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Extract medical evidence from the following clinical text that supports medical condition coding:
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[**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.
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Evidence: subarachnoid hemorrhage
Condition: Subarachnoid hemorrhage, unspecified
HCC: I609
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Initial set of enzymes showed a CK of 26, troponin-T less than 0.01. Previous cath performed in [**2186-4-12**] showed a 100% RCA lesion, LAD of 100% that was PTCA'd, EF 25%, with apical and anterolateral akinesis. HOSPITAL COURSE: The patient was admitted to cardiac medicine on telemetry. He was scheduled for an ICD pacer interrogation by EP. His enzymes were followed to rule out MI. On the evening of admission, [**4-12**], the patient experienced multiple runs of V-tach with the rate in the 200s. He was shocked by his ICD multiple times. His vital signs were initially stable, other than the rhythm of VT. He was given 150 mg IV amiodarone, 5 mg IV metoprolol x 2, 2 gm of magnesium, 40 mEq of KCL, and 0.5 mg of versed.
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Evidence: EF 25%
Condition: Chronic ischemic heart disease, unspecified
HCC: I259
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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He had 1+ pitting edema bilaterally to the knees with stasis dermatitis noted. LABS AND STUDIES: EKG showed sinus with AV delay, questionable right bundle branch pattern with left anterior fascicular block. Left axis deviation. Inverted T waves were noted in AVL. Q waves in V1, V2, with poor R wave progression. On rhythm strips taken during events, he was noted to have a wide complex regular tachycardia at a rate of approximately 250, that after shock responded by changing into an irregular more narrow complex tachycardia (AF). Initial CBC showed a white count of 8.1, hematocrit 34.4, platelet count 180. He had a PT of 16.6, PTT 22, INR 1.8. Chem-7 showed a sodium of 140, potassium 3.8, chloride 104, CO2 24, BUN 15, creatinine 0.8, glucose 170. He had a calcium of 9.2, mag 2.0, phos 3.4. Initial set of enzymes showed a CK of 26, troponin-T less than 0.01.
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Evidence: EKG showed sinus with AV delay, questionable right bundle branch pattern with left anterior
fascicular block. Left axis deviation. Inverted T waves
were noted in AVL. Q waves in V1, V2, with poor R wave
progression.
Condition: Chronic ischemic heart disease, unspecified
HCC: I259
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Initial set of enzymes showed a CK of 26, troponin-T less than 0.01. Previous cath performed in [**2186-4-12**] showed a 100% RCA lesion, LAD of 100% that was PTCA'd, EF 25%, with apical and anterolateral akinesis. HOSPITAL COURSE: The patient was admitted to cardiac medicine on telemetry. He was scheduled for an ICD pacer interrogation by EP. His enzymes were followed to rule out MI. On the evening of admission, [**4-12**], the patient experienced multiple runs of V-tach with the rate in the 200s.
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Evidence: Previous cath performed in
[**2186-4-12**] showed a 100% RCA lesion, LAD of 100% that was
PTCA'd, EF 25%, with apical and anterolateral akinesis.
Condition: Chronic ischemic heart disease, unspecified
HCC: I259
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Ventricular tachycardia. 3. Atrial fibrillation with rapid ventricular response. DISCHARGE MEDICATIONS: 1.
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Evidence: Coronary artery disease
Condition: Chronic ischemic heart disease, unspecified
HCC: I259
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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DISCHARGE MEDICATIONS: 1. Aspirin 325 mg qd. 2. Gabapentin 100 mg q 8 h. 3.
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Evidence: Aspirin 325 mg qd
Condition: Chronic ischemic heart disease, unspecified
HCC: I259
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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3. Gemfibrozil 600 mg [**Hospital1 **]. 4. Lasix 20 mg qd. 5. Glipizide 5 mg [**Hospital1 **]. 6. Metoprolol 37.5 mg tid.
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Evidence: Gemfibrozil 600 mg [**Hospital1 **]
Condition: Chronic ischemic heart disease, unspecified
HCC: I259
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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4. Lasix 20 mg qd. 5. Glipizide 5 mg [**Hospital1 **]. 6. Metoprolol 37.5 mg tid. 7.
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Evidence: Lasix 20 mg qd
Condition: Chronic ischemic heart disease, unspecified
HCC: I259
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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6. Metoprolol 37.5 mg tid. 7. Amiodarone 400 mg [**Hospital1 **] for the first 2 weeks post discharge, with instructions to the patient to decrease to 400 mg qd thereafter until seen in [**Hospital **] Clinic. 8.
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Evidence: Metoprolol 37.5 mg tid
Condition: Chronic ischemic heart disease, unspecified
HCC: I259
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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9. Captopril 6.25 tid. 10.Warfarin 2.5 qd. FOLLOW-UP: The patient is scheduled to be seen in Device Clinic and by Dr. [**Last Name (STitle) 1911**] on [**5-11**]. He was instructed to continue his Coumadin blood draws as he had been prior to his admission to the hospital. [**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D.
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Evidence: Captopril 6.25 tid
Condition: Chronic ischemic heart disease, unspecified
HCC: I259
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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PAST MEDICAL HISTORY: 1. CAD, status post anterior MI. 2. Prostate cancer, on chemotherapy, last dose 3 weeks ago. 3. Type 2 diabetes x 4 years with the complication of neuropathy. 4. ?History of atrial fibrillation.
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Evidence: CAD
Condition: Chronic ischemic heart disease, unspecified
HCC: I259
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Ventricular tachycardia. 3. Atrial fibrillation with rapid ventricular response. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg qd. 2.
