instruction
stringclasses 1
value | input
stringlengths 29
13.1k
| output
stringlengths 68
1.64k
|
|---|---|---|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
5. Hyperlipidemia. 6. History of prostate cancer. DISCHARGE MEDICATIONS: 1. Lipitor 10 mg p.o.
|
Evidence: Hyperlipidemia.
Condition: Pure hypercholesterolemia, unspecified
HCC: E7800
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
2. Lipitor 10 mg once a day. INITIAL PHYSICAL EXAMINATION: The patient was afebrile. Vital signs, within normal limits. Well developed male, no apparent distress.
|
Evidence: Lipitor 10 mg once a day.
Condition: Pure hypercholesterolemia, unspecified
HCC: E7800
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
DISCHARGE MEDICATIONS: 1. Lipitor 10 mg p.o. q d. 2. .................... 2 mg p.o. q hs. 3. Heparin subcutaneous 5,000 units b.i.d. 4.
|
Evidence: Lipitor 10 mg p.o. q d.
Condition: Pure hypercholesterolemia, unspecified
HCC: E7800
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
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.
|
Evidence: hypercholesterolemia
Condition: Pure hypercholesterolemia, unspecified
HCC: E7800
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
5. Hyperlipidemia. 6. History of prostate cancer. DISCHARGE MEDICATIONS: 1. Lipitor 10 mg p.o. q d. 2.
|
Evidence: Hyperlipidemia
Condition: Pure hypercholesterolemia, unspecified
HCC: E7800
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
6. Protonix 40 mg p.o. q d. 7. Lopressor 50 mg p.o. b.i.d.
|
Evidence: Protonix 40 mg p.o. q d.
Condition: Peptic ulcer, unspecified site, without hemorrhage or perforation
HCC: K275
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
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.
|
Evidence: peptic ulcer disease
Condition: Peptic ulcer, unspecified site, without hemorrhage or perforation
HCC: K275
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
A small red rubber catheter was placed in the stoma with some relief, however, the patient remained distended. His partial small bowel obstruction was slow to resolve where on postoperative day #18 he was started on clears with continued decompression through his ostomy via the red rubber catheter. Postoperative day #13, the patient became hypotensive with a severe abdominal pain in the right upper quadrant above his ostomy. Abdominal CT with p.o. and intravenous contrast was done which showed dilated loops of small bowel and mild edema proximal to the ostomy without free air or contrast extravasation.
|
Evidence: His partial small bowel obstruction was slow to
resolve
Condition: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction and as to cause
HCC: K56609
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
He was made NPO and resuscitated with intravenous fluids, however, later that evening, his O2 sats were noted to decrease to the 80s on room air. Electrocardiogram was obtained which showed no change from prior, however, in light of the patient's obstruction, marginal urine output and pending instability, he was transferred to the Intensive Care Unit for further management. There he underwent a VQ scan which was low probability for pulmonary embolus. On rectal examination, he was found to have an area of anterior separation of his anastomosis and about 30 cc of serosanguinous fluid was drained. He was kept on broad spectrum antibiotics and close observation. CT scan of the abdomen was repeated which showed, again, thickened bowel but no contrast extravasation. Of note, as well, the patient's white blood cell count had increased to 24, however, over the next few days, he stabilized with a decreasing white blood cell count, pain abating and better urine output. During this time, while he was NPO, he was also started on TPN for nutritional support.
|
Evidence: in light of the patient's obstruction
Condition: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction and as to cause
HCC: K56609
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
He also had an episode of emesis as well. KUB revealed a PSBO. A small red rubber catheter was placed in the stoma with some relief, however, the patient remained distended. His partial small bowel obstruction was slow to resolve where on postoperative day #18 he was started on clears with continued decompression through his ostomy via the red rubber catheter. Postoperative day #13, the patient became hypotensive with a severe abdominal pain in the right upper quadrant above his ostomy. Abdominal CT with p.o. and intravenous contrast was done which showed dilated loops of small bowel and mild edema proximal to the ostomy without free air or contrast extravasation.
|
Evidence: KUB revealed a PSBO.
Condition: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction and as to cause
HCC: K56609
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Postoperative day #13, the patient became hypotensive with a severe abdominal pain in the right upper quadrant above his ostomy. Abdominal CT with p.o. and intravenous contrast was done which showed dilated loops of small bowel and mild edema proximal to the ostomy without free air or contrast extravasation. He was made NPO and resuscitated with intravenous fluids, however, later that evening, his O2 sats were noted to decrease to the 80s on room air. Electrocardiogram was obtained which showed no change from prior, however, in light of the patient's obstruction, marginal urine output and pending instability, he was transferred to the Intensive Care Unit for further management. There he underwent a VQ scan which was low probability for pulmonary embolus. On rectal examination, he was found to have an area of anterior separation of his anastomosis and about 30 cc of serosanguinous fluid was drained. He was kept on broad spectrum antibiotics and close observation. CT scan of the abdomen was repeated which showed, again, thickened bowel but no contrast extravasation.
|
Evidence: Abdominal CT with p.o. and intravenous contrast was
done which showed dilated loops of small bowel
Condition: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction and as to cause
HCC: K56609
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
3. Partial small bowel obstruction, resolved. 4. Postoperative leak, resolved. 5. Hyperlipidemia. 6. History of prostate cancer. DISCHARGE MEDICATIONS: 1.
|
Evidence: Partial small bowel obstruction, resolved.
Condition: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction and as to cause
HCC: K56609
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
KUB revealed a PSBO. A small red rubber catheter was placed in the stoma with some relief, however, the patient remained distended. His partial small bowel obstruction was slow to resolve where on postoperative day #18 he was started on clears with continued decompression through his ostomy via the red rubber catheter. Postoperative day #13, the patient became hypotensive with a severe abdominal pain in the right upper quadrant above his ostomy. Abdominal CT with p.o.
|
Evidence: A small red rubber catheter was placed
in the stoma with some relief
Condition: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction and as to cause
HCC: K56609
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
A small red rubber catheter was placed in the stoma with some relief, however, the patient remained distended. His partial small bowel obstruction was slow to resolve where on postoperative day #18 he was started on clears with continued decompression through his ostomy via the red rubber catheter. Postoperative day #13, the patient became hypotensive with a severe abdominal pain in the right upper quadrant above his ostomy. Abdominal CT with p.o. and intravenous contrast was done which showed dilated loops of small bowel and mild edema proximal to the ostomy without free air or contrast extravasation. He was made NPO and resuscitated with intravenous fluids, however, later that evening, his O2 sats were noted to decrease to the 80s on room air. Electrocardiogram was obtained which showed no change from prior, however, in light of the patient's obstruction, marginal urine output and pending instability, he was transferred to the Intensive Care Unit for further management. There he underwent a VQ scan which was low probability for pulmonary embolus.
|
Evidence: he was started on
clears with continued decompression through his ostomy via
the red rubber catheter.
Condition: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction and as to cause
HCC: K56609
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
and intravenous contrast was done which showed dilated loops of small bowel and mild edema proximal to the ostomy without free air or contrast extravasation. He was made NPO and resuscitated with intravenous fluids, however, later that evening, his O2 sats were noted to decrease to the 80s on room air. Electrocardiogram was obtained which showed no change from prior, however, in light of the patient's obstruction, marginal urine output and pending instability, he was transferred to the Intensive Care Unit for further management. There he underwent a VQ scan which was low probability for pulmonary embolus. On rectal examination, he was found to have an area of anterior separation of his anastomosis and about 30 cc of serosanguinous fluid was drained. He was kept on broad spectrum antibiotics and close observation.
|
Evidence: He was made NPO and resuscitated with
intravenous fluids
Condition: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction and as to cause
HCC: K56609
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
He also had an episode of emesis as well. KUB revealed a PSBO. A small red rubber catheter was placed in the stoma with some relief, however, the patient remained distended. His partial small bowel obstruction was slow to resolve where on postoperative day #18 he was started on clears with continued decompression through his ostomy via the red rubber catheter. Postoperative day #13, the patient became hypotensive with a severe abdominal pain in the right upper quadrant above his ostomy.
|
Evidence: PSBO
Condition: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction and as to cause
HCC: K56609
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
A small red rubber catheter was placed in the stoma with some relief, however, the patient remained distended. His partial small bowel obstruction was slow to resolve where on postoperative day #18 he was started on clears with continued decompression through his ostomy via the red rubber catheter. Postoperative day #13, the patient became hypotensive with a severe abdominal pain in the right upper quadrant above his ostomy. Abdominal CT with p.o. and intravenous contrast was done which showed dilated loops of small bowel and mild edema proximal to the ostomy without free air or contrast extravasation. He was made NPO and resuscitated with intravenous fluids, however, later that evening, his O2 sats were noted to decrease to the 80s on room air. Electrocardiogram was obtained which showed no change from prior, however, in light of the patient's obstruction, marginal urine output and pending instability, he was transferred to the Intensive Care Unit for further management.
|
Evidence: partial small bowel obstruction
Condition: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction and as to cause
HCC: K56609
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
A small red rubber catheter was placed in the stoma with some relief, however, the patient remained distended. His partial small bowel obstruction was slow to resolve where on postoperative day #18 he was started on clears with continued decompression through his ostomy via the red rubber catheter. Postoperative day #13, the patient became hypotensive with a severe abdominal pain in the right upper quadrant above his ostomy. Abdominal CT with p.o. and intravenous contrast was done which showed dilated loops of small bowel and mild edema proximal to the ostomy without free air or contrast extravasation. He was made NPO and resuscitated with intravenous fluids, however, later that evening, his O2 sats were noted to decrease to the 80s on room air. Electrocardiogram was obtained which showed no change from prior, however, in light of the patient's obstruction, marginal urine output and pending instability, he was transferred to the Intensive Care Unit for further management. There he underwent a VQ scan which was low probability for pulmonary embolus. On rectal examination, he was found to have an area of anterior separation of his anastomosis and about 30 cc of serosanguinous fluid was drained.
|
Evidence: obstruction
Condition: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction and as to cause
HCC: K56609
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
3. Partial small bowel obstruction, resolved. 4. Postoperative leak, resolved. 5. Hyperlipidemia. 6. History of prostate cancer.
|
Evidence: Partial small bowel obstruction, resolved
Condition: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction and as to cause
HCC: K56609
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Postoperative day #13, the patient became hypotensive with a severe abdominal pain in the right upper quadrant above his ostomy. Abdominal CT with p.o. and intravenous contrast was done which showed dilated loops of small bowel and mild edema proximal to the ostomy without free air or contrast extravasation. He was made NPO and resuscitated with intravenous fluids, however, later that evening, his O2 sats were noted to decrease to the 80s on room air. Electrocardiogram was obtained which showed no change from prior, however, in light of the patient's obstruction, marginal urine output and pending instability, he was transferred to the Intensive Care Unit for further management. There he underwent a VQ scan which was low probability for pulmonary embolus. On rectal examination, he was found to have an area of anterior separation of his anastomosis and about 30 cc of serosanguinous fluid was drained.
|
Evidence: Abdominal CT with p.o. and intravenous contrast was
done which showed dilated loops of small bowel
Condition: Ileus, unspecified
HCC: K567
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Abdominal CT with p.o. and intravenous contrast was done which showed dilated loops of small bowel and mild edema proximal to the ostomy without free air or contrast extravasation. He was made NPO and resuscitated with intravenous fluids, however, later that evening, his O2 sats were noted to decrease to the 80s on room air. Electrocardiogram was obtained which showed no change from prior, however, in light of the patient's obstruction, marginal urine output and pending instability, he was transferred to the Intensive Care Unit for further management. There he underwent a VQ scan which was low probability for pulmonary embolus. On rectal examination, he was found to have an area of anterior separation of his anastomosis and about 30 cc of serosanguinous fluid was drained. He was kept on broad spectrum antibiotics and close observation. CT scan of the abdomen was repeated which showed, again, thickened bowel but no contrast extravasation.
|
Evidence: dilated loops of small bowel
Condition: Ileus, unspecified
HCC: K567
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
The first around the 17th and the 18th with the initial culture growing E-coli and Morganella Morgani and subsequent cultures with no growth. As note, throughout his period of sepsis, several blood cultures were drawn which have showed no growth to date. Due to the patient's poor p.o. intake, a nasal gastric feeding tube was placed and he was started on tube feeds which he tolerated well. His antibiotics were also continued through this interval as well. Around postoperative day #30, he was started on a regular diet. His tube feeds had been at goal, however, his ileostomy output again started to increase for which he was placed on intravenous fluid replacement.
|
Evidence: several blood cultures were
drawn which have showed no growth to date.
