Dilantin level rose to 12.9, which was in the therapeutic range, and he was continued on the maintenance dose. His atypical psychosis and MR [**First Name (Titles) **] [**Last Name (Titles) 1506**] throughout his stay. 3. GI: Immediately, postoperatively the G tube was placed to gravity. His tube feeds were resumed on [**7-10**], postoperative day one with a Nutrition team following him. He had very low residuals and no problems with aspiration into the oropharynx. 4.
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Evidence: His atypical psychosis and MR [**First Name (Titles) **] [**Last Name (Titles) 1506**] throughout his stay.
Condition: Unspecified nonorganic psychosis
HCC: F29
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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5. Olanzapine 2.5 mg q day. 6. Senna four tablets daily. 7. Levothyroxine 25 mcg q day.
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Evidence: Olanzapine 2.5 mg q day.
Condition: Unspecified nonorganic psychosis
HCC: F29
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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9. Atypical psychosis/frontal lobe syndrome. 10. Seizure disorder. 11. Dysphagia. 12. History of urinary tract infections. 13.
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Evidence: Atypical psychosis/frontal lobe syndrome
Condition: Unspecified nonorganic psychosis
HCC: F29
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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9. Atypical psychosis/frontal lobe syndrome. 10. Seizure disorder. 11.
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Evidence: atypical psychosis
Condition: Unspecified nonorganic psychosis
HCC: F29
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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He was loaded with 500 mg IV x1 and then placed on a maintenance dose of 100 mg tid. He did have seizure activity during his stay. His Dilantin level rose to 12.9, which was in the therapeutic range, and he was continued on the maintenance dose. His atypical psychosis and MR [**First Name (Titles) **] [**Last Name (Titles) 1506**] throughout his stay. 3. GI: Immediately, postoperatively the G tube was placed to gravity. His tube feeds were resumed on [**7-10**], postoperative day one with a Nutrition team following him. He had very low residuals and no problems with aspiration into the oropharynx.
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Evidence: He did have seizure activity during his stay.
Condition: Epilepsy, unspecified, not intractable, without status epilepticus
HCC: G40909
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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2. Neurologic: The patient's Dilantin level postoperatively was 4.3. He was loaded with 500 mg IV x1 and then placed on a maintenance dose of 100 mg tid. He did have seizure activity during his stay. His Dilantin level rose to 12.9, which was in the therapeutic range, and he was continued on the maintenance dose.
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Evidence: His Dilantin level postoperatively was 4.3.
Condition: Epilepsy, unspecified, not intractable, without status epilepticus
HCC: G40909
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
He did have seizure activity during his stay. His Dilantin level rose to 12.9, which was in the therapeutic range, and he was continued on the maintenance dose. His atypical psychosis and MR [**First Name (Titles) **] [**Last Name (Titles) 1506**] throughout his stay. 3. GI: Immediately, postoperatively the G tube was placed to gravity. His tube feeds were resumed on [**7-10**], postoperative day one with a Nutrition team following him.
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Evidence: His Dilantin level rose to 12.9, which was in the therapeutic range
Condition: Epilepsy, unspecified, not intractable, without status epilepticus
HCC: G40909
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
2. Neurologic: The patient's Dilantin level postoperatively was 4.3. He was loaded with 500 mg IV x1 and then placed on a maintenance dose of 100 mg tid. He did have seizure activity during his stay. His Dilantin level rose to 12.9, which was in the therapeutic range, and he was continued on the maintenance dose. His atypical psychosis and MR [**First Name (Titles) **] [**Last Name (Titles) 1506**] throughout his stay. 3. GI: Immediately, postoperatively the G tube was placed to gravity.
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Evidence: His Dilantin level postoperatively was 4.3.
Condition: Epilepsy, unspecified, not intractable, without status epilepticus
HCC: G40909
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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He did have seizure activity during his stay. His Dilantin level rose to 12.9, which was in the therapeutic range, and he was continued on the maintenance dose. His atypical psychosis and MR [**First Name (Titles) **] [**Last Name (Titles) 1506**] throughout his stay. 3. GI: Immediately, postoperatively the G tube was placed to gravity. His tube feeds were resumed on [**7-10**], postoperative day one with a Nutrition team following him. He had very low residuals and no problems with aspiration into the oropharynx. 4. Infectious Disease: The patient was afebrile throughout his stay.
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Evidence: His Dilantin level rose to 12.9, which was in the therapeutic range
Condition: Epilepsy, unspecified, not intractable, without status epilepticus
HCC: G40909
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
|
Neurologic: The patient's Dilantin level postoperatively was 4.3. He was loaded with 500 mg IV x1 and then placed on a maintenance dose of 100 mg tid. He did have seizure activity during his stay. His Dilantin level rose to 12.9, which was in the therapeutic range, and he was continued on the maintenance dose. His atypical psychosis and MR [**First Name (Titles) **] [**Last Name (Titles) 1506**] throughout his stay. 3. GI: Immediately, postoperatively the G tube was placed to gravity. His tube feeds were resumed on [**7-10**], postoperative day one with a Nutrition team following him.