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Evidence: Coronary artery disease
Condition: Chronic ischemic heart disease, unspecified
HCC: I259
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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He had a PT of 16.6, PTT 22, INR 1.8. Chem-7 showed a sodium of 140, potassium 3.8, chloride 104, CO2 24, BUN 15, creatinine 0.8, glucose 170. He had a calcium of 9.2, mag 2.0, phos 3.4. Initial set of enzymes showed a CK of 26, troponin-T less than 0.01. Previous cath performed in [**2186-4-12**] showed a 100% RCA lesion, LAD of 100% that was PTCA'd, EF 25%, with apical and anterolateral akinesis. HOSPITAL COURSE: The patient was admitted to cardiac medicine on telemetry. He was scheduled for an ICD pacer interrogation by EP.
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Evidence: glucose 170
Condition: Type 2 diabetes mellitus with diabetic neuropathy, unspecified
HCC: E1140
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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He had a PT of 16.6, PTT 22, INR 1.8. Chem-7 showed a sodium of 140, potassium 3.8, chloride 104, CO2 24, BUN 15, creatinine 0.8, glucose 170. He had a calcium of 9.2, mag 2.0, phos 3.4. Initial set of enzymes showed a CK of 26, troponin-T less than 0.01. Previous cath performed in [**2186-4-12**] showed a 100% RCA lesion, LAD of 100% that was PTCA'd, EF 25%, with apical and anterolateral akinesis. HOSPITAL COURSE: The patient was admitted to cardiac medicine on telemetry. He was scheduled for an ICD pacer interrogation by EP.
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Evidence: glucose 170
Condition: Type 2 diabetes mellitus with diabetic neuropathy, unspecified
HCC: E1140
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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5. Glipizide 5 mg [**Hospital1 **]. 6. Metoprolol 37.5 mg tid. 7. Amiodarone 400 mg [**Hospital1 **] for the first 2 weeks post discharge, with instructions to the patient to decrease to 400 mg qd thereafter until seen in [**Hospital **] Clinic.
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Evidence: Glipizide 5 mg [**Hospital1 **]
Condition: Type 2 diabetes mellitus with diabetic neuropathy, unspecified
HCC: E1140
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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2. Gabapentin 100 mg q 8 h. 3. Gemfibrozil 600 mg [**Hospital1 **]. 4. Lasix 20 mg qd. 5. Glipizide 5 mg [**Hospital1 **].
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Evidence: Gabapentin 100 mg q 8 h
Condition: Type 2 diabetes mellitus with diabetic neuropathy, unspecified
HCC: E1140
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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3. Type 2 diabetes x 4 years with the complication of neuropathy. 4. ?History of atrial fibrillation. 5. Hypertension. 6. Hyperlipidemia. MEDICATIONS: 1.
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Evidence: Type 2 diabetes
Condition: Type 2 diabetes mellitus with diabetic neuropathy, unspecified
HCC: E1140
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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3. Type 2 diabetes x 4 years with the complication of neuropathy. 4. ?History of atrial fibrillation. 5.
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Evidence: neuropathy
Condition: Type 2 diabetes mellitus with diabetic neuropathy, unspecified
HCC: E1140
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Lives with his wife. PHYSICAL EXAM: Vitals on arrival were temperature 98.7, blood pressure 100/60, heart rate 68, respiratory rate 18, 100% on 3 liters. This was an obese gentleman, sitting at 60%, in no apparent distress. He was alert and oriented x 3. He had dry mucous membranes.
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Evidence: blood pressure 100/60
Condition: Essential (primary) hypertension
HCC: I10
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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He was given 150 mg IV amiodarone, 5 mg IV metoprolol x 2, 2 gm of magnesium, 40 mEq of KCL, and 0.5 mg of versed. After receiving these medications, the patient's blood pressure decreased to the 70s/40s. He was given a bolus of fluids, after which he increased to 90/60. The EKG showed no ischemic changes. However, he was transferred to the ICU for further monitoring and continuation of the amiodarone GTT. He had a femoral line placement at that time. He was monitored in the ICU until [**4-13**]. At this point, he was determined stable enough to return to the floor.
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Evidence: patient's blood pressure
decreased to the 70s/40s
Condition: Essential (primary) hypertension
HCC: I10
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
After receiving these medications, the patient's blood pressure decreased to the 70s/40s. He was given a bolus of fluids, after which he increased to 90/60. The EKG showed no ischemic changes. However, he was transferred to the ICU for further monitoring and continuation of the amiodarone GTT. He had a femoral line placement at that time. He was monitored in the ICU until [**4-13**]. At this point, he was determined stable enough to return to the floor. He underwent a VT ablation procedure by electrophysiology on [**4-14**]. Overnight, on the [**4-15**], the patient developed intermittent AFIB with rates into the 120s-130s, and a blood pressure, systolic, in the 90s/70s.
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Evidence: increased to 90/60
Condition: Essential (primary) hypertension
HCC: I10
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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He underwent a VT ablation procedure by electrophysiology on [**4-14**]. Overnight, on the [**4-15**], the patient developed intermittent AFIB with rates into the 120s-130s, and a blood pressure, systolic, in the 90s/70s. He received IV beta blocker and converted back into normal sinus rhythm with a rate in the 80s. He had no chest pain or shortness of breath during this episode. In the early morning hours of [**4-16**], he developed rapid AFIB again with rates into the 140s. He was given IV diltiazem which decreased his systolic pressure from the 90s to 60s. At that point, he was given multiple small normal saline boluses to increase his pressure. He also received some IV Lopressor, as well as PO Lopressor. Given his recurrent episodes of AFIB with rapid ventricular response, he was taken to the EP Lab for a synchronous cardioversion on the morning of the 4.