Condition: Sepsis, unspecified organism
HCC: A419
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
These were percutaneously drained. The first around the 17th and the 18th with the initial culture growing E-coli and Morganella Morgani and subsequent cultures with no growth. As note, throughout his period of sepsis, several blood cultures were drawn which have showed no growth to date. Due to the patient's poor p.o. intake, a nasal gastric feeding tube was placed and he was started on tube feeds which he tolerated well. His antibiotics were also continued through this interval as well. Around postoperative day #30, he was started on a regular diet.
|
Evidence: initial culture growing E-coli and Morganella
Morgani
Condition: Sepsis, unspecified organism
HCC: A419
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
On rectal examination, he was found to have an area of anterior separation of his anastomosis and about 30 cc of serosanguinous fluid was drained. He was kept on broad spectrum antibiotics and close observation. CT scan of the abdomen was repeated which showed, again, thickened bowel but no contrast extravasation. Of note, as well, the patient's white blood cell count had increased to 24, however, over the next few days, he stabilized with a decreasing white blood cell count, pain abating and better urine output. During this time, while he was NPO, he was also started on TPN for nutritional support.
|
Evidence: He was kept on broad
spectrum antibiotics
Condition: Sepsis, unspecified organism
HCC: A419
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
intake, a nasal gastric feeding tube was placed and he was started on tube feeds which he tolerated well. His antibiotics were also continued through this interval as well. Around postoperative day #30, he was started on a regular diet. His tube feeds had been at goal, however, his ileostomy output again started to increase for which he was placed on intravenous fluid replacement. He had a CT scan of his abdomen which did not show evidence of a leak or any new intra-abdominal fluid collections. He was slowly able to advance his diet.
|
Evidence: His antibiotics were also continued
through this interval as well.
Condition: Sepsis, unspecified organism
HCC: A419
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
His tube feeds have been decreased to 35 cc per hour to compensate for what he himself may not take in. His antibiotics were stopped on postoperative day #32. He remained afebrile, hemodynamically stable and otherwise feeling well. CONDITION OF DISCHARGE: Good. DISCHARGE STATUS: The patient will be discharged to a rehabilitation facility for conditioning and regain of strength.
|
Evidence: His antibiotics were stopped on postoperative day #32.
Condition: Sepsis, unspecified organism
HCC: A419
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
The first around the 17th and the 18th with the initial culture growing E-coli and Morganella Morgani and subsequent cultures with no growth. As note, throughout his period of sepsis, several blood cultures were drawn which have showed no growth to date. Due to the patient's poor p.o. intake, a nasal gastric feeding tube was placed and he was started on tube feeds which he tolerated well. His antibiotics were also continued through this interval as well.
|
Evidence: sepsis
Condition: Sepsis, unspecified organism
HCC: A419
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Discharge Labs: [**2193-1-18**] 06:10AM BLOOD WBC-12.7* RBC-5.51 Hgb-16.5 Hct-49.6 MCV-90 MCH-30.0 MCHC-33.3 RDW-12.5 Plt Ct-352 [**2193-1-18**] 06:10AM BLOOD Glucose-97 UreaN-15 Creat-0.9 Na-139 K-3.9 Cl-101 HCO3-25 AnGap-17 [**2193-1-18**] 06:10AM BLOOD ALT-80* AST-68* LD(LDH)-267* CK(CPK)-213 AlkPhos-109 TotBili-0.3 [**2193-1-18**] 06:10AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.6 Mg-2.1 [**2193-1-14**] 06:15AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2193-1-16**] 05:50AM BLOOD %HbA1c-5.5 eAG-111 Studies pending at Discharge: None Brief Hospital Course: Mr. [**Known lastname 3776**] is a 51 year old male with history of depression, obsessive compulsive disorder (OCD), and coronary artery disease (CAD) who was admitted for catatonia and course was notable for waxing and [**Doctor Last Name 688**] catatonia and agitation. ACTIVE PROBLEMS BY ISSUES: # Catatonia: He was seen by psychiatry and they felt that his catatonia was most likely due to recent weaning from abilify with exacerbation of underlying mood disorder (depression with psychosis). In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg [**Hospital1 **], with ativan 1mg [**Hospital1 **]). Unfortunately, although his catatonia improved, Mr.
|
Evidence: waxing and [**Doctor Last Name 688**] catatonia
Condition: Catatonia
HCC: F4481
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
You were admitted to the hospital because you were having a manifestation of your depression called catatonia. There was concern that your muscles were ungoing breakdown because of the catatonia so we monitored you closely in the ICU, but your muscles turned out to be recovering well. . Your catatonia was treated with medications called haldol and lorazepam. Your depression and psychosis will need further treatment with a procedure known as electroconvulsive therapy. It is very important that you keep all of the appointments with your doctors listed below. You will be transfered to the psychiatric [**Hospital1 **] to continue to treat your depression and psychosis. Your psychiatric medications will be adjusted further during your psychiatric hospitalization. .
|
Evidence: monitored you closely in the ICU
Condition: Catatonia
HCC: F4481
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
In the ED, initial VS were: 97.8 70 158/90 18 96RA . He was evaluated by psychiatry who felt his symptoms were due to aquired catatonia in the setting of a mood disorder and weaning off abilify. They noted that in the ED he exhibited mutism, hypokinetic behavior, echolalia/echopraxia, posturing and decreased eye blink. He was placed on section 12 and bed search was initiated. However he became agitated yesterday afternoon when he was ready to be transferred to an outside facility. He was given ativan but eventurally required 4 point restraints. Restraints were kept in place overnight, removed this morning, but then replaced due to concern for fall risk as he would not remain in his bed. His CK was noted to be trending upward, and the ED requested that he be admitted to the MICU given possible need for ativan drip, rising CK, and high risk for NMS.
|
Evidence: He was evaluated by psychiatry who felt his symptoms were due to
aquired catatonia
Condition: Catatonia
HCC: F4481
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
He was evaluated by psychiatry who felt his symptoms were due to aquired catatonia in the setting of a mood disorder and weaning off abilify. They noted that in the ED he exhibited mutism, hypokinetic behavior, echolalia/echopraxia, posturing and decreased eye blink. He was placed on section 12 and bed search was initiated. However he became agitated yesterday afternoon when he was ready to be transferred to an outside facility. He was given ativan but eventurally required 4 point restraints. Restraints were kept in place overnight, removed this morning, but then replaced due to concern for fall risk as he would not remain in his bed.
|
Evidence: In ED, patient exhibited mutism, hypokinetic behavior, echolalia/echopraxia, posturing and decreased eye blink.
Condition: Catatonia
HCC: F4481
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2193-1-8**] Discharge Date: [**2193-1-18**] Date of Birth: [**2141-12-5**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 602**] Chief Complaint: catatonia Major Surgical or Invasive Procedure: none History of Present Illness: 51M w/ hx of depression, remote suicide attempts and OCD presented to ED on [**1-8**] with c/o being nonconversant. He was being weaned off abilify over the past 3 weeks due to "drowsiness", and 3 days ago the patient's mother, with whom he lives, noticed that he was pacing the floor, a behavior that is unusual for him, but otherwise was at his baseline which is fully functional and independent in ADLs. The next morning however he became nonconversant and minimally responsive to verbal commands. After contacting his psychiatrist, his mother brought the patient to the [**Name (NI) **] for evaluation. .
|
Evidence: catatonia
Condition: Catatonia
HCC: F4481
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2193-1-8**] Discharge Date: [**2193-1-18**] Date of Birth: [**2141-12-5**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 602**] Chief Complaint: catatonia Major Surgical or Invasive Procedure: none History of Present Illness: 51M w/ hx of depression, remote suicide attempts and OCD presented to ED on [**1-8**] with c/o being nonconversant. He was being weaned off abilify over the past 3 weeks due to "drowsiness", and 3 days ago the patient's mother, with whom he lives, noticed that he was pacing the floor, a behavior that is unusual for him, but otherwise was at his baseline which is fully functional and independent in ADLs. The next morning however he became nonconversant and minimally responsive to verbal commands. After contacting his psychiatrist, his mother brought the patient to the [**Name (NI) **] for evaluation.
|
Evidence: catatonia
Condition: Catatonia
HCC: F4481
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg [**Hospital1 **], with ativan 1mg [**Hospital1 **]). Unfortunately, although his catatonia improved, Mr. [**Known lastname 3777**] psychosis did not continue to improve with haloperidol from [**Date range (1) 3778**], and ECT was deemed necessary. He was scheduled to begin ECT on [**1-18**], and medical clearance was obtained, but unfortunately Mr. [**Known lastname 3776**] could not be consented for the procedure and health care proxy authority for his mother was not formalized.
|
Evidence: ECT was entertained as a possible intervention for catatonia
Condition: Catatonia
HCC: F4481
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2193-1-8**] Discharge Date: [**2193-1-18**] Date of Birth: [**2141-12-5**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 602**] Chief Complaint: catatonia Major Surgical or Invasive Procedure: none History of Present Illness: 51M w/ hx of depression, remote suicide attempts and OCD presented to ED on [**1-8**] with c/o being nonconversant. He was being weaned off abilify over the past 3 weeks due to "drowsiness", and 3 days ago the patient's mother, with whom he lives, noticed that he was pacing the floor, a behavior that is unusual for him, but otherwise was at his baseline which is fully functional and independent in ADLs. The next morning however he became nonconversant and minimally responsive to verbal commands. After contacting his psychiatrist, his mother brought the patient to the [**Name (NI) **] for evaluation. . In the ED, initial VS were: 97.8 70 158/90 18 96RA .
|
Evidence: catatonia
Condition: Catatonia
HCC: F4481
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2193-1-8**] Discharge Date: [**2193-1-18**] Date of Birth: [**2141-12-5**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 602**] Chief Complaint: catatonia Major Surgical or Invasive Procedure: none History of Present Illness: 51M w/ hx of depression, remote suicide attempts and OCD presented to ED on [**1-8**] with c/o being nonconversant. He was being weaned off abilify over the past 3 weeks due to "drowsiness", and 3 days ago the patient's mother, with whom he lives, noticed that he was pacing the floor, a behavior that is unusual for him, but otherwise was at his baseline which is fully functional and independent in ADLs. The next morning however he became nonconversant and minimally responsive to verbal commands. After contacting his psychiatrist, his mother brought the patient to the [**Name (NI) **] for evaluation. .
|
Evidence: catatonia
Condition: Catatonia
HCC: F4481
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg [**Hospital1 **], with ativan 1mg [**Hospital1 **]). Unfortunately, although his catatonia improved, Mr. [**Known lastname 3777**] psychosis did not continue to improve with haloperidol from [**Date range (1) 3778**], and ECT was deemed necessary. He was scheduled to begin ECT on [**1-18**], and medical clearance was obtained, but unfortunately Mr. [**Known lastname 3776**] could not be consented for the procedure and health care proxy authority for his mother was not formalized. Mr. [**Name14 (STitle) 3779**] remained in [**4-6**] point restraints during his floor stay.
|
Evidence: his catatonia resolved with standing
antipsychotics (haloperidol 10mg [**Hospital1 **], with ativan 1mg [**Hospital1 **])
Condition: Catatonia
HCC: F4481
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
. Your catatonia was treated with medications called haldol and lorazepam. Your depression and psychosis will need further treatment with a procedure known as electroconvulsive therapy. It is very important that you keep all of the appointments with your doctors listed below. You will be transfered to the psychiatric [**Hospital1 **] to continue to treat your depression and psychosis. Your psychiatric medications will be adjusted further during your psychiatric hospitalization.
|
Evidence: Your catatonia was treated with medications called haldol and
lorazepam.