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Evidence: He was loaded with 500 mg IV x1 and then placed on a maintenance dose of 100 mg tid.
Condition: Epilepsy, unspecified, not intractable, without status epilepticus
HCC: G40909
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
He did have seizure activity during his stay. His Dilantin level rose to 12.9, which was in the therapeutic range, and he was continued on the maintenance dose. His atypical psychosis and MR [**First Name (Titles) **] [**Last Name (Titles) 1506**] throughout his stay. 3. GI: Immediately, postoperatively the G tube was placed to gravity. His tube feeds were resumed on [**7-10**], postoperative day one with a Nutrition team following him. He had very low residuals and no problems with aspiration into the oropharynx. 4.
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Evidence: he was continued on the maintenance dose.
Condition: Epilepsy, unspecified, not intractable, without status epilepticus
HCC: G40909
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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2. Dilantin 300 mg q day. 3. Keflex 500 mg q6h. 4. Metronidazole 250 mg q8h. 5. Olanzapine 2.5 mg q day.
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Evidence: Dilantin 300 mg q day.
Condition: Epilepsy, unspecified, not intractable, without status epilepticus
HCC: G40909
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Neurologic: The patient's Dilantin level postoperatively was 4.3. He was loaded with 500 mg IV x1 and then placed on a maintenance dose of 100 mg tid. He did have seizure activity during his stay. His Dilantin level rose to 12.9, which was in the therapeutic range, and he was continued on the maintenance dose. His atypical psychosis and MR [**First Name (Titles) **] [**Last Name (Titles) 1506**] throughout his stay. 3.
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Evidence: He was loaded with 500 mg IV x1 and then placed on a maintenance dose of 100 mg tid.
Condition: Epilepsy, unspecified, not intractable, without status epilepticus
HCC: G40909
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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10. Seizure disorder. 11. Dysphagia. 12. History of urinary tract infections. 13. Mental retardation.
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Evidence: Seizure disorder
Condition: Epilepsy, unspecified, not intractable, without status epilepticus
HCC: G40909
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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His Dilantin level rose to 12.9, which was in the therapeutic range, and he was continued on the maintenance dose. His atypical psychosis and MR [**First Name (Titles) **] [**Last Name (Titles) 1506**] throughout his stay. 3. GI: Immediately, postoperatively the G tube was placed to gravity. His tube feeds were resumed on [**7-10**], postoperative day one with a Nutrition team following him. He had very low residuals and no problems with aspiration into the oropharynx. 4.
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Evidence: His atypical psychosis and MR [**First Name (Titles) **] [**Last Name (Titles) 1506**] throughout his stay.
Condition: Unspecified intellectual disabilities
HCC: F79
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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All four limbs can be extended left greater than right. Neurologic: Mental status: Alert, minimally verbal, follows simple requests. Cranial nerves II through XII intact except for exotropia. Deep tendon reflexes hyperreflexive lower extremities, normal reflexes upper extremities. PREOPERATIVE CHEST X-RAY: Showed pleural thickening with no acute consolidation or change. PREOPERATIVE ELECTROCARDIOGRAM: Within normal limits, rate 80, normal sinus rhythm, no change since previous electrocardiogram in [**2154**].
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Evidence: Mental status: Alert, minimally verbal, follows simple requests.
Condition: Unspecified intellectual disabilities
HCC: F79
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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13. Mental retardation. HOSPITALIZATIONS: 1. [**Date range (3) 12357**] at [**Hospital3 934**] Hospital for respiratory distress, pleural effusions, Pseudomonas urinary tract infection. 2. On [**2159-4-8**] returned to [**Hospital **] Hospital for vomiting with respiratory distress. ALLERGIES: Ampicillin that causes swelling and rash.
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Evidence: Mental retardation
Condition: Unspecified intellectual disabilities
HCC: F79
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2159-7-9**] Discharge Date: [**2159-7-16**] Date of Birth: [**2111-4-4**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 4223**] is a 48-year-old male resident at Rentham Developmental Center, who has a problem with chronic severe aspiration. This problem was first noticed around eight years ago. He had a gastrostomy tube placed in [**2150**]. He continued to have reflux, however, with aspiration and recurrent pneumonia. In [**2159-6-12**], he developed right pleural effusion. He had a thoracoscopy and chest tube placement. The fluid was an exudate with no infection or malignancy.
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Evidence: MR
Condition: Unspecified intellectual disabilities
HCC: F79
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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HOSPITAL COURSE AND TREATMENT: 1. Otolaryngology: The patient had bacitracin applied to his wounds [**Hospital1 **] throughout his stay. They continued to heal well. Staples were removed prior to discharge. He received humidified O2 by trache collar which was gradually weaned to 35% FIO2. He was on aspiration precautions throughout his stay to prevent reflux. Postoperative laboratories included a white count of 6.9, hematocrit of 29.7, which subsequently rose to 31.9. He continued to improve throughout his stay. His ionized calcium postoperatively was 1.15, which dropped to 0.97 and returned to 1.15 prior to discharge. He was transferred to the floor on postoperative day three, [**2159-7-12**].