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Evidence: blood
pressure, systolic, in the 90s/70s
Condition: Essential (primary) hypertension
HCC: I10
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
In the early morning hours of [**4-16**], he developed rapid AFIB again with rates into the 140s. He was given IV diltiazem which decreased his systolic pressure from the 90s to 60s. At that point, he was given multiple small normal saline boluses to increase his pressure. He also received some IV Lopressor, as well as PO Lopressor. Given his recurrent episodes of AFIB with rapid ventricular response, he was taken to the EP Lab for a synchronous cardioversion on the morning of the 4.
|
Evidence: decreased his systolic pressure
from the 90s to 60s
Condition: Essential (primary) hypertension
HCC: I10
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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Lives with his wife. PHYSICAL EXAM: Vitals on arrival were temperature 98.7, blood pressure 100/60, heart rate 68, respiratory rate 18, 100% on 3 liters. This was an obese gentleman, sitting at 60%, in no apparent distress. He was alert and oriented x 3. He had dry mucous membranes. Pupils were equal and reactive with anicteric sclerae. Neck was supple. It was difficult to assess JVP secondary to habitus. He had very distant heart sounds, but usually regular rate with occasional premature beats.
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Evidence: blood pressure 100/60
Condition: Essential (primary) hypertension
HCC: I10
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
He was given 150 mg IV amiodarone, 5 mg IV metoprolol x 2, 2 gm of magnesium, 40 mEq of KCL, and 0.5 mg of versed. After receiving these medications, the patient's blood pressure decreased to the 70s/40s. He was given a bolus of fluids, after which he increased to 90/60. The EKG showed no ischemic changes. However, he was transferred to the ICU for further monitoring and continuation of the amiodarone GTT. He had a femoral line placement at that time. He was monitored in the ICU until [**4-13**].
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Evidence: patient's blood pressure
decreased to the 70s/40s
Condition: Essential (primary) hypertension
HCC: I10
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
After receiving these medications, the patient's blood pressure decreased to the 70s/40s. He was given a bolus of fluids, after which he increased to 90/60. The EKG showed no ischemic changes. However, he was transferred to the ICU for further monitoring and continuation of the amiodarone GTT. He had a femoral line placement at that time. He was monitored in the ICU until [**4-13**].
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Evidence: increased to 90/60
Condition: Essential (primary) hypertension
HCC: I10
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
He underwent a VT ablation procedure by electrophysiology on [**4-14**]. Overnight, on the [**4-15**], the patient developed intermittent AFIB with rates into the 120s-130s, and a blood pressure, systolic, in the 90s/70s. He received IV beta blocker and converted back into normal sinus rhythm with a rate in the 80s. He had no chest pain or shortness of breath during this episode. In the early morning hours of [**4-16**], he developed rapid AFIB again with rates into the 140s. He was given IV diltiazem which decreased his systolic pressure from the 90s to 60s.
|
Evidence: blood
pressure, systolic, in the 90s/70s
Condition: Essential (primary) hypertension
HCC: I10
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
In the early morning hours of [**4-16**], he developed rapid AFIB again with rates into the 140s. He was given IV diltiazem which decreased his systolic pressure from the 90s to 60s. At that point, he was given multiple small normal saline boluses to increase his pressure. He also received some IV Lopressor, as well as PO Lopressor. Given his recurrent episodes of AFIB with rapid ventricular response, he was taken to the EP Lab for a synchronous cardioversion on the morning of the 4. He received 1 shock of 200 joules and converted to normal sinus rhythm with a rate in the mid-80s. He was changed to an amiodarone rate of 400 [**Hospital1 **], his beta blocker was increased to tid dosing of 37.5 metoprolol, a low dose ACE inhibitor was added at 6.25 tid, and digoxin qd of 0.125 was added as well. The patient remained stable status post cardioversion, and by the [**4-17**], on hospital day #6, he was feeling well with stable heart rate and blood pressure. His INR was noted to be therapeutic between 2 and 3.
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Evidence: decreased his systolic pressure
from the 90s to 60s
Condition: Essential (primary) hypertension
HCC: I10
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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MEDICATIONS: 1. Hydralazine 25 mg. 2. Isosorbide 10 mg tid. 3.
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Evidence: Hydralazine 25 mg
Condition: Essential (primary) hypertension
HCC: I10
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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3. Metoprolol 50 [**Hospital1 **]. 4. Gemfibrozil 600 [**Hospital1 **]. 5. Warfarin alternating doses of 2 and 4 mg qd. 6. Furosemide.
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Evidence: Metoprolol 50 [**Hospital1 **]
Condition: Essential (primary) hypertension
HCC: I10
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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6. Furosemide. 7. Aspirin 325 qd 8. Glipizide 5 [**Hospital1 **]. 9. Potassium 20 qd. 10.Neurontin 100 tid.
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Evidence: Furosemide
Condition: Essential (primary) hypertension
HCC: I10
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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9. Captopril 6.25 tid. 10.Warfarin 2.5 qd. FOLLOW-UP: The patient is scheduled to be seen in Device Clinic and by Dr. [**Last Name (STitle) 1911**] on [**5-11**]. He was instructed to continue his Coumadin blood draws as he had been prior to his admission to the hospital. [**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**] Dictated By:[**Last Name (NamePattern1) 10454**] MEDQUIST36 D: [**2195-4-17**] 12:21 T: [**2195-4-17**] 12:25 JOB#: [**Job Number 10455**]
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Evidence: Captopril 6.25 tid
Condition: Essential (primary) hypertension
HCC: I10
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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5. Hypertension. 6. Hyperlipidemia. MEDICATIONS: 1. Hydralazine 25 mg. 2.