Condition: Catatonia
HCC: F4481
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2193-1-8**] Discharge Date: [**2193-1-18**] Date of Birth: [**2141-12-5**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 602**] Chief Complaint: catatonia Major Surgical or Invasive Procedure: none History of Present Illness: 51M w/ hx of depression, remote suicide attempts and OCD presented to ED on [**1-8**] with c/o being nonconversant. He was being weaned off abilify over the past 3 weeks due to "drowsiness", and 3 days ago the patient's mother, with whom he lives, noticed that he was pacing the floor, a behavior that is unusual for him, but otherwise was at his baseline which is fully functional and independent in ADLs. The next morning however he became nonconversant and minimally responsive to verbal commands. After contacting his psychiatrist, his mother brought the patient to the [**Name (NI) **] for evaluation. . In the ED, initial VS were: 97.8 70 158/90 18 96RA .
|
Evidence: catatonia
Condition: Catatonia
HCC: F4481
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
In the ED, initial VS were: 97.8 70 158/90 18 96RA . He was evaluated by psychiatry who felt his symptoms were due to aquired catatonia in the setting of a mood disorder and weaning off abilify. They noted that in the ED he exhibited mutism, hypokinetic behavior, echolalia/echopraxia, posturing and decreased eye blink. He was placed on section 12 and bed search was initiated. However he became agitated yesterday afternoon when he was ready to be transferred to an outside facility. He was given ativan but eventurally required 4 point restraints. Restraints were kept in place overnight, removed this morning, but then replaced due to concern for fall risk as he would not remain in his bed. His CK was noted to be trending upward, and the ED requested that he be admitted to the MICU given possible need for ativan drip, rising CK, and high risk for NMS. .
|
Evidence: aquired catatonia in the setting of a mood disorder
Condition: Catatonia
HCC: F4481
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2193-1-8**] Discharge Date: [**2193-1-18**] Date of Birth: [**2141-12-5**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 602**] Chief Complaint: catatonia Major Surgical or Invasive Procedure: none History of Present Illness: 51M w/ hx of depression, remote suicide attempts and OCD presented to ED on [**1-8**] with c/o being nonconversant. He was being weaned off abilify over the past 3 weeks due to "drowsiness", and 3 days ago the patient's mother, with whom he lives, noticed that he was pacing the floor, a behavior that is unusual for him, but otherwise was at his baseline which is fully functional and independent in ADLs. The next morning however he became nonconversant and minimally responsive to verbal commands. After contacting his psychiatrist, his mother brought the patient to the [**Name (NI) **] for evaluation.
|
Evidence: catatonia
Condition: Catatonia
HCC: F4481
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Discharge Labs: [**2193-1-18**] 06:10AM BLOOD WBC-12.7* RBC-5.51 Hgb-16.5 Hct-49.6 MCV-90 MCH-30.0 MCHC-33.3 RDW-12.5 Plt Ct-352 [**2193-1-18**] 06:10AM BLOOD Glucose-97 UreaN-15 Creat-0.9 Na-139 K-3.9 Cl-101 HCO3-25 AnGap-17 [**2193-1-18**] 06:10AM BLOOD ALT-80* AST-68* LD(LDH)-267* CK(CPK)-213 AlkPhos-109 TotBili-0.3 [**2193-1-18**] 06:10AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.6 Mg-2.1 [**2193-1-14**] 06:15AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2193-1-16**] 05:50AM BLOOD %HbA1c-5.5 eAG-111 Studies pending at Discharge: None Brief Hospital Course: Mr. [**Known lastname 3776**] is a 51 year old male with history of depression, obsessive compulsive disorder (OCD), and coronary artery disease (CAD) who was admitted for catatonia and course was notable for waxing and [**Doctor Last Name 688**] catatonia and agitation. ACTIVE PROBLEMS BY ISSUES: # Catatonia: He was seen by psychiatry and they felt that his catatonia was most likely due to recent weaning from abilify with exacerbation of underlying mood disorder (depression with psychosis). In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg [**Hospital1 **], with ativan 1mg [**Hospital1 **]).
|
Evidence: waxing and [**Doctor Last Name 688**] catatonia
Condition: Catatonia
HCC: F4481
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2193-1-8**] Discharge Date: [**2193-1-18**] Date of Birth: [**2141-12-5**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 602**] Chief Complaint: catatonia Major Surgical or Invasive Procedure: none History of Present Illness: 51M w/ hx of depression, remote suicide attempts and OCD presented to ED on [**1-8**] with c/o being nonconversant. He was being weaned off abilify over the past 3 weeks due to "drowsiness", and 3 days ago the patient's mother, with whom he lives, noticed that he was pacing the floor, a behavior that is unusual for him, but otherwise was at his baseline which is fully functional and independent in ADLs. The next morning however he became nonconversant and minimally responsive to verbal commands. After contacting his psychiatrist, his mother brought the patient to the [**Name (NI) **] for evaluation. . In the ED, initial VS were: 97.8 70 158/90 18 96RA . He was evaluated by psychiatry who felt his symptoms were due to aquired catatonia in the setting of a mood disorder and weaning off abilify.
|
Evidence: catatonia
Condition: Catatonia
HCC: F4481
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
[**Known lastname 3776**] is a 51 year old male with history of depression, obsessive compulsive disorder (OCD), and coronary artery disease (CAD) who was admitted for catatonia and course was notable for waxing and [**Doctor Last Name 688**] catatonia and agitation. ACTIVE PROBLEMS BY ISSUES: # Catatonia: He was seen by psychiatry and they felt that his catatonia was most likely due to recent weaning from abilify with exacerbation of underlying mood disorder (depression with psychosis). In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg [**Hospital1 **], with ativan 1mg [**Hospital1 **]). Unfortunately, although his catatonia improved, Mr. [**Known lastname 3777**] psychosis did not continue to improve with haloperidol from [**Date range (1) 3778**], and ECT was deemed necessary. He was scheduled to begin ECT on [**1-18**], and medical clearance was obtained, but unfortunately Mr. [**Known lastname 3776**] could not be consented for the procedure and health care proxy authority for his mother was not formalized. Mr.
|
Evidence: psychiatry and they felt that his
catatonia was most likely due to recent weaning from abilify
with exacerbation of underlying mood disorder (depression with
psychosis)
Condition: Other depressive episodes with psychotic features
HCC: F3289
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
. Review of systems: - Reviewed and negative except per HPI Past Medical History: - depression w/ psychotic feactures, s/p ECT, hx of suicide attempts - Obsessive-compulsive traits - CAD s/p AMI [**2180**], stent placed in [**2188**] - chronic low back pain - asthma - obesity Social History: - Tobacco: smokes 1-1.5ppd x 30yrs - Alcohol: none per mother - [**Name (NI) 3264**]: hx of cocaine and marijuana abuse, none for past 20yrs - Divorced 20yrs ago, has 2 adult children, lives with mother in [**Name (NI) 3494**] Family History: - sister: post-partum depression, suicide - grandfather: OCD Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 96.9 BP: 153/87 P: 76 R: 17 O2: 94%RA General: A/Ox2, answers basic questions HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Obese, protuberant abdomen, nontender, bowel sounds GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, unable to complete finger-to-nose d/t restraints Pertinent Results: ADMISSION LABS: [**2193-1-8**] 02:20PM BLOOD WBC-12.7* RBC-5.61 Hgb-17.0 Hct-50.7 MCV-90 MCH-30.3 MCHC-33.6 RDW-12.7 Plt Ct-269 [**2193-1-8**] 02:20PM BLOOD Neuts-76.9* Lymphs-17.0* Monos-4.8 Eos-1.0 Baso-0.4 [**2193-1-8**] 02:20PM BLOOD Glucose-115* UreaN-19 Creat-1.1 Na-139 K-4.7 Cl-100 HCO3-29 AnGap-15 [**2193-1-8**] 02:20PM BLOOD CK(CPK)-565* [**2193-1-10**] 02:40AM BLOOD ALT-27 AST-53* LD(LDH)-223 CK(CPK)-1354* AlkPhos-111 TotBili-0.4 [**2193-1-10**] 02:40AM BLOOD Lipase-29 [**2193-1-8**] 02:20PM BLOOD cTropnT-<0.01 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 09:25AM BLOOD CK-MB-16* MB Indx-1.1 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD CK-MB-14* MB Indx-1.2 cTropnT-<0.01 [**2193-1-11**] 05:17AM BLOOD CK-MB-12* MB Indx-1.2 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD Albumin-3.7 Calcium-8.6 Phos-3.5 Mg-2.0 [**2193-1-8**] 02:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2193-1-12**] 07:56PM BLOOD Type-[**Last Name (un) **] Temp-37.9 pO2-100 pCO2-26* pH-7.56* calTCO2-24 Base XS-2 Intubat-NOT INTUBA Comment-GREEN TOP [**2193-1-12**] 07:56PM BLOOD freeCa-0.94* [**2193-1-12**] 07:56PM BLOOD Lactate-1.1 . MICRO: [**2193-1-11**] 8:02 pm SWAB Source: left groin. WOUND CULTURE (Preliminary): STAPH AUREUS COAG +. MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. .
|
Evidence: depression w/ psychotic feactures
Condition: Other depressive episodes with psychotic features
HCC: F3289
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
[**Known lastname 3776**] is a 51 year old male with history of depression, obsessive compulsive disorder (OCD), and coronary artery disease (CAD) who was admitted for catatonia and course was notable for waxing and [**Doctor Last Name 688**] catatonia and agitation. ACTIVE PROBLEMS BY ISSUES: # Catatonia: He was seen by psychiatry and they felt that his catatonia was most likely due to recent weaning from abilify with exacerbation of underlying mood disorder (depression with psychosis). In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg [**Hospital1 **], with ativan 1mg [**Hospital1 **]). Unfortunately, although his catatonia improved, Mr. [**Known lastname 3777**] psychosis did not continue to improve with haloperidol from [**Date range (1) 3778**], and ECT was deemed necessary.
|
Evidence: exacerbation of underlying mood disorder (depression with
psychosis)
Condition: Other depressive episodes with psychotic features
HCC: F3289
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
[**Known lastname 3776**] is a 51 year old male with history of depression, obsessive compulsive disorder (OCD), and coronary artery disease (CAD) who was admitted for catatonia and course was notable for waxing and [**Doctor Last Name 688**] catatonia and agitation. ACTIVE PROBLEMS BY ISSUES: # Catatonia: He was seen by psychiatry and they felt that his catatonia was most likely due to recent weaning from abilify with exacerbation of underlying mood disorder (depression with psychosis). In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg [**Hospital1 **], with ativan 1mg [**Hospital1 **]). Unfortunately, although his catatonia improved, Mr. [**Known lastname 3777**] psychosis did not continue to improve with haloperidol from [**Date range (1) 3778**], and ECT was deemed necessary. He was scheduled to begin ECT on [**1-18**], and medical clearance was obtained, but unfortunately Mr. [**Known lastname 3776**] could not be consented for the procedure and health care proxy authority for his mother was not formalized. Mr.
|
Evidence: mood disorder (depression with
psychosis)
Condition: Other depressive episodes with psychotic features
HCC: F3289
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
[**Known lastname 3776**] is a 51 year old male with history of depression, obsessive compulsive disorder (OCD), and coronary artery disease (CAD) who was admitted for catatonia and course was notable for waxing and [**Doctor Last Name 688**] catatonia and agitation. ACTIVE PROBLEMS BY ISSUES: # Catatonia: He was seen by psychiatry and they felt that his catatonia was most likely due to recent weaning from abilify with exacerbation of underlying mood disorder (depression with psychosis). In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg [**Hospital1 **], with ativan 1mg [**Hospital1 **]). Unfortunately, although his catatonia improved, Mr. [**Known lastname 3777**] psychosis did not continue to improve with haloperidol from [**Date range (1) 3778**], and ECT was deemed necessary.
|
Evidence: psychosis
Condition: Other depressive episodes with psychotic features
HCC: F3289
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Discharge Diagnosis: PRIMARY DIAGNOSIS Depression with psychotic features Asthma Obesity Coronary Artery Disease Discharge Condition: Mental Status: Clear and coherent. Discharge Instructions: Dear Mr. [**Known lastname 3776**], . It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted to the hospital because you were having a manifestation of your depression called catatonia.
|
Evidence: Depression with psychotic features
Condition: Other depressive episodes with psychotic features
HCC: F3289
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2193-1-8**] Discharge Date: [**2193-1-18**] Date of Birth: [**2141-12-5**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 602**] Chief Complaint: catatonia Major Surgical or Invasive Procedure: none History of Present Illness: 51M w/ hx of depression, remote suicide attempts and OCD presented to ED on [**1-8**] with c/o being nonconversant. He was being weaned off abilify over the past 3 weeks due to "drowsiness", and 3 days ago the patient's mother, with whom he lives, noticed that he was pacing the floor, a behavior that is unusual for him, but otherwise was at his baseline which is fully functional and independent in ADLs. The next morning however he became nonconversant and minimally responsive to verbal commands. After contacting his psychiatrist, his mother brought the patient to the [**Name (NI) **] for evaluation. .
|
Evidence: depression
Condition: Other depressive episodes with psychotic features
HCC: F3289
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
[**Known lastname 3776**] is a 51 year old male with history of depression, obsessive compulsive disorder (OCD), and coronary artery disease (CAD) who was admitted for catatonia and course was notable for waxing and [**Doctor Last Name 688**] catatonia and agitation. ACTIVE PROBLEMS BY ISSUES: # Catatonia: He was seen by psychiatry and they felt that his catatonia was most likely due to recent weaning from abilify with exacerbation of underlying mood disorder (depression with psychosis). In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg [**Hospital1 **], with ativan 1mg [**Hospital1 **]). Unfortunately, although his catatonia improved, Mr. [**Known lastname 3777**] psychosis did not continue to improve with haloperidol from [**Date range (1) 3778**], and ECT was deemed necessary.