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Evidence: The patient had bacitracin applied to his wounds [**Hospital1 **] throughout his stay. They continued to heal well.
Condition: Laryngostomy status
HCC: Z933
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Staples were removed prior to discharge. He received humidified O2 by trache collar which was gradually weaned to 35% FIO2. He was on aspiration precautions throughout his stay to prevent reflux. Postoperative laboratories included a white count of 6.9, hematocrit of 29.7, which subsequently rose to 31.9. He continued to improve throughout his stay.
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Evidence: He received humidified O2 by trache collar which was gradually weaned to 35% FIO2.
Condition: Laryngostomy status
HCC: Z933
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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On [**7-16**], staples and drains were discontinued. The patient was in good condition with continuing needs for frequent suctioning. He was discharged to Rentham with antibiotics, pain medication, and instructed to followup with Dr. [**Last Name (STitle) 1837**] in [**12-14**] weeks. [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 6152**], M.D. [**MD Number(1) 6153**] Dictated By:[**Last Name (NamePattern1) 12358**] MEDQUIST36 D: [**2159-7-16**] 08:23 T: [**2159-7-16**] 08:25 JOB#: [**Job Number 12359**]
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Evidence: continuing needs for frequent suctioning.
Condition: Laryngostomy status
HCC: Z933
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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PREOPERATIVE ELECTROCARDIOGRAM: Within normal limits, rate 80, normal sinus rhythm, no change since previous electrocardiogram in [**2154**]. Patient underwent a total laryngectomy on [**2159-7-9**] with Dr. [**Last Name (STitle) 1837**]. There were no complications. He received 4800 cc of crystalloid. Urine output 425 cc, 200 cc estimated blood loss. He was transferred to the Intensive Care Unit postoperatively. HOSPITAL COURSE AND TREATMENT: 1.
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Evidence: Patient underwent a total laryngectomy on [**2159-7-9**]
Condition: Laryngostomy status
HCC: Z933
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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HOSPITAL COURSE AND TREATMENT: 1. Otolaryngology: The patient had bacitracin applied to his wounds [**Hospital1 **] throughout his stay. They continued to heal well. Staples were removed prior to discharge. He received humidified O2 by trache collar which was gradually weaned to 35% FIO2.
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Evidence: The patient had bacitracin applied to his wounds
Condition: Laryngostomy status
HCC: Z933
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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They continued to heal well. Staples were removed prior to discharge. He received humidified O2 by trache collar which was gradually weaned to 35% FIO2. He was on aspiration precautions throughout his stay to prevent reflux. Postoperative laboratories included a white count of 6.9, hematocrit of 29.7, which subsequently rose to 31.9. He continued to improve throughout his stay.
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Evidence: Staples were removed prior to discharge.
Condition: Laryngostomy status
HCC: Z933
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Staples were removed prior to discharge. He received humidified O2 by trache collar which was gradually weaned to 35% FIO2. He was on aspiration precautions throughout his stay to prevent reflux. Postoperative laboratories included a white count of 6.9, hematocrit of 29.7, which subsequently rose to 31.9. He continued to improve throughout his stay. His ionized calcium postoperatively was 1.15, which dropped to 0.97 and returned to 1.15 prior to discharge. He was transferred to the floor on postoperative day three, [**2159-7-12**]. His drains were originally to wall suction with high output around 100 cc a day until [**7-13**] and 2nd when they are switched to bulb suction, and the output came down to between 50-70 cc a day. JP #2 was removed on [**2159-7-15**] after putting out 30 cc over 24 hours.
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Evidence: He received humidified O2 by trache collar
Condition: Laryngostomy status
HCC: Z933
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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The fluid was an exudate with no infection or malignancy. Due to the recurrent nature of the problem, he was scheduled for a tracheoesophageal separation by total laryngectomy with Dr. [**Last Name (STitle) 1837**] on [**2159-7-9**]. PAST MEDICAL HISTORY: 1. Chronic aspiration. 2. Pulmonary fibrosis secondary to Macrodantin. 3.
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Evidence: total laryngectomy
Condition: Laryngostomy status
HCC: Z933
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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He was loaded with 500 mg IV x1 and then placed on a maintenance dose of 100 mg tid. He did have seizure activity during his stay. His Dilantin level rose to 12.9, which was in the therapeutic range, and he was continued on the maintenance dose. His atypical psychosis and MR [**First Name (Titles) **] [**Last Name (Titles) 1506**] throughout his stay. 3. GI: Immediately, postoperatively the G tube was placed to gravity. His tube feeds were resumed on [**7-10**], postoperative day one with a Nutrition team following him. He had very low residuals and no problems with aspiration into the oropharynx. 4.
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Evidence: He did have seizure activity during his stay.