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Evidence: Hypertension
Condition: Essential (primary) hypertension
HCC: I10
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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4. Gemfibrozil 600 [**Hospital1 **]. 5. Warfarin alternating doses of 2 and 4 mg qd. 6.
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Evidence: Gemfibrozil 600 [**Hospital1 **]
Condition: Hyperlipidemia, unspecified
HCC: E785
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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6. Hyperlipidemia. MEDICATIONS: 1. Hydralazine 25 mg. 2. Isosorbide 10 mg tid. 3.
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Evidence: Hyperlipidemia
Condition: Hyperlipidemia, unspecified
HCC: E785
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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HISTORY OF PRESENT ILLNESS: This is a 65-year-old gentleman, with a history of CD, status post a VT arrest, and PTCA of the LAD in [**2186**], who presents with ICD firing several times over last night. The patient had instances of the ICD firing about 2 weeks ago without any preceding symptoms. He was seen at [**Hospital3 68**] where he was observed for about four days and then released. He had been feeling well until the night before admission when, at about 2:00 am, he began to feel nauseous and then the ICD fired. He did not have preceding chest pain, shortness of breath, palpitations, lightheadedness, or diaphoresis. The ICD fired a second time, and he was seen again at [**Hospital3 68**]. He was observed overnight and then discharged. When the ICD fired again that next day, he called 911 and was brought to [**Hospital1 18**]. He was noted to be in recurrent V-tach and was shocked multiple times by the ICD.
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Evidence: patient had instances of the ICD firing
about 2 weeks ago without any preceding symptoms.
Condition: Ventricular tachycardia
HCC: I472
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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When the ICD fired again that next day, he called 911 and was brought to [**Hospital1 18**]. He was noted to be in recurrent V-tach and was shocked multiple times by the ICD. RECENT REVIEW OF SYSTEMS: Notable only for diarrhea for the last several days. PAST MEDICAL HISTORY: 1. CAD, status post anterior MI.
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Evidence: He was noted to be in
recurrent V-tach and was shocked multiple times by the ICD.
Condition: Ventricular tachycardia
HCC: I472
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Previous cath performed in [**2186-4-12**] showed a 100% RCA lesion, LAD of 100% that was PTCA'd, EF 25%, with apical and anterolateral akinesis. HOSPITAL COURSE: The patient was admitted to cardiac medicine on telemetry. He was scheduled for an ICD pacer interrogation by EP. His enzymes were followed to rule out MI. On the evening of admission, [**4-12**], the patient experienced multiple runs of V-tach with the rate in the 200s. He was shocked by his ICD multiple times. His vital signs were initially stable, other than the rhythm of VT. He was given 150 mg IV amiodarone, 5 mg IV metoprolol x 2, 2 gm of magnesium, 40 mEq of KCL, and 0.5 mg of versed. After receiving these medications, the patient's blood pressure decreased to the 70s/40s.
|
Evidence: The patient was admitted to cardiac
medicine on telemetry.
Condition: Ventricular tachycardia
HCC: I472
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
His enzymes were followed to rule out MI. On the evening of admission, [**4-12**], the patient experienced multiple runs of V-tach with the rate in the 200s. He was shocked by his ICD multiple times. His vital signs were initially stable, other than the rhythm of VT. He was given 150 mg IV amiodarone, 5 mg IV metoprolol x 2, 2 gm of magnesium, 40 mEq of KCL, and 0.5 mg of versed. After receiving these medications, the patient's blood pressure decreased to the 70s/40s.
|
Evidence: On the evening of admission, [**4-12**], the patient
experienced multiple runs of V-tach with the rate in the
200s.
Condition: Ventricular tachycardia
HCC: I472
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Q waves in V1, V2, with poor R wave progression. On rhythm strips taken during events, he was noted to have a wide complex regular tachycardia at a rate of approximately 250, that after shock responded by changing into an irregular more narrow complex tachycardia (AF). Initial CBC showed a white count of 8.1, hematocrit 34.4, platelet count 180. He had a PT of 16.6, PTT 22, INR 1.8. Chem-7 showed a sodium of 140, potassium 3.8, chloride 104, CO2 24, BUN 15, creatinine 0.8, glucose 170. He had a calcium of 9.2, mag 2.0, phos 3.4. Initial set of enzymes showed a CK of 26, troponin-T less than 0.01. Previous cath performed in [**2186-4-12**] showed a 100% RCA lesion, LAD of 100% that was PTCA'd, EF 25%, with apical and anterolateral akinesis. HOSPITAL COURSE: The patient was admitted to cardiac medicine on telemetry.
|
Evidence: On rhythm strips taken during events, he was
noted to have a wide complex regular tachycardia at a rate of
approximately 250
Condition: Ventricular tachycardia
HCC: I472
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
HOSPITAL COURSE: The patient was admitted to cardiac medicine on telemetry. He was scheduled for an ICD pacer interrogation by EP. His enzymes were followed to rule out MI. On the evening of admission, [**4-12**], the patient experienced multiple runs of V-tach with the rate in the 200s. He was shocked by his ICD multiple times. His vital signs were initially stable, other than the rhythm of VT. He was given 150 mg IV amiodarone, 5 mg IV metoprolol x 2, 2 gm of magnesium, 40 mEq of KCL, and 0.5 mg of versed. After receiving these medications, the patient's blood pressure decreased to the 70s/40s.
|
Evidence: He was scheduled for an ICD pacer
interrogation by EP.