|
Evidence: psychosis
Condition: Other depressive episodes with psychotic features
HCC: F3289
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Unfortunately, although his catatonia improved, Mr. [**Known lastname 3777**] psychosis did not continue to improve with haloperidol from [**Date range (1) 3778**], and ECT was deemed necessary. He was scheduled to begin ECT on [**1-18**], and medical clearance was obtained, but unfortunately Mr. [**Known lastname 3776**] could not be consented for the procedure and health care proxy authority for his mother was not formalized. Mr. [**Name14 (STitle) 3779**] remained in [**4-6**] point restraints during his floor stay. # Leukocytosis/Fever/Pneumonia: Mr. [**Name14 (STitle) 3779**] was noted to have difficulty with secretions on [**1-12**] after recieving ativan for agitation.
|
Evidence: ECT was deemed necessary. He was scheduled to
begin ECT on [**1-18**]
Condition: Other depressive episodes with psychotic features
HCC: F3289
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Unfortunately, although his catatonia improved, Mr. [**Known lastname 3777**] psychosis did not continue to improve with haloperidol from [**Date range (1) 3778**], and ECT was deemed necessary. He was scheduled to begin ECT on [**1-18**], and medical clearance was obtained, but unfortunately Mr. [**Known lastname 3776**] could not be consented for the procedure and health care proxy authority for his mother was not formalized. Mr. [**Name14 (STitle) 3779**] remained in [**4-6**] point restraints during his floor stay. # Leukocytosis/Fever/Pneumonia: Mr. [**Name14 (STitle) 3779**] was noted to have difficulty with secretions on [**1-12**] after recieving ativan for agitation.
|
Evidence: psychosis did not continue to improve with haloperidol
Condition: Other depressive episodes with psychotic features
HCC: F3289
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Your catatonia was treated with medications called haldol and lorazepam. Your depression and psychosis will need further treatment with a procedure known as electroconvulsive therapy. It is very important that you keep all of the appointments with your doctors listed below. You will be transfered to the psychiatric [**Hospital1 **] to continue to treat your depression and psychosis. Your psychiatric medications will be adjusted further during your psychiatric hospitalization. .
|
Evidence: Your depression and psychosis will need further
treatment with a procedure known as electroconvulsive therapy.
Condition: Other depressive episodes with psychotic features
HCC: F3289
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
You will be transfered to the psychiatric [**Hospital1 **] to continue to treat your depression and psychosis. Your psychiatric medications will be adjusted further during your psychiatric hospitalization. . It is also very important that you take your medications everyday. The following changes were made to your medications: 1. Your Luvox and lamictal (treatments for depression and other mood disorders) have been stopped, please consult with your psychiatrists regarding whether to restart these.
|
Evidence: Your psychiatric medications will be adjusted further during
your psychiatric hospitalization.
Condition: Other depressive episodes with psychotic features
HCC: F3289
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Your Luvox and lamictal (treatments for depression and other mood disorders) have been stopped, please consult with your psychiatrists regarding whether to restart these. START haloperidol (for your confusion) START levofloxacin (for pneumonia), you will have 2 more days START ativan for agitation STOP simvastatin and START atorvastatin because we need to treat your lipids, but the simvastatin may have been harming your liver Followup Instructions: Please follow up with your PCP after you are discharged from deaconness 4.
|
Evidence: START haloperidol (for your confusion)
Condition: Other depressive episodes with psychotic features
HCC: F3289
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2193-1-8**] Discharge Date: [**2193-1-18**] Date of Birth: [**2141-12-5**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 602**] Chief Complaint: catatonia Major Surgical or Invasive Procedure: none History of Present Illness: 51M w/ hx of depression, remote suicide attempts and OCD presented to ED on [**1-8**] with c/o being nonconversant. He was being weaned off abilify over the past 3 weeks due to "drowsiness", and 3 days ago the patient's mother, with whom he lives, noticed that he was pacing the floor, a behavior that is unusual for him, but otherwise was at his baseline which is fully functional and independent in ADLs. The next morning however he became nonconversant and minimally responsive to verbal commands. After contacting his psychiatrist, his mother brought the patient to the [**Name (NI) **] for evaluation.
|
Evidence: depression
Condition: Other depressive episodes with psychotic features
HCC: F3289
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
. Review of systems: - Reviewed and negative except per HPI Past Medical History: - depression w/ psychotic feactures, s/p ECT, hx of suicide attempts - Obsessive-compulsive traits - CAD s/p AMI [**2180**], stent placed in [**2188**] - chronic low back pain - asthma - obesity Social History: - Tobacco: smokes 1-1.5ppd x 30yrs - Alcohol: none per mother - [**Name (NI) 3264**]: hx of cocaine and marijuana abuse, none for past 20yrs - Divorced 20yrs ago, has 2 adult children, lives with mother in [**Name (NI) 3494**] Family History: - sister: post-partum depression, suicide - grandfather: OCD Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 96.9 BP: 153/87 P: 76 R: 17 O2: 94%RA General: A/Ox2, answers basic questions HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Obese, protuberant abdomen, nontender, bowel sounds GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, unable to complete finger-to-nose d/t restraints Pertinent Results: ADMISSION LABS: [**2193-1-8**] 02:20PM BLOOD WBC-12.7* RBC-5.61 Hgb-17.0 Hct-50.7 MCV-90 MCH-30.3 MCHC-33.6 RDW-12.7 Plt Ct-269 [**2193-1-8**] 02:20PM BLOOD Neuts-76.9* Lymphs-17.0* Monos-4.8 Eos-1.0 Baso-0.4 [**2193-1-8**] 02:20PM BLOOD Glucose-115* UreaN-19 Creat-1.1 Na-139 K-4.7 Cl-100 HCO3-29 AnGap-15 [**2193-1-8**] 02:20PM BLOOD CK(CPK)-565* [**2193-1-10**] 02:40AM BLOOD ALT-27 AST-53* LD(LDH)-223 CK(CPK)-1354* AlkPhos-111 TotBili-0.4 [**2193-1-10**] 02:40AM BLOOD Lipase-29 [**2193-1-8**] 02:20PM BLOOD cTropnT-<0.01 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 09:25AM BLOOD CK-MB-16* MB Indx-1.1 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD CK-MB-14* MB Indx-1.2 cTropnT-<0.01 [**2193-1-11**] 05:17AM BLOOD CK-MB-12* MB Indx-1.2 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD Albumin-3.7 Calcium-8.6 Phos-3.5 Mg-2.0 [**2193-1-8**] 02:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2193-1-12**] 07:56PM BLOOD Type-[**Last Name (un) **] Temp-37.9 pO2-100 pCO2-26* pH-7.56* calTCO2-24 Base XS-2 Intubat-NOT INTUBA Comment-GREEN TOP [**2193-1-12**] 07:56PM BLOOD freeCa-0.94* [**2193-1-12**] 07:56PM BLOOD Lactate-1.1 . MICRO: [**2193-1-11**] 8:02 pm SWAB Source: left groin. WOUND CULTURE (Preliminary): STAPH AUREUS COAG +. MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH.
|
Evidence: depression w/ psychotic feactures
Condition: Other depressive episodes with psychotic features
HCC: F3289
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
[**Known lastname 3776**] is a 51 year old male with history of depression, obsessive compulsive disorder (OCD), and coronary artery disease (CAD) who was admitted for catatonia and course was notable for waxing and [**Doctor Last Name 688**] catatonia and agitation. ACTIVE PROBLEMS BY ISSUES: # Catatonia: He was seen by psychiatry and they felt that his catatonia was most likely due to recent weaning from abilify with exacerbation of underlying mood disorder (depression with psychosis). In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg [**Hospital1 **], with ativan 1mg [**Hospital1 **]). Unfortunately, although his catatonia improved, Mr. [**Known lastname 3777**] psychosis did not continue to improve with haloperidol from [**Date range (1) 3778**], and ECT was deemed necessary. He was scheduled to begin ECT on [**1-18**], and medical clearance was obtained, but unfortunately Mr. [**Known lastname 3776**] could not be consented for the procedure and health care proxy authority for his mother was not formalized.
|
Evidence: exacerbation of underlying mood disorder (depression with
psychosis)
Condition: Other depressive episodes with psychotic features
HCC: F3289
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
[**Known lastname 3776**] is a 51 year old male with history of depression, obsessive compulsive disorder (OCD), and coronary artery disease (CAD) who was admitted for catatonia and course was notable for waxing and [**Doctor Last Name 688**] catatonia and agitation. ACTIVE PROBLEMS BY ISSUES: # Catatonia: He was seen by psychiatry and they felt that his catatonia was most likely due to recent weaning from abilify with exacerbation of underlying mood disorder (depression with psychosis). In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg [**Hospital1 **], with ativan 1mg [**Hospital1 **]). Unfortunately, although his catatonia improved, Mr. [**Known lastname 3777**] psychosis did not continue to improve with haloperidol from [**Date range (1) 3778**], and ECT was deemed necessary. He was scheduled to begin ECT on [**1-18**], and medical clearance was obtained, but unfortunately Mr. [**Known lastname 3776**] could not be consented for the procedure and health care proxy authority for his mother was not formalized.
|
Evidence: mood disorder (depression with
psychosis)
Condition: Other depressive episodes with psychotic features
HCC: F3289
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
[**Known lastname 3776**] is a 51 year old male with history of depression, obsessive compulsive disorder (OCD), and coronary artery disease (CAD) who was admitted for catatonia and course was notable for waxing and [**Doctor Last Name 688**] catatonia and agitation. ACTIVE PROBLEMS BY ISSUES: # Catatonia: He was seen by psychiatry and they felt that his catatonia was most likely due to recent weaning from abilify with exacerbation of underlying mood disorder (depression with psychosis). In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg [**Hospital1 **], with ativan 1mg [**Hospital1 **]). Unfortunately, although his catatonia improved, Mr. [**Known lastname 3777**] psychosis did not continue to improve with haloperidol from [**Date range (1) 3778**], and ECT was deemed necessary. He was scheduled to begin ECT on [**1-18**], and medical clearance was obtained, but unfortunately Mr.
|
Evidence: psychosis
Condition: Other depressive episodes with psychotic features
HCC: F3289
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Discharge Diagnosis: PRIMARY DIAGNOSIS Depression with psychotic features Asthma Obesity Coronary Artery Disease Discharge Condition: Mental Status: Clear and coherent. Discharge Instructions: Dear Mr. [**Known lastname 3776**], . It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted to the hospital because you were having a manifestation of your depression called catatonia. There was concern that your muscles were ungoing breakdown because of the catatonia so we monitored you closely in the ICU, but your muscles turned out to be recovering well.
|
Evidence: Depression with psychotic features
Condition: Other depressive episodes with psychotic features
HCC: F3289
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2193-1-8**] Discharge Date: [**2193-1-18**] Date of Birth: [**2141-12-5**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 602**] Chief Complaint: catatonia Major Surgical or Invasive Procedure: none History of Present Illness: 51M w/ hx of depression, remote suicide attempts and OCD presented to ED on [**1-8**] with c/o being nonconversant. He was being weaned off abilify over the past 3 weeks due to "drowsiness", and 3 days ago the patient's mother, with whom he lives, noticed that he was pacing the floor, a behavior that is unusual for him, but otherwise was at his baseline which is fully functional and independent in ADLs. The next morning however he became nonconversant and minimally responsive to verbal commands. After contacting his psychiatrist, his mother brought the patient to the [**Name (NI) **] for evaluation.
|
Evidence: depression
Condition: Other depressive episodes with psychotic features
HCC: F3289
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
[**Known lastname 3776**] is a 51 year old male with history of depression, obsessive compulsive disorder (OCD), and coronary artery disease (CAD) who was admitted for catatonia and course was notable for waxing and [**Doctor Last Name 688**] catatonia and agitation. ACTIVE PROBLEMS BY ISSUES: # Catatonia: He was seen by psychiatry and they felt that his catatonia was most likely due to recent weaning from abilify with exacerbation of underlying mood disorder (depression with psychosis). In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg [**Hospital1 **], with ativan 1mg [**Hospital1 **]). Unfortunately, although his catatonia improved, Mr. [**Known lastname 3777**] psychosis did not continue to improve with haloperidol from [**Date range (1) 3778**], and ECT was deemed necessary. He was scheduled to begin ECT on [**1-18**], and medical clearance was obtained, but unfortunately Mr. [**Known lastname 3776**] could not be consented for the procedure and health care proxy authority for his mother was not formalized. Mr.
|
Evidence: psychosis
Condition: Other depressive episodes with psychotic features
HCC: F3289
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
# Coronary artery disease (CAD): History of acute myocardial infarction in [**2178**], stent placed in [**2188**]. ECG showed sinus rhythm with no acute ischemic changes. He has a baseline widened mediastinum found on prior CT to be fat deposits and lymphadenopathy. We initially held his simvastatin and zetia given elevated LFTs. We continued his aspirin given his LAD stent. #Poor PO intake: Mr. [**Known lastname 3776**] [**Last Name (Titles) 3781**] refused to take PO intake while on the floor. We continued IV fluids with D5 1/2 NS at 125 cc/hr during his stay, but his hematocrit increased from 41 to 49 indicating hemoconcentration. We increased his IVF to 150 cc/hr on [**1-17**], but his hct continued to rise from [**1-17**] to [**1-18**] from 47.6 to 49.6.
|
Evidence: ECG showed sinus
rhythm with no acute ischemic changes.