Condition: Unspecified convulsions
HCC: R569
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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He was loaded with 500 mg IV x1 and then placed on a maintenance dose of 100 mg tid. He did have seizure activity during his stay. His Dilantin level rose to 12.9, which was in the therapeutic range, and he was continued on the maintenance dose. His atypical psychosis and MR [**First Name (Titles) **] [**Last Name (Titles) 1506**] throughout his stay. 3. GI: Immediately, postoperatively the G tube was placed to gravity. His tube feeds were resumed on [**7-10**], postoperative day one with a Nutrition team following him. He had very low residuals and no problems with aspiration into the oropharynx. 4.
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Evidence: seizure activity
Condition: Unspecified convulsions
HCC: R569
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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2. Status post aortic valve replacement complicated by seizures, acute renal failure, respiratory failure. 5. Status post tracheostomy and percutaneous intragastrostomy. MEDICATIONS ON DISCHARGE: Lactulose 30 cc per G tube q day, Fluconazole 200 mg per G tube q.d., NPH insulin 30 units subQ q.a.m., 25 units subQ at hour of sleep. Trileptal 600 mg per G tube b.i.d., Lopressor 25 mg per G tube b.i.d., Zosyn 2.2 grams intravenous q 6 hours, Vancomycin 1 gram intravenous q 12 hours. Aspirin 325 mg per G tube q.d., Colace elixir 100 mg per G tube b.i.d., Nystatin swish and swallow 5 cc po q 6 hours, heparin 5000 units subQ b.i.d., Hydralazine 10 mg per G tube t.i.d., regular insulin sliding scale. For glucoses of 121 to 150 2 units, 151 to 175 3 units, 176 to 200 4 units, 201 to 250 5 units, 251 to 300 6 units, 300 to 350 7 units and for blood glucoses greater then 351 a medical doctor should be called.
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Evidence: seizures
Condition: Unspecified convulsions
HCC: R569
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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MEDICATIONS ON DISCHARGE: Lactulose 30 cc per G tube q day, Fluconazole 200 mg per G tube q.d., NPH insulin 30 units subQ q.a.m., 25 units subQ at hour of sleep. Trileptal 600 mg per G tube b.i.d., Lopressor 25 mg per G tube b.i.d., Zosyn 2.2 grams intravenous q 6 hours, Vancomycin 1 gram intravenous q 12 hours. Aspirin 325 mg per G tube q.d., Colace elixir 100 mg per G tube b.i.d., Nystatin swish and swallow 5 cc po q 6 hours, heparin 5000 units subQ b.i.d., Hydralazine 10 mg per G tube t.i.d., regular insulin sliding scale. For glucoses of 121 to 150 2 units, 151 to 175 3 units, 176 to 200 4 units, 201 to 250 5 units, 251 to 300 6 units, 300 to 350 7 units and for blood glucoses greater then 351 a medical doctor should be called. Zantac 50 mg intravenous q.d., Ciprofloxacin 200 mg intravenous q 12 hours, Nitrophos one packet per G tube t.i.d. for 24 hours at which point this will be discontinued.
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Evidence: Trileptal 600 mg per G tube b.i.d.
Condition: Unspecified convulsions
HCC: R569
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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2. Status post aortic valve replacement complicated by seizures, acute renal failure, respiratory failure. 5. Status post tracheostomy and percutaneous intragastrostomy. MEDICATIONS ON DISCHARGE: Lactulose 30 cc per G tube q day, Fluconazole 200 mg per G tube q.d., NPH insulin 30 units subQ q.a.m., 25 units subQ at hour of sleep. Trileptal 600 mg per G tube b.i.d., Lopressor 25 mg per G tube b.i.d., Zosyn 2.2 grams intravenous q 6 hours, Vancomycin 1 gram intravenous q 12 hours. Aspirin 325 mg per G tube q.d., Colace elixir 100 mg per G tube b.i.d., Nystatin swish and swallow 5 cc po q 6 hours, heparin 5000 units subQ b.i.d., Hydralazine 10 mg per G tube t.i.d., regular insulin sliding scale.
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Evidence: seizures
Condition: Unspecified convulsions
HCC: R569
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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2. Status post aortic valve replacement complicated by seizures, acute renal failure, respiratory failure. 5. Status post tracheostomy and percutaneous intragastrostomy. MEDICATIONS ON DISCHARGE: Lactulose 30 cc per G tube q day, Fluconazole 200 mg per G tube q.d., NPH insulin 30 units subQ q.a.m., 25 units subQ at hour of sleep. Trileptal 600 mg per G tube b.i.d., Lopressor 25 mg per G tube b.i.d., Zosyn 2.2 grams intravenous q 6 hours, Vancomycin 1 gram intravenous q 12 hours.