Condition: Ventricular tachycardia
HCC: I472
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
At this point, he was determined stable enough to return to the floor. He underwent a VT ablation procedure by electrophysiology on [**4-14**]. Overnight, on the [**4-15**], the patient developed intermittent AFIB with rates into the 120s-130s, and a blood pressure, systolic, in the 90s/70s. He received IV beta blocker and converted back into normal sinus rhythm with a rate in the 80s. He had no chest pain or shortness of breath during this episode. In the early morning hours of [**4-16**], he developed rapid AFIB again with rates into the 140s. He was given IV diltiazem which decreased his systolic pressure from the 90s to 60s. At that point, he was given multiple small normal saline boluses to increase his pressure. He also received some IV Lopressor, as well as PO Lopressor.
|
Evidence: He underwent a VT ablation procedure by electrophysiology on
[**4-14**].
Condition: Ventricular tachycardia
HCC: I472
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
2. Ventricular tachycardia. 3. Atrial fibrillation with rapid ventricular response. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg qd. 2. Gabapentin 100 mg q 8 h.
|
Evidence: Ventricular tachycardia
Condition: Ventricular tachycardia
HCC: I472
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
When the ICD fired again that next day, he called 911 and was brought to [**Hospital1 18**]. He was noted to be in recurrent V-tach and was shocked multiple times by the ICD. RECENT REVIEW OF SYSTEMS: Notable only for diarrhea for the last several days. PAST MEDICAL HISTORY: 1. CAD, status post anterior MI. 2. Prostate cancer, on chemotherapy, last dose 3 weeks ago.
|
Evidence: shocked multiple times by the ICD
Condition: Ventricular tachycardia
HCC: I472
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
His vital signs were initially stable, other than the rhythm of VT. He was given 150 mg IV amiodarone, 5 mg IV metoprolol x 2, 2 gm of magnesium, 40 mEq of KCL, and 0.5 mg of versed. After receiving these medications, the patient's blood pressure decreased to the 70s/40s. He was given a bolus of fluids, after which he increased to 90/60. The EKG showed no ischemic changes. However, he was transferred to the ICU for further monitoring and continuation of the amiodarone GTT. He had a femoral line placement at that time. He was monitored in the ICU until [**4-13**].
|
Evidence: He was given 150 mg IV amiodarone, 5 mg IV metoprolol x 2, 2 gm
of magnesium, 40 mEq of KCL, and 0.5 mg of versed.
Condition: Ventricular tachycardia
HCC: I472
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
At this point, he was determined stable enough to return to the floor. He underwent a VT ablation procedure by electrophysiology on [**4-14**]. Overnight, on the [**4-15**], the patient developed intermittent AFIB with rates into the 120s-130s, and a blood pressure, systolic, in the 90s/70s. He received IV beta blocker and converted back into normal sinus rhythm with a rate in the 80s. He had no chest pain or shortness of breath during this episode. In the early morning hours of [**4-16**], he developed rapid AFIB again with rates into the 140s. He was given IV diltiazem which decreased his systolic pressure from the 90s to 60s. At that point, he was given multiple small normal saline boluses to increase his pressure.
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Evidence: He underwent a VT ablation procedure by electrophysiology on
[**4-14**].
Condition: Ventricular tachycardia
HCC: I472
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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The EKG showed no ischemic changes. However, he was transferred to the ICU for further monitoring and continuation of the amiodarone GTT. He had a femoral line placement at that time. He was monitored in the ICU until [**4-13**]. At this point, he was determined stable enough to return to the floor. He underwent a VT ablation procedure by electrophysiology on [**4-14**]. Overnight, on the [**4-15**], the patient developed intermittent AFIB with rates into the 120s-130s, and a blood pressure, systolic, in the 90s/70s. He received IV beta blocker and converted back into normal sinus rhythm with a rate in the 80s. He had no chest pain or shortness of breath during this episode.
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Evidence: continuation of the amiodarone GTT.
Condition: Ventricular tachycardia
HCC: I472
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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7. Amiodarone 400 mg [**Hospital1 **] for the first 2 weeks post discharge, with instructions to the patient to decrease to 400 mg qd thereafter until seen in [**Hospital **] Clinic. 8. Digoxin 0.125 qd. 9. Captopril 6.25 tid. 10.Warfarin 2.5 qd. FOLLOW-UP: The patient is scheduled to be seen in Device Clinic and by Dr.
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Evidence: Amiodarone 400 mg [**Hospital1 **] for the first 2 weeks post
discharge, with instructions to the patient to decrease to
400 mg qd thereafter until seen in [**Hospital **] Clinic.
Condition: Ventricular tachycardia
HCC: I472
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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When the ICD fired again that next day, he called 911 and was brought to [**Hospital1 18**]. He was noted to be in recurrent V-tach and was shocked multiple times by the ICD. RECENT REVIEW OF SYSTEMS: Notable only for diarrhea for the last several days. PAST MEDICAL HISTORY: 1. CAD, status post anterior MI. 2. Prostate cancer, on chemotherapy, last dose 3 weeks ago. 3.
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Evidence: recurrent V-tach
Condition: Ventricular tachycardia
HCC: I472
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Q waves in V1, V2, with poor R wave progression. On rhythm strips taken during events, he was noted to have a wide complex regular tachycardia at a rate of approximately 250, that after shock responded by changing into an irregular more narrow complex tachycardia (AF). Initial CBC showed a white count of 8.1, hematocrit 34.4, platelet count 180. He had a PT of 16.6, PTT 22, INR 1.8. Chem-7 showed a sodium of 140, potassium 3.8, chloride 104, CO2 24, BUN 15, creatinine 0.8, glucose 170. He had a calcium of 9.2, mag 2.0, phos 3.4. Initial set of enzymes showed a CK of 26, troponin-T less than 0.01. Previous cath performed in [**2186-4-12**] showed a 100% RCA lesion, LAD of 100% that was PTCA'd, EF 25%, with apical and anterolateral akinesis.