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
. Review of systems: - Reviewed and negative except per HPI Past Medical History: - depression w/ psychotic feactures, s/p ECT, hx of suicide attempts - Obsessive-compulsive traits - CAD s/p AMI [**2180**], stent placed in [**2188**] - chronic low back pain - asthma - obesity Social History: - Tobacco: smokes 1-1.5ppd x 30yrs - Alcohol: none per mother - [**Name (NI) 3264**]: hx of cocaine and marijuana abuse, none for past 20yrs - Divorced 20yrs ago, has 2 adult children, lives with mother in [**Name (NI) 3494**] Family History: - sister: post-partum depression, suicide - grandfather: OCD Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 96.9 BP: 153/87 P: 76 R: 17 O2: 94%RA General: A/Ox2, answers basic questions HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Obese, protuberant abdomen, nontender, bowel sounds GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, unable to complete finger-to-nose d/t restraints Pertinent Results: ADMISSION LABS: [**2193-1-8**] 02:20PM BLOOD WBC-12.7* RBC-5.61 Hgb-17.0 Hct-50.7 MCV-90 MCH-30.3 MCHC-33.6 RDW-12.7 Plt Ct-269 [**2193-1-8**] 02:20PM BLOOD Neuts-76.9* Lymphs-17.0* Monos-4.8 Eos-1.0 Baso-0.4 [**2193-1-8**] 02:20PM BLOOD Glucose-115* UreaN-19 Creat-1.1 Na-139 K-4.7 Cl-100 HCO3-29 AnGap-15 [**2193-1-8**] 02:20PM BLOOD CK(CPK)-565* [**2193-1-10**] 02:40AM BLOOD ALT-27 AST-53* LD(LDH)-223 CK(CPK)-1354* AlkPhos-111 TotBili-0.4 [**2193-1-10**] 02:40AM BLOOD Lipase-29 [**2193-1-8**] 02:20PM BLOOD cTropnT-<0.01 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 09:25AM BLOOD CK-MB-16* MB Indx-1.1 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD CK-MB-14* MB Indx-1.2 cTropnT-<0.01 [**2193-1-11**] 05:17AM BLOOD CK-MB-12* MB Indx-1.2 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD Albumin-3.7 Calcium-8.6 Phos-3.5 Mg-2.0 [**2193-1-8**] 02:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2193-1-12**] 07:56PM BLOOD Type-[**Last Name (un) **] Temp-37.9 pO2-100 pCO2-26* pH-7.56* calTCO2-24 Base XS-2 Intubat-NOT INTUBA Comment-GREEN TOP [**2193-1-12**] 07:56PM BLOOD freeCa-0.94* [**2193-1-12**] 07:56PM BLOOD Lactate-1.1 . MICRO: [**2193-1-11**] 8:02 pm SWAB Source: left groin. WOUND CULTURE (Preliminary): STAPH AUREUS COAG +. MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE.
|
Evidence: CAD
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Discharge Labs: [**2193-1-18**] 06:10AM BLOOD WBC-12.7* RBC-5.51 Hgb-16.5 Hct-49.6 MCV-90 MCH-30.0 MCHC-33.3 RDW-12.5 Plt Ct-352 [**2193-1-18**] 06:10AM BLOOD Glucose-97 UreaN-15 Creat-0.9 Na-139 K-3.9 Cl-101 HCO3-25 AnGap-17 [**2193-1-18**] 06:10AM BLOOD ALT-80* AST-68* LD(LDH)-267* CK(CPK)-213 AlkPhos-109 TotBili-0.3 [**2193-1-18**] 06:10AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.6 Mg-2.1 [**2193-1-14**] 06:15AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2193-1-16**] 05:50AM BLOOD %HbA1c-5.5 eAG-111 Studies pending at Discharge: None Brief Hospital Course: Mr. [**Known lastname 3776**] is a 51 year old male with history of depression, obsessive compulsive disorder (OCD), and coronary artery disease (CAD) who was admitted for catatonia and course was notable for waxing and [**Doctor Last Name 688**] catatonia and agitation. ACTIVE PROBLEMS BY ISSUES: # Catatonia: He was seen by psychiatry and they felt that his catatonia was most likely due to recent weaning from abilify with exacerbation of underlying mood disorder (depression with psychosis). In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg [**Hospital1 **], with ativan 1mg [**Hospital1 **]).
|
Evidence: Coronary artery disease
(CAD)
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Discharge Labs: [**2193-1-18**] 06:10AM BLOOD WBC-12.7* RBC-5.51 Hgb-16.5 Hct-49.6 MCV-90 MCH-30.0 MCHC-33.3 RDW-12.5 Plt Ct-352 [**2193-1-18**] 06:10AM BLOOD Glucose-97 UreaN-15 Creat-0.9 Na-139 K-3.9 Cl-101 HCO3-25 AnGap-17 [**2193-1-18**] 06:10AM BLOOD ALT-80* AST-68* LD(LDH)-267* CK(CPK)-213 AlkPhos-109 TotBili-0.3 [**2193-1-18**] 06:10AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.6 Mg-2.1 [**2193-1-14**] 06:15AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2193-1-16**] 05:50AM BLOOD %HbA1c-5.5 eAG-111 Studies pending at Discharge: None Brief Hospital Course: Mr. [**Known lastname 3776**] is a 51 year old male with history of depression, obsessive compulsive disorder (OCD), and coronary artery disease (CAD) who was admitted for catatonia and course was notable for waxing and [**Doctor Last Name 688**] catatonia and agitation. ACTIVE PROBLEMS BY ISSUES: # Catatonia: He was seen by psychiatry and they felt that his catatonia was most likely due to recent weaning from abilify with exacerbation of underlying mood disorder (depression with psychosis). In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg [**Hospital1 **], with ativan 1mg [**Hospital1 **]). Unfortunately, although his catatonia improved, Mr. [**Known lastname 3777**] psychosis did not continue to improve with haloperidol from [**Date range (1) 3778**], and ECT was deemed necessary. He was scheduled to begin ECT on [**1-18**], and medical clearance was obtained, but unfortunately Mr.
|
Evidence: Coronary artery disease (CAD)
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Discharge Labs: [**2193-1-18**] 06:10AM BLOOD WBC-12.7* RBC-5.51 Hgb-16.5 Hct-49.6 MCV-90 MCH-30.0 MCHC-33.3 RDW-12.5 Plt Ct-352 [**2193-1-18**] 06:10AM BLOOD Glucose-97 UreaN-15 Creat-0.9 Na-139 K-3.9 Cl-101 HCO3-25 AnGap-17 [**2193-1-18**] 06:10AM BLOOD ALT-80* AST-68* LD(LDH)-267* CK(CPK)-213 AlkPhos-109 TotBili-0.3 [**2193-1-18**] 06:10AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.6 Mg-2.1 [**2193-1-14**] 06:15AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2193-1-16**] 05:50AM BLOOD %HbA1c-5.5 eAG-111 Studies pending at Discharge: None Brief Hospital Course: Mr. [**Known lastname 3776**] is a 51 year old male with history of depression, obsessive compulsive disorder (OCD), and coronary artery disease (CAD) who was admitted for catatonia and course was notable for waxing and [**Doctor Last Name 688**] catatonia and agitation. ACTIVE PROBLEMS BY ISSUES: # Catatonia: He was seen by psychiatry and they felt that his catatonia was most likely due to recent weaning from abilify with exacerbation of underlying mood disorder (depression with psychosis). In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg [**Hospital1 **], with ativan 1mg [**Hospital1 **]).
|
Evidence: Coronary Artery Disease
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
He has a baseline widened mediastinum found on prior CT to be fat deposits and lymphadenopathy. We initially held his simvastatin and zetia given elevated LFTs. We continued his aspirin given his LAD stent. #Poor PO intake: Mr. [**Known lastname 3776**] [**Last Name (Titles) 3781**] refused to take PO intake while on the floor. We continued IV fluids with D5 1/2 NS at 125 cc/hr during his stay, but his hematocrit increased from 41 to 49 indicating hemoconcentration. We increased his IVF to 150 cc/hr on [**1-17**], but his hct continued to rise from [**1-17**] to [**1-18**] from 47.6 to 49.6. We suggest increasing his IVF to D5 [**2-5**] NS at 200 cc/hr if he continues to refuse oral intake.
|
Evidence: We initially held his simvastatin and zetia given elevated LFTs. We continued his aspirin given his LAD
stent.
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) 5000 unit injection 5,000 unit injection Injection TID (3 times a day). 4. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 5. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).
|
Evidence: aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
11. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Discharge Diagnosis: PRIMARY DIAGNOSIS Depression with psychotic features Asthma Obesity Coronary Artery Disease Discharge Condition: Mental Status: Clear and coherent. Discharge Instructions: Dear Mr. [**Known lastname 3776**], .
|
Evidence: atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
. Review of systems: - Reviewed and negative except per HPI Past Medical History: - depression w/ psychotic feactures, s/p ECT, hx of suicide attempts - Obsessive-compulsive traits - CAD s/p AMI [**2180**], stent placed in [**2188**] - chronic low back pain - asthma - obesity Social History: - Tobacco: smokes 1-1.5ppd x 30yrs - Alcohol: none per mother - [**Name (NI) 3264**]: hx of cocaine and marijuana abuse, none for past 20yrs - Divorced 20yrs ago, has 2 adult children, lives with mother in [**Name (NI) 3494**] Family History: - sister: post-partum depression, suicide - grandfather: OCD Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 96.9 BP: 153/87 P: 76 R: 17 O2: 94%RA General: A/Ox2, answers basic questions HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Obese, protuberant abdomen, nontender, bowel sounds GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, unable to complete finger-to-nose d/t restraints Pertinent Results: ADMISSION LABS: [**2193-1-8**] 02:20PM BLOOD WBC-12.7* RBC-5.61 Hgb-17.0 Hct-50.7 MCV-90 MCH-30.3 MCHC-33.6 RDW-12.7 Plt Ct-269 [**2193-1-8**] 02:20PM BLOOD Neuts-76.9* Lymphs-17.0* Monos-4.8 Eos-1.0 Baso-0.4 [**2193-1-8**] 02:20PM BLOOD Glucose-115* UreaN-19 Creat-1.1 Na-139 K-4.7 Cl-100 HCO3-29 AnGap-15 [**2193-1-8**] 02:20PM BLOOD CK(CPK)-565* [**2193-1-10**] 02:40AM BLOOD ALT-27 AST-53* LD(LDH)-223 CK(CPK)-1354* AlkPhos-111 TotBili-0.4 [**2193-1-10**] 02:40AM BLOOD Lipase-29 [**2193-1-8**] 02:20PM BLOOD cTropnT-<0.01 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 09:25AM BLOOD CK-MB-16* MB Indx-1.1 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD CK-MB-14* MB Indx-1.2 cTropnT-<0.01 [**2193-1-11**] 05:17AM BLOOD CK-MB-12* MB Indx-1.2 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD Albumin-3.7 Calcium-8.6 Phos-3.5 Mg-2.0 [**2193-1-8**] 02:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2193-1-12**] 07:56PM BLOOD Type-[**Last Name (un) **] Temp-37.9 pO2-100 pCO2-26* pH-7.56* calTCO2-24 Base XS-2 Intubat-NOT INTUBA Comment-GREEN TOP [**2193-1-12**] 07:56PM BLOOD freeCa-0.94* [**2193-1-12**] 07:56PM BLOOD Lactate-1.1 . MICRO: [**2193-1-11**] 8:02 pm SWAB Source: left groin. WOUND CULTURE (Preliminary): STAPH AUREUS COAG +. MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE.