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Evidence: acute renal failure
Condition: Acute kidney failure, unspecified
HCC: N179
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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2. Status post aortic valve replacement complicated by seizures, acute renal failure, respiratory failure. 5. Status post tracheostomy and percutaneous intragastrostomy. MEDICATIONS ON DISCHARGE: Lactulose 30 cc per G tube q day, Fluconazole 200 mg per G tube q.d., NPH insulin 30 units subQ q.a.m., 25 units subQ at hour of sleep. Trileptal 600 mg per G tube b.i.d., Lopressor 25 mg per G tube b.i.d., Zosyn 2.2 grams intravenous q 6 hours, Vancomycin 1 gram intravenous q 12 hours. Aspirin 325 mg per G tube q.d., Colace elixir 100 mg per G tube b.i.d., Nystatin swish and swallow 5 cc po q 6 hours, heparin 5000 units subQ b.i.d., Hydralazine 10 mg per G tube t.i.d., regular insulin sliding scale. For glucoses of 121 to 150 2 units, 151 to 175 3 units, 176 to 200 4 units, 201 to 250 5 units, 251 to 300 6 units, 300 to 350 7 units and for blood glucoses greater then 351 a medical doctor should be called.
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Evidence: acute renal failure
Condition: Acute kidney failure, unspecified
HCC: N179
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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The patient was somewhat more agitated and remained in the hospital. He remained on pressure support for his ventilatory support. His abdomen was somewhat distended, so his tube feeds were held. His glucose was controlled with his insulin sliding scale. He was making adequate urine. His hematocrit had dropped somewhat to 26.6 and the patient was transfused one unit. His wounds remained clean, dry and intact.
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Evidence: He remained on pressure support for his ventilatory support.
Condition: Respiratory failure, unspecified, associated with hypoxia or hypercapnia
HCC: J9690
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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On the day of discharge [**2176-12-21**], Mr. [**Known lastname **] was afebrile with a temperature max of 98.2, heart rate of 70 and first degree AV block, blood pressure 139/50 beating 20 times per minute, sating at 98%, pressure support and CPAP of 10 and 5 with FIO2 of 50%. He was tolerating tube feeds and had tolerated 780 cc over the previous 24 hour period. He received some intravenous fluids making adequate urine. His pigtail drains put out 125 cc. He was sleeping, but restless. Chest was clear to auscultation bilaterally.
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Evidence: pressure support and CPAP of 10 and 5 with FIO2 of 50%.
Condition: Respiratory failure, unspecified, associated with hypoxia or hypercapnia
HCC: J9690
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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2. Status post aortic valve replacement complicated by seizures, acute renal failure, respiratory failure. 5. Status post tracheostomy and percutaneous intragastrostomy. MEDICATIONS ON DISCHARGE: Lactulose 30 cc per G tube q day, Fluconazole 200 mg per G tube q.d., NPH insulin 30 units subQ q.a.m., 25 units subQ at hour of sleep.
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Evidence: respiratory failure
Condition: Respiratory failure, unspecified, associated with hypoxia or hypercapnia
HCC: J9690
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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The patient was somewhat more agitated and remained in the hospital. He remained on pressure support for his ventilatory support. His abdomen was somewhat distended, so his tube feeds were held. His glucose was controlled with his insulin sliding scale. He was making adequate urine.
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Evidence: He remained on pressure support for his ventilatory support.
Condition: Respiratory failure, unspecified, associated with hypoxia or hypercapnia
HCC: J9690
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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On the day of discharge [**2176-12-21**], Mr. [**Known lastname **] was afebrile with a temperature max of 98.2, heart rate of 70 and first degree AV block, blood pressure 139/50 beating 20 times per minute, sating at 98%, pressure support and CPAP of 10 and 5 with FIO2 of 50%. He was tolerating tube feeds and had tolerated 780 cc over the previous 24 hour period. He received some intravenous fluids making adequate urine. His pigtail drains put out 125 cc. He was sleeping, but restless. Chest was clear to auscultation bilaterally. Cardiac was regular rate and rhythm.
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Evidence: pressure support and CPAP of 10 and 5 with FIO2 of 50%.
Condition: Respiratory failure, unspecified, associated with hypoxia or hypercapnia
HCC: J9690
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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2. Status post aortic valve replacement complicated by seizures, acute renal failure, respiratory failure. 5. Status post tracheostomy and percutaneous intragastrostomy. MEDICATIONS ON DISCHARGE: Lactulose 30 cc per G tube q day, Fluconazole 200 mg per G tube q.d., NPH insulin 30 units subQ q.a.m., 25 units subQ at hour of sleep. Trileptal 600 mg per G tube b.i.d., Lopressor 25 mg per G tube b.i.d., Zosyn 2.2 grams intravenous q 6 hours, Vancomycin 1 gram intravenous q 12 hours.
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Evidence: respiratory failure
Condition: Respiratory failure, unspecified, associated with hypoxia or hypercapnia
HCC: J9690
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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5. Status post tracheostomy and percutaneous intragastrostomy. MEDICATIONS ON DISCHARGE: Lactulose 30 cc per G tube q day, Fluconazole 200 mg per G tube q.d., NPH insulin 30 units subQ q.a.m., 25 units subQ at hour of sleep. Trileptal 600 mg per G tube b.i.d., Lopressor 25 mg per G tube b.i.d., Zosyn 2.2 grams intravenous q 6 hours, Vancomycin 1 gram intravenous q 12 hours. Aspirin 325 mg per G tube q.d., Colace elixir 100 mg per G tube b.i.d., Nystatin swish and swallow 5 cc po q 6 hours, heparin 5000 units subQ b.i.d., Hydralazine 10 mg per G tube t.i.d., regular insulin sliding scale. For glucoses of 121 to 150 2 units, 151 to 175 3 units, 176 to 200 4 units, 201 to 250 5 units, 251 to 300 6 units, 300 to 350 7 units and for blood glucoses greater then 351 a medical doctor should be called.