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Evidence: wide complex regular tachycardia at a rate of
approximately 250
Condition: Ventricular tachycardia
HCC: I472
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
|
His enzymes were followed to rule out MI. On the evening of admission, [**4-12**], the patient experienced multiple runs of V-tach with the rate in the 200s. He was shocked by his ICD multiple times. His vital signs were initially stable, other than the rhythm of VT. He was given 150 mg IV amiodarone, 5 mg IV metoprolol x 2, 2 gm of magnesium, 40 mEq of KCL, and 0.5 mg of versed. After receiving these medications, the patient's blood pressure decreased to the 70s/40s.
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Evidence: multiple runs of V-tach with the rate in the
200s
Condition: Ventricular tachycardia
HCC: I472
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2195-4-12**] Discharge Date: [**2195-4-17**] Date of Birth: [**2129-11-25**] Sex: M Service: CARDIAC MEDICINE CHIEF COMPLAINT: ICD firing. HISTORY OF PRESENT ILLNESS: This is a 65-year-old gentleman, with a history of CD, status post a VT arrest, and PTCA of the LAD in [**2186**], who presents with ICD firing several times over last night. The patient had instances of the ICD firing about 2 weeks ago without any preceding symptoms. He was seen at [**Hospital3 68**] where he was observed for about four days and then released. He had been feeling well until the night before admission when, at about 2:00 am, he began to feel nauseous and then the ICD fired. He did not have preceding chest pain, shortness of breath, palpitations, lightheadedness, or diaphoresis.
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Evidence: VT
Condition: Ventricular tachycardia
HCC: I472
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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2. Ventricular tachycardia. 3. Atrial fibrillation with rapid ventricular response. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg qd.
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Evidence: Ventricular tachycardia
Condition: Ventricular tachycardia
HCC: I472
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
|
He underwent a VT ablation procedure by electrophysiology on [**4-14**]. Overnight, on the [**4-15**], the patient developed intermittent AFIB with rates into the 120s-130s, and a blood pressure, systolic, in the 90s/70s. He received IV beta blocker and converted back into normal sinus rhythm with a rate in the 80s. He had no chest pain or shortness of breath during this episode. In the early morning hours of [**4-16**], he developed rapid AFIB again with rates into the 140s. He was given IV diltiazem which decreased his systolic pressure from the 90s to 60s. At that point, he was given multiple small normal saline boluses to increase his pressure. He also received some IV Lopressor, as well as PO Lopressor. Given his recurrent episodes of AFIB with rapid ventricular response, he was taken to the EP Lab for a synchronous cardioversion on the morning of the 4.
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Evidence: patient developed
intermittent AFIB with rates into the 120s-130s
Condition: Chronic atrial fibrillation with rapid ventricular response
HCC: I4820
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
He had no chest pain or shortness of breath during this episode. In the early morning hours of [**4-16**], he developed rapid AFIB again with rates into the 140s. He was given IV diltiazem which decreased his systolic pressure from the 90s to 60s. At that point, he was given multiple small normal saline boluses to increase his pressure. He also received some IV Lopressor, as well as PO Lopressor. Given his recurrent episodes of AFIB with rapid ventricular response, he was taken to the EP Lab for a synchronous cardioversion on the morning of the 4.
|
Evidence: developed rapid AFIB again with rates into the 140s
Condition: Chronic atrial fibrillation with rapid ventricular response
HCC: I4820
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
He was changed to an amiodarone rate of 400 [**Hospital1 **], his beta blocker was increased to tid dosing of 37.5 metoprolol, a low dose ACE inhibitor was added at 6.25 tid, and digoxin qd of 0.125 was added as well. The patient remained stable status post cardioversion, and by the [**4-17**], on hospital day #6, he was feeling well with stable heart rate and blood pressure. His INR was noted to be therapeutic between 2 and 3. The patient was evaluated by physical therapy and determined that he did not need home services. It was decided that he was prepared for discharge with a 4-week follow-up with Device Clinic and [**Doctor Last Name 1911**] in cardiology.
|
Evidence: stable heart rate and blood pressure
Condition: Chronic atrial fibrillation with rapid ventricular response
HCC: I4820
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Q waves in V1, V2, with poor R wave progression. On rhythm strips taken during events, he was noted to have a wide complex regular tachycardia at a rate of approximately 250, that after shock responded by changing into an irregular more narrow complex tachycardia (AF). Initial CBC showed a white count of 8.1, hematocrit 34.4, platelet count 180. He had a PT of 16.6, PTT 22, INR 1.8. Chem-7 showed a sodium of 140, potassium 3.8, chloride 104, CO2 24, BUN 15, creatinine 0.8, glucose 170. He had a calcium of 9.2, mag 2.0, phos 3.4. Initial set of enzymes showed a CK of 26, troponin-T less than 0.01. Previous cath performed in [**2186-4-12**] showed a 100% RCA lesion, LAD of 100% that was PTCA'd, EF 25%, with apical and anterolateral akinesis.
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Evidence: after shock responded by changing
into an irregular more narrow complex tachycardia (AF).