|
Evidence: CAD
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Discharge Labs: [**2193-1-18**] 06:10AM BLOOD WBC-12.7* RBC-5.51 Hgb-16.5 Hct-49.6 MCV-90 MCH-30.0 MCHC-33.3 RDW-12.5 Plt Ct-352 [**2193-1-18**] 06:10AM BLOOD Glucose-97 UreaN-15 Creat-0.9 Na-139 K-3.9 Cl-101 HCO3-25 AnGap-17 [**2193-1-18**] 06:10AM BLOOD ALT-80* AST-68* LD(LDH)-267* CK(CPK)-213 AlkPhos-109 TotBili-0.3 [**2193-1-18**] 06:10AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.6 Mg-2.1 [**2193-1-14**] 06:15AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2193-1-16**] 05:50AM BLOOD %HbA1c-5.5 eAG-111 Studies pending at Discharge: None Brief Hospital Course: Mr. [**Known lastname 3776**] is a 51 year old male with history of depression, obsessive compulsive disorder (OCD), and coronary artery disease (CAD) who was admitted for catatonia and course was notable for waxing and [**Doctor Last Name 688**] catatonia and agitation. ACTIVE PROBLEMS BY ISSUES: # Catatonia: He was seen by psychiatry and they felt that his catatonia was most likely due to recent weaning from abilify with exacerbation of underlying mood disorder (depression with psychosis). In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg [**Hospital1 **], with ativan 1mg [**Hospital1 **]).
|
Evidence: coronary artery disease
(CAD)
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Discharge Labs: [**2193-1-18**] 06:10AM BLOOD WBC-12.7* RBC-5.51 Hgb-16.5 Hct-49.6 MCV-90 MCH-30.0 MCHC-33.3 RDW-12.5 Plt Ct-352 [**2193-1-18**] 06:10AM BLOOD Glucose-97 UreaN-15 Creat-0.9 Na-139 K-3.9 Cl-101 HCO3-25 AnGap-17 [**2193-1-18**] 06:10AM BLOOD ALT-80* AST-68* LD(LDH)-267* CK(CPK)-213 AlkPhos-109 TotBili-0.3 [**2193-1-18**] 06:10AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.6 Mg-2.1 [**2193-1-14**] 06:15AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2193-1-16**] 05:50AM BLOOD %HbA1c-5.5 eAG-111 Studies pending at Discharge: None Brief Hospital Course: Mr. [**Known lastname 3776**] is a 51 year old male with history of depression, obsessive compulsive disorder (OCD), and coronary artery disease (CAD) who was admitted for catatonia and course was notable for waxing and [**Doctor Last Name 688**] catatonia and agitation. ACTIVE PROBLEMS BY ISSUES: # Catatonia: He was seen by psychiatry and they felt that his catatonia was most likely due to recent weaning from abilify with exacerbation of underlying mood disorder (depression with psychosis). In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg [**Hospital1 **], with ativan 1mg [**Hospital1 **]). Unfortunately, although his catatonia improved, Mr. [**Known lastname 3777**] psychosis did not continue to improve with haloperidol from [**Date range (1) 3778**], and ECT was deemed necessary. He was scheduled to begin ECT on [**1-18**], and medical clearance was obtained, but unfortunately Mr.
|
Evidence: Coronary artery disease (CAD)
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Discharge Labs: [**2193-1-18**] 06:10AM BLOOD WBC-12.7* RBC-5.51 Hgb-16.5 Hct-49.6 MCV-90 MCH-30.0 MCHC-33.3 RDW-12.5 Plt Ct-352 [**2193-1-18**] 06:10AM BLOOD Glucose-97 UreaN-15 Creat-0.9 Na-139 K-3.9 Cl-101 HCO3-25 AnGap-17 [**2193-1-18**] 06:10AM BLOOD ALT-80* AST-68* LD(LDH)-267* CK(CPK)-213 AlkPhos-109 TotBili-0.3 [**2193-1-18**] 06:10AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.6 Mg-2.1 [**2193-1-14**] 06:15AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2193-1-16**] 05:50AM BLOOD %HbA1c-5.5 eAG-111 Studies pending at Discharge: None Brief Hospital Course: Mr. [**Known lastname 3776**] is a 51 year old male with history of depression, obsessive compulsive disorder (OCD), and coronary artery disease (CAD) who was admitted for catatonia and course was notable for waxing and [**Doctor Last Name 688**] catatonia and agitation. ACTIVE PROBLEMS BY ISSUES: # Catatonia: He was seen by psychiatry and they felt that his catatonia was most likely due to recent weaning from abilify with exacerbation of underlying mood disorder (depression with psychosis). In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg [**Hospital1 **], with ativan 1mg [**Hospital1 **]). Unfortunately, although his catatonia improved, Mr. [**Known lastname 3777**] psychosis did not continue to improve with haloperidol from [**Date range (1) 3778**], and ECT was deemed necessary. He was scheduled to begin ECT on [**1-18**], and medical clearance was obtained, but unfortunately Mr. [**Known lastname 3776**] could not be consented for the procedure and health care proxy authority for his mother was not formalized.
|
Evidence: Coronary Artery Disease
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
. Review of systems: - Reviewed and negative except per HPI Past Medical History: - depression w/ psychotic feactures, s/p ECT, hx of suicide attempts - Obsessive-compulsive traits - CAD s/p AMI [**2180**], stent placed in [**2188**] - chronic low back pain - asthma - obesity Social History: - Tobacco: smokes 1-1.5ppd x 30yrs - Alcohol: none per mother - [**Name (NI) 3264**]: hx of cocaine and marijuana abuse, none for past 20yrs - Divorced 20yrs ago, has 2 adult children, lives with mother in [**Name (NI) 3494**] Family History: - sister: post-partum depression, suicide - grandfather: OCD Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 96.9 BP: 153/87 P: 76 R: 17 O2: 94%RA General: A/Ox2, answers basic questions HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Obese, protuberant abdomen, nontender, bowel sounds GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, unable to complete finger-to-nose d/t restraints Pertinent Results: ADMISSION LABS: [**2193-1-8**] 02:20PM BLOOD WBC-12.7* RBC-5.61 Hgb-17.0 Hct-50.7 MCV-90 MCH-30.3 MCHC-33.6 RDW-12.7 Plt Ct-269 [**2193-1-8**] 02:20PM BLOOD Neuts-76.9* Lymphs-17.0* Monos-4.8 Eos-1.0 Baso-0.4 [**2193-1-8**] 02:20PM BLOOD Glucose-115* UreaN-19 Creat-1.1 Na-139 K-4.7 Cl-100 HCO3-29 AnGap-15 [**2193-1-8**] 02:20PM BLOOD CK(CPK)-565* [**2193-1-10**] 02:40AM BLOOD ALT-27 AST-53* LD(LDH)-223 CK(CPK)-1354* AlkPhos-111 TotBili-0.4 [**2193-1-10**] 02:40AM BLOOD Lipase-29 [**2193-1-8**] 02:20PM BLOOD cTropnT-<0.01 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 09:25AM BLOOD CK-MB-16* MB Indx-1.1 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD CK-MB-14* MB Indx-1.2 cTropnT-<0.01 [**2193-1-11**] 05:17AM BLOOD CK-MB-12* MB Indx-1.2 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD Albumin-3.7 Calcium-8.6 Phos-3.5 Mg-2.0 [**2193-1-8**] 02:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2193-1-12**] 07:56PM BLOOD Type-[**Last Name (un) **] Temp-37.9 pO2-100 pCO2-26* pH-7.56* calTCO2-24 Base XS-2 Intubat-NOT INTUBA Comment-GREEN TOP [**2193-1-12**] 07:56PM BLOOD freeCa-0.94* [**2193-1-12**] 07:56PM BLOOD Lactate-1.1 . MICRO: [**2193-1-11**] 8:02 pm SWAB Source: left groin. WOUND CULTURE (Preliminary): STAPH AUREUS COAG +. MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE.
|
Evidence: asthma
Condition: Unspecified asthma, uncomplicated
HCC: J45909
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
. Review of systems: - Reviewed and negative except per HPI Past Medical History: - depression w/ psychotic feactures, s/p ECT, hx of suicide attempts - Obsessive-compulsive traits - CAD s/p AMI [**2180**], stent placed in [**2188**] - chronic low back pain - asthma - obesity Social History: - Tobacco: smokes 1-1.5ppd x 30yrs - Alcohol: none per mother - [**Name (NI) 3264**]: hx of cocaine and marijuana abuse, none for past 20yrs - Divorced 20yrs ago, has 2 adult children, lives with mother in [**Name (NI) 3494**] Family History: - sister: post-partum depression, suicide - grandfather: OCD Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 96.9 BP: 153/87 P: 76 R: 17 O2: 94%RA General: A/Ox2, answers basic questions HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Obese, protuberant abdomen, nontender, bowel sounds GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, unable to complete finger-to-nose d/t restraints Pertinent Results: ADMISSION LABS: [**2193-1-8**] 02:20PM BLOOD WBC-12.7* RBC-5.61 Hgb-17.0 Hct-50.7 MCV-90 MCH-30.3 MCHC-33.6 RDW-12.7 Plt Ct-269 [**2193-1-8**] 02:20PM BLOOD Neuts-76.9* Lymphs-17.0* Monos-4.8 Eos-1.0 Baso-0.4 [**2193-1-8**] 02:20PM BLOOD Glucose-115* UreaN-19 Creat-1.1 Na-139 K-4.7 Cl-100 HCO3-29 AnGap-15 [**2193-1-8**] 02:20PM BLOOD CK(CPK)-565* [**2193-1-10**] 02:40AM BLOOD ALT-27 AST-53* LD(LDH)-223 CK(CPK)-1354* AlkPhos-111 TotBili-0.4 [**2193-1-10**] 02:40AM BLOOD Lipase-29 [**2193-1-8**] 02:20PM BLOOD cTropnT-<0.01 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 09:25AM BLOOD CK-MB-16* MB Indx-1.1 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD CK-MB-14* MB Indx-1.2 cTropnT-<0.01 [**2193-1-11**] 05:17AM BLOOD CK-MB-12* MB Indx-1.2 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD Albumin-3.7 Calcium-8.6 Phos-3.5 Mg-2.0 [**2193-1-8**] 02:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2193-1-12**] 07:56PM BLOOD Type-[**Last Name (un) **] Temp-37.9 pO2-100 pCO2-26* pH-7.56* calTCO2-24 Base XS-2 Intubat-NOT INTUBA Comment-GREEN TOP [**2193-1-12**] 07:56PM BLOOD freeCa-0.94* [**2193-1-12**] 07:56PM BLOOD Lactate-1.1 . MICRO: [**2193-1-11**] 8:02 pm SWAB Source: left groin. WOUND CULTURE (Preliminary): STAPH AUREUS COAG +. MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. . IMAGING: [**1-10**] CT HEAD TECHNIQUE: Contiguous axial images were obtained through the brain.
|
Evidence: Asthma
Condition: Unspecified asthma, uncomplicated
HCC: J45909
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
. Review of systems: - Reviewed and negative except per HPI Past Medical History: - depression w/ psychotic feactures, s/p ECT, hx of suicide attempts - Obsessive-compulsive traits - CAD s/p AMI [**2180**], stent placed in [**2188**] - chronic low back pain - asthma - obesity Social History: - Tobacco: smokes 1-1.5ppd x 30yrs - Alcohol: none per mother - [**Name (NI) 3264**]: hx of cocaine and marijuana abuse, none for past 20yrs - Divorced 20yrs ago, has 2 adult children, lives with mother in [**Name (NI) 3494**] Family History: - sister: post-partum depression, suicide - grandfather: OCD Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 96.9 BP: 153/87 P: 76 R: 17 O2: 94%RA General: A/Ox2, answers basic questions HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Obese, protuberant abdomen, nontender, bowel sounds GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, unable to complete finger-to-nose d/t restraints Pertinent Results: ADMISSION LABS: [**2193-1-8**] 02:20PM BLOOD WBC-12.7* RBC-5.61 Hgb-17.0 Hct-50.7 MCV-90 MCH-30.3 MCHC-33.6 RDW-12.7 Plt Ct-269 [**2193-1-8**] 02:20PM BLOOD Neuts-76.9* Lymphs-17.0* Monos-4.8 Eos-1.0 Baso-0.4 [**2193-1-8**] 02:20PM BLOOD Glucose-115* UreaN-19 Creat-1.1 Na-139 K-4.7 Cl-100 HCO3-29 AnGap-15 [**2193-1-8**] 02:20PM BLOOD CK(CPK)-565* [**2193-1-10**] 02:40AM BLOOD ALT-27 AST-53* LD(LDH)-223 CK(CPK)-1354* AlkPhos-111 TotBili-0.4 [**2193-1-10**] 02:40AM BLOOD Lipase-29 [**2193-1-8**] 02:20PM BLOOD cTropnT-<0.01 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 09:25AM BLOOD CK-MB-16* MB Indx-1.1 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD CK-MB-14* MB Indx-1.2 cTropnT-<0.01 [**2193-1-11**] 05:17AM BLOOD CK-MB-12* MB Indx-1.2 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD Albumin-3.7 Calcium-8.6 Phos-3.5 Mg-2.0 [**2193-1-8**] 02:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2193-1-12**] 07:56PM BLOOD Type-[**Last Name (un) **] Temp-37.9 pO2-100 pCO2-26* pH-7.56* calTCO2-24 Base XS-2 Intubat-NOT INTUBA Comment-GREEN TOP [**2193-1-12**] 07:56PM BLOOD freeCa-0.94* [**2193-1-12**] 07:56PM BLOOD Lactate-1.1 . MICRO: [**2193-1-11**] 8:02 pm SWAB Source: left groin. WOUND CULTURE (Preliminary): STAPH AUREUS COAG +. MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. . IMAGING: [**1-10**] CT HEAD TECHNIQUE: Contiguous axial images were obtained through the brain.
|
Evidence: Asthma
Condition: Unspecified asthma, uncomplicated
HCC: J45909
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
We suggest increasing his IVF to D5 [**2-5**] NS at 200 cc/hr if he continues to refuse oral intake. # Asthma: Continued home albuterol and ipratropium PRN. # Communication: mother, [**Name (NI) 3782**] psychiatrist Dr. [**Last Name (STitle) 3783**] ([**Telephone/Fax (1) 3784**]) TRANSITIONAL ISSUES: - Please determine if luvox and lamictal are to be restarted. These were held upon admission for unclear reasons, and were not restarted upon transfer to the floor as they had been held for 8 days. Medications on Admission: - diazepam 5-10mg qhs prn insomnia - luvox cr 300mg qhs - lamictal 300mg qhs - simvastatin 40mg daily - aspirin 325mg daily - atrovent Q6hrs prn - zetia 10mg daily - acebutolol 200mg [**Hospital1 **] Discharge Medications: 1. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
|
Evidence: Continued home albuterol and ipratropium PRN.