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Evidence: Status post tracheostomy
Condition: Tracheostomy status
HCC: Z930
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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5. Status post tracheostomy and percutaneous intragastrostomy. MEDICATIONS ON DISCHARGE: Lactulose 30 cc per G tube q day, Fluconazole 200 mg per G tube q.d., NPH insulin 30 units subQ q.a.m., 25 units subQ at hour of sleep. Trileptal 600 mg per G tube b.i.d., Lopressor 25 mg per G tube b.i.d., Zosyn 2.2 grams intravenous q 6 hours, Vancomycin 1 gram intravenous q 12 hours. Aspirin 325 mg per G tube q.d., Colace elixir 100 mg per G tube b.i.d., Nystatin swish and swallow 5 cc po q 6 hours, heparin 5000 units subQ b.i.d., Hydralazine 10 mg per G tube t.i.d., regular insulin sliding scale. For glucoses of 121 to 150 2 units, 151 to 175 3 units, 176 to 200 4 units, 201 to 250 5 units, 251 to 300 6 units, 300 to 350 7 units and for blood glucoses greater then 351 a medical doctor should be called.
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Evidence: Status post tracheostomy
Condition: Tracheostomy status
HCC: Z930
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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[**Known lastname **] was afebrile with a temperature max of 98.2, heart rate of 70 and first degree AV block, blood pressure 139/50 beating 20 times per minute, sating at 98%, pressure support and CPAP of 10 and 5 with FIO2 of 50%. He was tolerating tube feeds and had tolerated 780 cc over the previous 24 hour period. He received some intravenous fluids making adequate urine. His pigtail drains put out 125 cc. He was sleeping, but restless. Chest was clear to auscultation bilaterally.
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Evidence: G tube
Condition: Gastrostomy status
HCC: Z931
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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His wounds remained clean, dry and intact. Over the ensuing days the patient's neurological status returned to his baseline and his ventilatory support was weaned. His right chest tube pigtail drain continued to put out fluid. On [**12-19**] a left chest tube was placed, which the patient pulled out on the following day. Compute tomography was obtained of the chest, which revealed bilateral pleural catheters present. The right loculated pleural effusion was decreased in size and the left pleural effusion was stable. His pericardial effusion was stable. On the day of discharge [**2176-12-21**], Mr.
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Evidence: Status post...percutaneous
intragastrostomy.
Condition: Gastrostomy status
HCC: Z931
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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[**Known lastname **] was afebrile with a temperature max of 98.2, heart rate of 70 and first degree AV block, blood pressure 139/50 beating 20 times per minute, sating at 98%, pressure support and CPAP of 10 and 5 with FIO2 of 50%. He was tolerating tube feeds and had tolerated 780 cc over the previous 24 hour period. He received some intravenous fluids making adequate urine. His pigtail drains put out 125 cc. He was sleeping, but restless. Chest was clear to auscultation bilaterally. Cardiac was regular rate and rhythm.
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Evidence: G tube
Condition: Gastrostomy status
HCC: Z931
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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5. Status post tracheostomy and percutaneous intragastrostomy. MEDICATIONS ON DISCHARGE: Lactulose 30 cc per G tube q day, Fluconazole 200 mg per G tube q.d., NPH insulin 30 units subQ q.a.m., 25 units subQ at hour of sleep. Trileptal 600 mg per G tube b.i.d., Lopressor 25 mg per G tube b.i.d., Zosyn 2.2 grams intravenous q 6 hours, Vancomycin 1 gram intravenous q 12 hours. Aspirin 325 mg per G tube q.d., Colace elixir 100 mg per G tube b.i.d., Nystatin swish and swallow 5 cc po q 6 hours, heparin 5000 units subQ b.i.d., Hydralazine 10 mg per G tube t.i.d., regular insulin sliding scale. For glucoses of 121 to 150 2 units, 151 to 175 3 units, 176 to 200 4 units, 201 to 250 5 units, 251 to 300 6 units, 300 to 350 7 units and for blood glucoses greater then 351 a medical doctor should be called. Zantac 50 mg intravenous q.d., Ciprofloxacin 200 mg intravenous q 12 hours, Nitrophos one packet per G tube t.i.d.