Condition: Chronic atrial fibrillation with rapid ventricular response
HCC: I4820
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
3. Atrial fibrillation with rapid ventricular response. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg qd. 2. Gabapentin 100 mg q 8 h. 3. Gemfibrozil 600 mg [**Hospital1 **].
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Evidence: Atrial fibrillation with rapid ventricular response
Condition: Chronic atrial fibrillation with rapid ventricular response
HCC: I4820
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Overnight, on the [**4-15**], the patient developed intermittent AFIB with rates into the 120s-130s, and a blood pressure, systolic, in the 90s/70s. He received IV beta blocker and converted back into normal sinus rhythm with a rate in the 80s. He had no chest pain or shortness of breath during this episode. In the early morning hours of [**4-16**], he developed rapid AFIB again with rates into the 140s. He was given IV diltiazem which decreased his systolic pressure from the 90s to 60s. At that point, he was given multiple small normal saline boluses to increase his pressure. He also received some IV Lopressor, as well as PO Lopressor.
|
Evidence: He received IV beta
blocker and converted back into normal sinus rhythm
Condition: Chronic atrial fibrillation with rapid ventricular response
HCC: I4820
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
In the early morning hours of [**4-16**], he developed rapid AFIB again with rates into the 140s. He was given IV diltiazem which decreased his systolic pressure from the 90s to 60s. At that point, he was given multiple small normal saline boluses to increase his pressure. He also received some IV Lopressor, as well as PO Lopressor. Given his recurrent episodes of AFIB with rapid ventricular response, he was taken to the EP Lab for a synchronous cardioversion on the morning of the 4. He received 1 shock of 200 joules and converted to normal sinus rhythm with a rate in the mid-80s. He was changed to an amiodarone rate of 400 [**Hospital1 **], his beta blocker was increased to tid dosing of 37.5 metoprolol, a low dose ACE inhibitor was added at 6.25 tid, and digoxin qd of 0.125 was added as well. The patient remained stable status post cardioversion, and by the [**4-17**], on hospital day #6, he was feeling well with stable heart rate and blood pressure.
|
Evidence: He
was given IV diltiazem
Condition: Chronic atrial fibrillation with rapid ventricular response
HCC: I4820
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
At that point, he was given multiple small normal saline boluses to increase his pressure. He also received some IV Lopressor, as well as PO Lopressor. Given his recurrent episodes of AFIB with rapid ventricular response, he was taken to the EP Lab for a synchronous cardioversion on the morning of the 4. He received 1 shock of 200 joules and converted to normal sinus rhythm with a rate in the mid-80s. He was changed to an amiodarone rate of 400 [**Hospital1 **], his beta blocker was increased to tid dosing of 37.5 metoprolol, a low dose ACE inhibitor was added at 6.25 tid, and digoxin qd of 0.125 was added as well. The patient remained stable status post cardioversion, and by the [**4-17**], on hospital day #6, he was feeling well with stable heart rate and blood pressure. His INR was noted to be therapeutic between 2 and 3.
|
Evidence: He
also received some IV Lopressor, as well as PO Lopressor.
Condition: Chronic atrial fibrillation with rapid ventricular response
HCC: I4820
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
He also received some IV Lopressor, as well as PO Lopressor. Given his recurrent episodes of AFIB with rapid ventricular response, he was taken to the EP Lab for a synchronous cardioversion on the morning of the 4. He received 1 shock of 200 joules and converted to normal sinus rhythm with a rate in the mid-80s. He was changed to an amiodarone rate of 400 [**Hospital1 **], his beta blocker was increased to tid dosing of 37.5 metoprolol, a low dose ACE inhibitor was added at 6.25 tid, and digoxin qd of 0.125 was added as well. The patient remained stable status post cardioversion, and by the [**4-17**], on hospital day #6, he was feeling well with stable heart rate and blood pressure. His INR was noted to be therapeutic between 2 and 3. The patient was evaluated by physical therapy and determined that he did not need home services. It was decided that he was prepared for discharge with a 4-week follow-up with Device Clinic and [**Doctor Last Name 1911**] in cardiology. DISCHARGE CONDITION: Good. DISCHARGE STATUS: To home.
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Evidence: He was taken to the EP Lab for a synchronous
cardioversion on the morning of the 4. He received 1 shock
of 200 joules and converted to normal sinus rhythm
Condition: Chronic atrial fibrillation with rapid ventricular response
HCC: I4820
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
He received 1 shock of 200 joules and converted to normal sinus rhythm with a rate in the mid-80s. He was changed to an amiodarone rate of 400 [**Hospital1 **], his beta blocker was increased to tid dosing of 37.5 metoprolol, a low dose ACE inhibitor was added at 6.25 tid, and digoxin qd of 0.125 was added as well. The patient remained stable status post cardioversion, and by the [**4-17**], on hospital day #6, he was feeling well with stable heart rate and blood pressure. His INR was noted to be therapeutic between 2 and 3. The patient was evaluated by physical therapy and determined that he did not need home services. It was decided that he was prepared for discharge with a 4-week follow-up with Device Clinic and [**Doctor Last Name 1911**] in cardiology. DISCHARGE CONDITION: Good.
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Evidence: He was changed to an amiodarone rate of
400 [**Hospital1 **], his beta blocker was increased to tid dosing of 37.5
metoprolol, a low dose ACE inhibitor was added at 6.25 tid,
and digoxin qd of 0.125 was added as well.
Condition: Chronic atrial fibrillation with rapid ventricular response
HCC: I4820
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
5. Warfarin alternating doses of 2 and 4 mg qd. 6. Furosemide. 7.
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Evidence: Warfarin alternating doses of 2 and 4 mg qd.