Condition: Unspecified asthma, uncomplicated
HCC: J45909
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 8. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days: Last day of course will be [**2193-1-20**]. 9. haloperidol 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).
|
Evidence: ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Condition: Unspecified asthma, uncomplicated
HCC: J45909
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 8. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days: Last day of course will be [**2193-1-20**]. 9. haloperidol 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day).
|
Evidence: albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
Condition: Unspecified asthma, uncomplicated
HCC: J45909
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
. Review of systems: - Reviewed and negative except per HPI Past Medical History: - depression w/ psychotic feactures, s/p ECT, hx of suicide attempts - Obsessive-compulsive traits - CAD s/p AMI [**2180**], stent placed in [**2188**] - chronic low back pain - asthma - obesity Social History: - Tobacco: smokes 1-1.5ppd x 30yrs - Alcohol: none per mother - [**Name (NI) 3264**]: hx of cocaine and marijuana abuse, none for past 20yrs - Divorced 20yrs ago, has 2 adult children, lives with mother in [**Name (NI) 3494**] Family History: - sister: post-partum depression, suicide - grandfather: OCD Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 96.9 BP: 153/87 P: 76 R: 17 O2: 94%RA General: A/Ox2, answers basic questions HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Obese, protuberant abdomen, nontender, bowel sounds GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, unable to complete finger-to-nose d/t restraints Pertinent Results: ADMISSION LABS: [**2193-1-8**] 02:20PM BLOOD WBC-12.7* RBC-5.61 Hgb-17.0 Hct-50.7 MCV-90 MCH-30.3 MCHC-33.6 RDW-12.7 Plt Ct-269 [**2193-1-8**] 02:20PM BLOOD Neuts-76.9* Lymphs-17.0* Monos-4.8 Eos-1.0 Baso-0.4 [**2193-1-8**] 02:20PM BLOOD Glucose-115* UreaN-19 Creat-1.1 Na-139 K-4.7 Cl-100 HCO3-29 AnGap-15 [**2193-1-8**] 02:20PM BLOOD CK(CPK)-565* [**2193-1-10**] 02:40AM BLOOD ALT-27 AST-53* LD(LDH)-223 CK(CPK)-1354* AlkPhos-111 TotBili-0.4 [**2193-1-10**] 02:40AM BLOOD Lipase-29 [**2193-1-8**] 02:20PM BLOOD cTropnT-<0.01 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 09:25AM BLOOD CK-MB-16* MB Indx-1.1 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD CK-MB-14* MB Indx-1.2 cTropnT-<0.01 [**2193-1-11**] 05:17AM BLOOD CK-MB-12* MB Indx-1.2 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD Albumin-3.7 Calcium-8.6 Phos-3.5 Mg-2.0 [**2193-1-8**] 02:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2193-1-12**] 07:56PM BLOOD Type-[**Last Name (un) **] Temp-37.9 pO2-100 pCO2-26* pH-7.56* calTCO2-24 Base XS-2 Intubat-NOT INTUBA Comment-GREEN TOP [**2193-1-12**] 07:56PM BLOOD freeCa-0.94* [**2193-1-12**] 07:56PM BLOOD Lactate-1.1 . MICRO: [**2193-1-11**] 8:02 pm SWAB Source: left groin. WOUND CULTURE (Preliminary): STAPH AUREUS COAG +. MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. .
|
Evidence: asthma
Condition: Unspecified asthma, uncomplicated
HCC: J45909
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
. Review of systems: - Reviewed and negative except per HPI Past Medical History: - depression w/ psychotic feactures, s/p ECT, hx of suicide attempts - Obsessive-compulsive traits - CAD s/p AMI [**2180**], stent placed in [**2188**] - chronic low back pain - asthma - obesity Social History: - Tobacco: smokes 1-1.5ppd x 30yrs - Alcohol: none per mother - [**Name (NI) 3264**]: hx of cocaine and marijuana abuse, none for past 20yrs - Divorced 20yrs ago, has 2 adult children, lives with mother in [**Name (NI) 3494**] Family History: - sister: post-partum depression, suicide - grandfather: OCD Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 96.9 BP: 153/87 P: 76 R: 17 O2: 94%RA General: A/Ox2, answers basic questions HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Obese, protuberant abdomen, nontender, bowel sounds GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, unable to complete finger-to-nose d/t restraints Pertinent Results: ADMISSION LABS: [**2193-1-8**] 02:20PM BLOOD WBC-12.7* RBC-5.61 Hgb-17.0 Hct-50.7 MCV-90 MCH-30.3 MCHC-33.6 RDW-12.7 Plt Ct-269 [**2193-1-8**] 02:20PM BLOOD Neuts-76.9* Lymphs-17.0* Monos-4.8 Eos-1.0 Baso-0.4 [**2193-1-8**] 02:20PM BLOOD Glucose-115* UreaN-19 Creat-1.1 Na-139 K-4.7 Cl-100 HCO3-29 AnGap-15 [**2193-1-8**] 02:20PM BLOOD CK(CPK)-565* [**2193-1-10**] 02:40AM BLOOD ALT-27 AST-53* LD(LDH)-223 CK(CPK)-1354* AlkPhos-111 TotBili-0.4 [**2193-1-10**] 02:40AM BLOOD Lipase-29 [**2193-1-8**] 02:20PM BLOOD cTropnT-<0.01 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 09:25AM BLOOD CK-MB-16* MB Indx-1.1 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD CK-MB-14* MB Indx-1.2 cTropnT-<0.01 [**2193-1-11**] 05:17AM BLOOD CK-MB-12* MB Indx-1.2 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD Albumin-3.7 Calcium-8.6 Phos-3.5 Mg-2.0 [**2193-1-8**] 02:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2193-1-12**] 07:56PM BLOOD Type-[**Last Name (un) **] Temp-37.9 pO2-100 pCO2-26* pH-7.56* calTCO2-24 Base XS-2 Intubat-NOT INTUBA Comment-GREEN TOP [**2193-1-12**] 07:56PM BLOOD freeCa-0.94* [**2193-1-12**] 07:56PM BLOOD Lactate-1.1 . MICRO: [**2193-1-11**] 8:02 pm SWAB Source: left groin. WOUND CULTURE (Preliminary): STAPH AUREUS COAG +. MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE.
|
Evidence: Asthma
Condition: Unspecified asthma, uncomplicated
HCC: J45909
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
. Review of systems: - Reviewed and negative except per HPI Past Medical History: - depression w/ psychotic feactures, s/p ECT, hx of suicide attempts - Obsessive-compulsive traits - CAD s/p AMI [**2180**], stent placed in [**2188**] - chronic low back pain - asthma - obesity Social History: - Tobacco: smokes 1-1.5ppd x 30yrs - Alcohol: none per mother - [**Name (NI) 3264**]: hx of cocaine and marijuana abuse, none for past 20yrs - Divorced 20yrs ago, has 2 adult children, lives with mother in [**Name (NI) 3494**] Family History: - sister: post-partum depression, suicide - grandfather: OCD Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 96.9 BP: 153/87 P: 76 R: 17 O2: 94%RA General: A/Ox2, answers basic questions HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Obese, protuberant abdomen, nontender, bowel sounds GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, unable to complete finger-to-nose d/t restraints Pertinent Results: ADMISSION LABS: [**2193-1-8**] 02:20PM BLOOD WBC-12.7* RBC-5.61 Hgb-17.0 Hct-50.7 MCV-90 MCH-30.3 MCHC-33.6 RDW-12.7 Plt Ct-269 [**2193-1-8**] 02:20PM BLOOD Neuts-76.9* Lymphs-17.0* Monos-4.8 Eos-1.0 Baso-0.4 [**2193-1-8**] 02:20PM BLOOD Glucose-115* UreaN-19 Creat-1.1 Na-139 K-4.7 Cl-100 HCO3-29 AnGap-15 [**2193-1-8**] 02:20PM BLOOD CK(CPK)-565* [**2193-1-10**] 02:40AM BLOOD ALT-27 AST-53* LD(LDH)-223 CK(CPK)-1354* AlkPhos-111 TotBili-0.4 [**2193-1-10**] 02:40AM BLOOD Lipase-29 [**2193-1-8**] 02:20PM BLOOD cTropnT-<0.01 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 09:25AM BLOOD CK-MB-16* MB Indx-1.1 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD CK-MB-14* MB Indx-1.2 cTropnT-<0.01 [**2193-1-11**] 05:17AM BLOOD CK-MB-12* MB Indx-1.2 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD Albumin-3.7 Calcium-8.6 Phos-3.5 Mg-2.0 [**2193-1-8**] 02:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2193-1-12**] 07:56PM BLOOD Type-[**Last Name (un) **] Temp-37.9 pO2-100 pCO2-26* pH-7.56* calTCO2-24 Base XS-2 Intubat-NOT INTUBA Comment-GREEN TOP [**2193-1-12**] 07:56PM BLOOD freeCa-0.94* [**2193-1-12**] 07:56PM BLOOD Lactate-1.1 . MICRO: [**2193-1-11**] 8:02 pm SWAB Source: left groin. WOUND CULTURE (Preliminary): STAPH AUREUS COAG +. MODERATE GROWTH.
|
Evidence: Asthma
Condition: Unspecified asthma, uncomplicated
HCC: J45909
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
[**Known lastname 3776**] [**Last Name (Titles) 3781**] refused to take PO intake while on the floor. We continued IV fluids with D5 1/2 NS at 125 cc/hr during his stay, but his hematocrit increased from 41 to 49 indicating hemoconcentration. We increased his IVF to 150 cc/hr on [**1-17**], but his hct continued to rise from [**1-17**] to [**1-18**] from 47.6 to 49.6. We suggest increasing his IVF to D5 [**2-5**] NS at 200 cc/hr if he continues to refuse oral intake. # Asthma: Continued home albuterol and ipratropium PRN. # Communication: mother, [**Name (NI) 3782**] psychiatrist Dr. [**Last Name (STitle) 3783**] ([**Telephone/Fax (1) 3784**]) TRANSITIONAL ISSUES: - Please determine if luvox and lamictal are to be restarted. These were held upon admission for unclear reasons, and were not restarted upon transfer to the floor as they had been held for 8 days.
|
Evidence: his hematocrit increased from
41 to 49 indicating hemoconcentration.
Condition: Hemoconcentration
HCC: D7581
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
We continued IV fluids with D5 1/2 NS at 125 cc/hr during his stay, but his hematocrit increased from 41 to 49 indicating hemoconcentration. We increased his IVF to 150 cc/hr on [**1-17**], but his hct continued to rise from [**1-17**] to [**1-18**] from 47.6 to 49.6. We suggest increasing his IVF to D5 [**2-5**] NS at 200 cc/hr if he continues to refuse oral intake. # Asthma: Continued home albuterol and ipratropium PRN. # Communication: mother, [**Name (NI) 3782**] psychiatrist Dr.
|
Evidence: his hct continued to rise from [**1-17**] to
[**1-18**] from 47.6 to 49.6.