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Evidence: Status post...percutaneous
intragastrostomy
Condition: Gastrostomy status
HCC: Z931
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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HOSPITAL COURSE: This patient was admitted to the Intensive Care Unit for q. 1 hour neurological checks and strict blood pressure control as necessary. She did well over night, did not show any deficit of her neurological examination and did not require any medications for blood pressure control. Neurosurgery was also consulted and assisted in management of her subdural hematoma. The patient then on the following day, [**2110-1-1**], underwent a repeat head computerized tomography scan which showed small improvement in the subdural hematoma, definitely stable and no evidence of any new or enlarged area of bleeding. The patient was advanced diet and physical therapy was consulted to assist with ambulation. The patient on hospital day #2 is tolerating p.o. well and is noted to be walking decently with assistance.
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Evidence: strict blood pressure control as necessary
Condition: Essential (primary) hypertension
HCC: I10
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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1 hour neurological checks and strict blood pressure control as necessary. She did well over night, did not show any deficit of her neurological examination and did not require any medications for blood pressure control. Neurosurgery was also consulted and assisted in management of her subdural hematoma. The patient then on the following day, [**2110-1-1**], underwent a repeat head computerized tomography scan which showed small improvement in the subdural hematoma, definitely stable and no evidence of any new or enlarged area of bleeding. The patient was advanced diet and physical therapy was consulted to assist with ambulation. The patient on hospital day #2 is tolerating p.o. well and is noted to be walking decently with assistance.
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Evidence: did not require any medications for blood pressure control
Condition: Essential (primary) hypertension
HCC: I10
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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SOCIAL HISTORY: Denies any alcohol or tobacco. MEDICATIONS AT HOME: Lisinopril 10 mg p.o. q.d.; Hydrochlorothiazide 50 mg p.o. q.d.; Zoloft 50 mg p.o. q.d.; multivitamin, Vitamin E and Aspirin. PHYSICAL EXAMINATION: On examination she was afebrile. Her pulse was 58, blood pressure was 130/68. Her neurological examination is nonfocal. She had no tenderness over her cervical spine. LABORATORY DATA: This patient had a chest x-ray which was within normal limits, no evidence for any pneumothorax or rib fractures. She also had a head computerized tomography scan done which did show a small right subtemporal subdural hematoma and a nasal bone film which showed a positive fracture but nondisplaced.
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Evidence: Lisinopril 10 mg p.o. q.d.; Hydrochlorothiazide 50 mg p.o. q.d.
Condition: Essential (primary) hypertension
HCC: I10
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2109-12-31**] Discharge Date: [**2110-1-2**] Service: HISTORY OF PRESENT ILLNESS: The patient is an 81 year old female with a history of hypertension and anxiety who tripped over a piece of concrete slab and fell onto her face. She denied any chest pain or dizziness at the time of the fall and clearly remembers tripping over a piece of concrete. She had no loss of consciousness and completely recalls the event. She got up immediately from the fall and was noticed to be bleeding slightly from her lower lip. The patient presented to the Emergency Department with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma scale of 15 with her daughter. PAST MEDICAL HISTORY: Significant for hypertension and anxiety.
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Evidence: hypertension
Condition: Essential (primary) hypertension
HCC: I10
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2109-12-31**] Discharge Date: [**2110-1-2**] Service: HISTORY OF PRESENT ILLNESS: The patient is an 81 year old female with a history of hypertension and anxiety who tripped over a piece of concrete slab and fell onto her face. She denied any chest pain or dizziness at the time of the fall and clearly remembers tripping over a piece of concrete. She had no loss of consciousness and completely recalls the event. She got up immediately from the fall and was noticed to be bleeding slightly from her lower lip. The patient presented to the Emergency Department with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma scale of 15 with her daughter. PAST MEDICAL HISTORY: Significant for hypertension and anxiety.
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Evidence: hypertension
Condition: Essential (primary) hypertension
HCC: I10
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2169-1-24**] Discharge Date: [**2169-3-1**] Date of Birth: [**2095-1-13**] Sex: M Service: COLORECTAL SURGERY SERVICE HISTORY OF PRESENT ILLNESS: This is a 74 year old gentleman with a history of prostate cancer who presented in [**Month (only) 1096**] of last year with rectal bleeding. Evaluation included a colonoscopy which showed an ulcerative lesion in the rectum. These were biopsied and showed moderately differentiated adenocarcinoma. The patient presents for curative resection. PAST MEDICAL HISTORY: Prostate cancer with radiation implants and external beam radiation; hypercholesterolemia; history of peptic ulcer disease. SOCIAL HISTORY: No tobacco; occasional alcohol. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Cardura 2 mg once a day. 2.
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Evidence: Evaluation included a
colonoscopy which showed an ulcerative lesion in the rectum.
These were biopsied and showed moderately differentiated
adenocarcinoma.
Condition: Malignant neoplasm of rectum
HCC: C20
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
DISCHARGE DIAGNOSIS: 1. Rectal cancer. 2. Status post proctocolectomy with coloanal anastomosis and a loop ileostomy. 3. Partial small bowel obstruction, resolved. 4. Postoperative leak, resolved. 5.
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Evidence: Rectal cancer.