Condition: Hemoconcentration
HCC: D7581
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
. Review of systems: - Reviewed and negative except per HPI Past Medical History: - depression w/ psychotic feactures, s/p ECT, hx of suicide attempts - Obsessive-compulsive traits - CAD s/p AMI [**2180**], stent placed in [**2188**] - chronic low back pain - asthma - obesity Social History: - Tobacco: smokes 1-1.5ppd x 30yrs - Alcohol: none per mother - [**Name (NI) 3264**]: hx of cocaine and marijuana abuse, none for past 20yrs - Divorced 20yrs ago, has 2 adult children, lives with mother in [**Name (NI) 3494**] Family History: - sister: post-partum depression, suicide - grandfather: OCD Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 96.9 BP: 153/87 P: 76 R: 17 O2: 94%RA General: A/Ox2, answers basic questions HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Obese, protuberant abdomen, nontender, bowel sounds GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, unable to complete finger-to-nose d/t restraints Pertinent Results: ADMISSION LABS: [**2193-1-8**] 02:20PM BLOOD WBC-12.7* RBC-5.61 Hgb-17.0 Hct-50.7 MCV-90 MCH-30.3 MCHC-33.6 RDW-12.7 Plt Ct-269 [**2193-1-8**] 02:20PM BLOOD Neuts-76.9* Lymphs-17.0* Monos-4.8 Eos-1.0 Baso-0.4 [**2193-1-8**] 02:20PM BLOOD Glucose-115* UreaN-19 Creat-1.1 Na-139 K-4.7 Cl-100 HCO3-29 AnGap-15 [**2193-1-8**] 02:20PM BLOOD CK(CPK)-565* [**2193-1-10**] 02:40AM BLOOD ALT-27 AST-53* LD(LDH)-223 CK(CPK)-1354* AlkPhos-111 TotBili-0.4 [**2193-1-10**] 02:40AM BLOOD Lipase-29 [**2193-1-8**] 02:20PM BLOOD cTropnT-<0.01 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 02:40AM BLOOD CK-MB-14* MB Indx-1.0 [**2193-1-10**] 09:25AM BLOOD CK-MB-16* MB Indx-1.1 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD CK-MB-14* MB Indx-1.2 cTropnT-<0.01 [**2193-1-11**] 05:17AM BLOOD CK-MB-12* MB Indx-1.2 cTropnT-<0.01 [**2193-1-10**] 09:29PM BLOOD Albumin-3.7 Calcium-8.6 Phos-3.5 Mg-2.0 [**2193-1-8**] 02:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2193-1-12**] 07:56PM BLOOD Type-[**Last Name (un) **] Temp-37.9 pO2-100 pCO2-26* pH-7.56* calTCO2-24 Base XS-2 Intubat-NOT INTUBA Comment-GREEN TOP [**2193-1-12**] 07:56PM BLOOD freeCa-0.94* [**2193-1-12**] 07:56PM BLOOD Lactate-1.1 . MICRO: [**2193-1-11**] 8:02 pm SWAB Source: left groin. WOUND CULTURE (Preliminary): STAPH AUREUS COAG +. MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE.
|
Evidence: Hct-50.7
Condition: Hemoconcentration
HCC: D7581
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Mediastinal widening due to fat deposition is longstanding. Discharge Labs: [**2193-1-18**] 06:10AM BLOOD WBC-12.7* RBC-5.51 Hgb-16.5 Hct-49.6 MCV-90 MCH-30.0 MCHC-33.3 RDW-12.5 Plt Ct-352 [**2193-1-18**] 06:10AM BLOOD Glucose-97 UreaN-15 Creat-0.9 Na-139 K-3.9 Cl-101 HCO3-25 AnGap-17 [**2193-1-18**] 06:10AM BLOOD ALT-80* AST-68* LD(LDH)-267* CK(CPK)-213 AlkPhos-109 TotBili-0.3 [**2193-1-18**] 06:10AM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.6 Mg-2.1 [**2193-1-14**] 06:15AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2193-1-16**] 05:50AM BLOOD %HbA1c-5.5 eAG-111 Studies pending at Discharge: None Brief Hospital Course: Mr. [**Known lastname 3776**] is a 51 year old male with history of depression, obsessive compulsive disorder (OCD), and coronary artery disease (CAD) who was admitted for catatonia and course was notable for waxing and [**Doctor Last Name 688**] catatonia and agitation. ACTIVE PROBLEMS BY ISSUES: # Catatonia: He was seen by psychiatry and they felt that his catatonia was most likely due to recent weaning from abilify with exacerbation of underlying mood disorder (depression with psychosis). In ED, patient exhibited agitation requiring 4 point restraints for prolonged course, and 20mg lorazepman total. ECT was entertained as a possible intervention for catatonia, and was initially deferred as his catatonia resolved with standing antipsychotics (haloperidol 10mg [**Hospital1 **], with ativan 1mg [**Hospital1 **]). Unfortunately, although his catatonia improved, Mr.
|
Evidence: Hct-49.6
Condition: Hemoconcentration
HCC: D7581
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
[**Known lastname 3776**] [**Last Name (Titles) 3781**] refused to take PO intake while on the floor. We continued IV fluids with D5 1/2 NS at 125 cc/hr during his stay, but his hematocrit increased from 41 to 49 indicating hemoconcentration. We increased his IVF to 150 cc/hr on [**1-17**], but his hct continued to rise from [**1-17**] to [**1-18**] from 47.6 to 49.6. We suggest increasing his IVF to D5 [**2-5**] NS at 200 cc/hr if he continues to refuse oral intake. # Asthma: Continued home albuterol and ipratropium PRN. # Communication: mother, [**Name (NI) 3782**] psychiatrist Dr. [**Last Name (STitle) 3783**] ([**Telephone/Fax (1) 3784**]) TRANSITIONAL ISSUES: - Please determine if luvox and lamictal are to be restarted. These were held upon admission for unclear reasons, and were not restarted upon transfer to the floor as they had been held for 8 days.
|
Evidence: hemoconcentration
Condition: Hemoconcentration
HCC: D7581
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
[**Known lastname 3776**] [**Last Name (Titles) 3781**] refused to take PO intake while on the floor. We continued IV fluids with D5 1/2 NS at 125 cc/hr during his stay, but his hematocrit increased from 41 to 49 indicating hemoconcentration. We increased his IVF to 150 cc/hr on [**1-17**], but his hct continued to rise from [**1-17**] to [**1-18**] from 47.6 to 49.6. We suggest increasing his IVF to D5 [**2-5**] NS at 200 cc/hr if he continues to refuse oral intake. # Asthma: Continued home albuterol and ipratropium PRN. # Communication: mother, [**Name (NI) 3782**] psychiatrist Dr. [**Last Name (STitle) 3783**] ([**Telephone/Fax (1) 3784**]) TRANSITIONAL ISSUES: - Please determine if luvox and lamictal are to be restarted. These were held upon admission for unclear reasons, and were not restarted upon transfer to the floor as they had been held for 8 days.
|
Evidence: hemoconcentration
Condition: Hemoconcentration
HCC: D7581
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Your Luvox and lamictal (treatments for depression and other mood disorders) have been stopped, please consult with your psychiatrists regarding whether to restart these. START haloperidol (for your confusion) START levofloxacin (for pneumonia), you will have 2 more days START ativan for agitation STOP simvastatin and START atorvastatin because we need to treat your lipids, but the simvastatin may have been harming your liver Followup Instructions: Please follow up with your PCP after you are discharged from deaconness 4.
|
Evidence: we need to treat
your lipids
Condition: Hyperlipidemia, unspecified
HCC: E785
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Your Luvox and lamictal (treatments for depression and other mood disorders) have been stopped, please consult with your psychiatrists regarding whether to restart these. START haloperidol (for your confusion) START levofloxacin (for pneumonia), you will have 2 more days START ativan for agitation STOP simvastatin and START atorvastatin because we need to treat your lipids, but the simvastatin may have been harming your liver Followup Instructions: Please follow up with your PCP after you are discharged from deaconness 4.
|
Evidence: STOP simvastatin and START atorvastatin because we need to treat
your lipids
Condition: Hyperlipidemia, unspecified
HCC: E785
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
11. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Discharge Diagnosis: PRIMARY DIAGNOSIS Depression with psychotic features Asthma Obesity Coronary Artery Disease Discharge Condition: Mental Status: Clear and coherent. Discharge Instructions: Dear Mr. [**Known lastname 3776**], . It was a pleasure taking care of you at [**Hospital1 18**].
|
Evidence: atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Condition: Hyperlipidemia, unspecified
HCC: E785
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Your Luvox and lamictal (treatments for depression and other mood disorders) have been stopped, please consult with your psychiatrists regarding whether to restart these. START haloperidol (for your confusion) START levofloxacin (for pneumonia), you will have 2 more days START ativan for agitation STOP simvastatin and START atorvastatin because we need to treat your lipids, but the simvastatin may have been harming your liver Followup Instructions: Please follow up with your PCP after you are discharged from deaconness 4.
|
Evidence: lipids
Condition: Hyperlipidemia, unspecified
HCC: E785
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
She was admitted to the ICU and started on AED / Nimodipine and antiemetics. Her exam on arrival was non focal except for some headahces and mild nuchal rigidity. She suffered with some nausea and vomiting as well. The following morning she was brought to the angio suite for a diagnostic cerebral angiogram. This was without incident and she tolerated it well. The Angiogram was negative for aneurysm.
|
Evidence: mild nuchal rigidity
Condition: Subarachnoid hemorrhage, unspecified
HCC: I609
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Sensation: Intact to light touch throughout. Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally Coordination: normal on finger-nose-finger ON DISCHARGE: Non focal exam Pertinent Results: [**2117-9-22**] CT Head: FINDINGS: There is a small amount of subarachnoid blood in the right quadrigeminal, ambient, and suprasellar cisterns, as well as within the interpeduncular fossa. No other areas of hemorrhage are noted. There is no edema, shift of midline structures, or mass effect. The ventricles and sulci are normal in size and there is no intraventricular hemorrhage. Paranasal sinuses show mucosal thickening within the ethmoid air cells, likely due to inflammation. Mastoid air cells are clear.
|
Evidence: small amount of subarachnoid blood in the
right
quadrigeminal, ambient, and suprasellar cisterns, as well as
within the
interpeduncular fossa
Condition: Subarachnoid hemorrhage, unspecified
HCC: I609
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
[**2117-9-23**] cerbral angiogram final report pending at time of dsicharge [**2117-9-26**] MRI MRA brain Final Report STUDY: MRI and MRA of the brain. CLINICAL INDICATION: History of subarachnoid hemorrhage, CTA and angio negative for aneurysm, reevaluate for subarachnoid hemorrhage. COMPARISON: Prior MRI of the cervical spine dated [**2117-9-24**] and prior cerebral angiogram dated [**2117-9-23**], prior CTA of the head dated [**2117-9-22**]. TECHNIQUE: Sagittal T1, axial T2, axial FLAIR, axial magnetic susceptibility and axial diffusion-weighted sequences were obtained. MRA OF THE HEAD: 3D time-of-flight arteriography of the head was obtained, multiple rotational images and axial source images were provided. FINDINGS: MRI OF THE HEAD: There is no evidence of intracranial hemorrhage, mass, mass effect, or shifting of the normally midline structures. The ventricles and sulci are normal in size and configuration for the patient's age.
|
Evidence: subarachnoid hemorrhage
Condition: Subarachnoid hemorrhage, unspecified
HCC: I609
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
[**Last Name (STitle) **] [**Name (STitle) **] in [**1-10**] weeks. Department:Neurology Division:Behavioral Neurology Unit Organization:[**Hospital1 18**] Office Location:E/KS 284 Office Phone:([**Telephone/Fax (1) 1703**] Office Fax:([**Telephone/Fax (1) 9382**] Patient Location:[**Hospital Ward Name 860**] 253 / [**Hospital Ward Name **] please set up an appointment for neurology eval after your subarachnoid hemorrhage PLEASE CALL THE OFFICE AT [**Telephone/Fax (1) **] TO SCHEDULE THIS APPOINTMENT Completed by:[**2117-9-29**]
|
Evidence: neurology eval after your
subarachnoid hemorrhage
Condition: Subarachnoid hemorrhage, unspecified
HCC: I609
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Brief Hospital Course: Pt was admitted after being BIBA to [**Hospital1 18**] after c/o worst headache of life. She was admitted to the ICU and started on AED / Nimodipine and antiemetics. Her exam on arrival was non focal except for some headahces and mild nuchal rigidity. She suffered with some nausea and vomiting as well. The following morning she was brought to the angio suite for a diagnostic cerebral angiogram. This was without incident and she tolerated it well.
|
Evidence: Nimodipine
Condition: Subarachnoid hemorrhage, unspecified
HCC: I609
Category: Treatment
|
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.