Condition: Malignant neoplasm of rectum
HCC: C20
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
These were biopsied and showed moderately differentiated adenocarcinoma. The patient presents for curative resection. PAST MEDICAL HISTORY: Prostate cancer with radiation implants and external beam radiation; hypercholesterolemia; history of peptic ulcer disease. SOCIAL HISTORY: No tobacco; occasional alcohol. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Cardura 2 mg once a day. 2. Lipitor 10 mg once a day.
|
Evidence: patient presents for curative resection.
Condition: Malignant neoplasm of rectum
HCC: C20
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
PREOPERATIVE LABORATORY: Preoperative labs were significant for a hematocrit of 40.4. BRIEF HOSPITAL COURSE: The patient was taken to the Operating Room on [**2169-1-24**], where he underwent a proctocolectomy with a coloanal anastomosis and a loop ileostomy under general endotracheal anesthesia. Estimated blood loss was 500 cc. The patient had a #14 French q day catheter placed due to his history of prostate cancer and ureteral stenosis. He tolerated the procedure well. There were no intraoperative complications and he was transported to the Recovery Room in stable condition. Immediately postoperatively, the patient was relatively comfortable with an epidural catheter in place for pain control. He remained hemodynamically stable, however, was without flatus. He was started on clear liquids on postoperative day #2 as well as restarted on his whole medications.
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Evidence: patient was taken to the
Operating Room on [**2169-1-24**], where he underwent a
proctocolectomy with a coloanal anastomosis and a loop
ileostomy
Condition: Malignant neoplasm of rectum
HCC: C20
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
DISCHARGE DIAGNOSIS: 1. Rectal cancer. 2. Status post proctocolectomy with coloanal anastomosis and a loop ileostomy. 3. Partial small bowel obstruction, resolved. 4. Postoperative leak, resolved.
|
Evidence: Rectal cancer
Condition: Malignant neoplasm of rectum
HCC: C20
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Evaluation included a colonoscopy which showed an ulcerative lesion in the rectum. These were biopsied and showed moderately differentiated adenocarcinoma. The patient presents for curative resection. PAST MEDICAL HISTORY: Prostate cancer with radiation implants and external beam radiation; hypercholesterolemia; history of peptic ulcer disease. SOCIAL HISTORY: No tobacco; occasional alcohol. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Cardura 2 mg once a day. 2.
|
Evidence: moderately differentiated
adenocarcinoma
Condition: Malignant neoplasm of rectum
HCC: C20
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Estimated blood loss was 500 cc. The patient had a #14 French q day catheter placed due to his history of prostate cancer and ureteral stenosis. He tolerated the procedure well. There were no intraoperative complications and he was transported to the Recovery Room in stable condition. Immediately postoperatively, the patient was relatively comfortable with an epidural catheter in place for pain control. He remained hemodynamically stable, however, was without flatus. He was started on clear liquids on postoperative day #2 as well as restarted on his whole medications. Of note, he began to have a large amount of light brown loose output from his ostomy. Due to the large volume, he was started on intravenous fluid replacement to prevent dehydration.
|
Evidence: patient had a #14 French q day
catheter placed due to his history of prostate cancer and
ureteral stenosis.
Condition: Malignant neoplasm of prostate
HCC: C61
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
6. History of prostate cancer. DISCHARGE MEDICATIONS: 1. Lipitor 10 mg p.o. q d.
|
Evidence: History of prostate cancer.
Condition: Malignant neoplasm of prostate
HCC: C61
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2169-1-24**] Discharge Date: [**2169-3-1**] Date of Birth: [**2095-1-13**] Sex: M Service: COLORECTAL SURGERY SERVICE HISTORY OF PRESENT ILLNESS: This is a 74 year old gentleman with a history of prostate cancer who presented in [**Month (only) 1096**] of last year with rectal bleeding. Evaluation included a colonoscopy which showed an ulcerative lesion in the rectum. These were biopsied and showed moderately differentiated adenocarcinoma. The patient presents for curative resection. PAST MEDICAL HISTORY: Prostate cancer with radiation implants and external beam radiation; hypercholesterolemia; history of peptic ulcer disease. SOCIAL HISTORY: No tobacco; occasional alcohol.
|
Evidence: prostate cancer
Condition: Malignant neoplasm of prostate
HCC: C61
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2169-1-24**] Discharge Date: [**2169-3-1**] Date of Birth: [**2095-1-13**] Sex: M Service: COLORECTAL SURGERY SERVICE HISTORY OF PRESENT ILLNESS: This is a 74 year old gentleman with a history of prostate cancer who presented in [**Month (only) 1096**] of last year with rectal bleeding. Evaluation included a colonoscopy which showed an ulcerative lesion in the rectum. These were biopsied and showed moderately differentiated adenocarcinoma. The patient presents for curative resection. PAST MEDICAL HISTORY: Prostate cancer with radiation implants and external beam radiation; hypercholesterolemia; history of peptic ulcer disease. SOCIAL HISTORY: No tobacco; occasional alcohol.
|
Evidence: Prostate cancer
Condition: Malignant neoplasm of prostate
HCC: C61
Category: condition_evidence
|
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