Condition: Chronic atrial fibrillation with rapid ventricular response
HCC: I4820
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Captopril 6.25 tid. 10.Warfarin 2.5 qd. FOLLOW-UP: The patient is scheduled to be seen in Device Clinic and by Dr. [**Last Name (STitle) 1911**] on [**5-11**]. He was instructed to continue his Coumadin blood draws as he had been prior to his admission to the hospital.
|
Evidence: Warfarin 2.5 qd.
Condition: Chronic atrial fibrillation with rapid ventricular response
HCC: I4820
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Q waves in V1, V2, with poor R wave progression. On rhythm strips taken during events, he was noted to have a wide complex regular tachycardia at a rate of approximately 250, that after shock responded by changing into an irregular more narrow complex tachycardia (AF). Initial CBC showed a white count of 8.1, hematocrit 34.4, platelet count 180. He had a PT of 16.6, PTT 22, INR 1.8. Chem-7 showed a sodium of 140, potassium 3.8, chloride 104, CO2 24, BUN 15, creatinine 0.8, glucose 170. He had a calcium of 9.2, mag 2.0, phos 3.4. Initial set of enzymes showed a CK of 26, troponin-T less than 0.01. Previous cath performed in [**2186-4-12**] showed a 100% RCA lesion, LAD of 100% that was PTCA'd, EF 25%, with apical and anterolateral akinesis.
|
Evidence: irregular more narrow complex tachycardia (AF)
Condition: Chronic atrial fibrillation with rapid ventricular response
HCC: I4820
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
He underwent a VT ablation procedure by electrophysiology on [**4-14**]. Overnight, on the [**4-15**], the patient developed intermittent AFIB with rates into the 120s-130s, and a blood pressure, systolic, in the 90s/70s. He received IV beta blocker and converted back into normal sinus rhythm with a rate in the 80s. He had no chest pain or shortness of breath during this episode. In the early morning hours of [**4-16**], he developed rapid AFIB again with rates into the 140s. He was given IV diltiazem which decreased his systolic pressure from the 90s to 60s. At that point, he was given multiple small normal saline boluses to increase his pressure. He also received some IV Lopressor, as well as PO Lopressor. Given his recurrent episodes of AFIB with rapid ventricular response, he was taken to the EP Lab for a synchronous cardioversion on the morning of the 4.
|
Evidence: intermittent AFIB with rates into the 120s-130s
Condition: Chronic atrial fibrillation with rapid ventricular response
HCC: I4820
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
He had no chest pain or shortness of breath during this episode. In the early morning hours of [**4-16**], he developed rapid AFIB again with rates into the 140s. He was given IV diltiazem which decreased his systolic pressure from the 90s to 60s. At that point, he was given multiple small normal saline boluses to increase his pressure. He also received some IV Lopressor, as well as PO Lopressor.
|
Evidence: rapid AFIB again with rates into the 140s
Condition: Chronic atrial fibrillation with rapid ventricular response
HCC: I4820
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
He also received some IV Lopressor, as well as PO Lopressor. Given his recurrent episodes of AFIB with rapid ventricular response, he was taken to the EP Lab for a synchronous cardioversion on the morning of the 4. He received 1 shock of 200 joules and converted to normal sinus rhythm with a rate in the mid-80s. He was changed to an amiodarone rate of 400 [**Hospital1 **], his beta blocker was increased to tid dosing of 37.5 metoprolol, a low dose ACE inhibitor was added at 6.25 tid, and digoxin qd of 0.125 was added as well. The patient remained stable status post cardioversion, and by the [**4-17**], on hospital day #6, he was feeling well with stable heart rate and blood pressure.
|
Evidence: recurrent episodes of AFIB with rapid ventricular
response
Condition: Chronic atrial fibrillation with rapid ventricular response
HCC: I4820
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
3. Atrial fibrillation with rapid ventricular response. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg qd. 2. Gabapentin 100 mg q 8 h. 3. Gemfibrozil 600 mg [**Hospital1 **]. 4.
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Evidence: Atrial fibrillation with rapid ventricular response
Condition: Chronic atrial fibrillation with rapid ventricular response
HCC: I4820
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
3. Zestril 5 mg p.o. q.d. 4. Lipitor 20 mg p.o. q.d. 5. Lopressor 100 mg p.o. b.i.d.
|
Evidence: Zestril 5 mg p.o. q.d.
Condition: Essential (primary) hypertension
HCC: I10
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
5. Lopressor 100 mg p.o. b.i.d. 6. Protonix 40 mg p.o. q.d. 7.
|
Evidence: Lopressor 100 mg p.o. b.i.d.
Condition: Essential (primary) hypertension
HCC: I10
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
DISCHARGE MEDICATIONS: 1. Lopressor 75 mg p.o. b.i.d. 2. Colace 100 mg p.o. b.i.d.
|
Evidence: Lopressor 75 mg p.o. b.i.d.
Condition: Essential (primary) hypertension
HCC: I10
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
PAST MEDICAL HISTORY: 1. Hypertension. 2. Hyperlipidemia. 3. Type 2 diabetes, now insulin-dependent.
|
Evidence: Hypertension
Condition: Essential (primary) hypertension
HCC: I10
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
4. Lipitor 20 mg p.o. q.d. 5. Lopressor 100 mg p.o. b.i.d.
|
Evidence: Lipitor 20 mg p.o. q.d.
Condition: Hyperlipidemia, unspecified
HCC: E785
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
4. Lipitor 20 mg p.o. q.d. 5. Lopressor 100 mg p.o. b.i.d.
|
Evidence: Lipitor 20 mg p.o. q.d.
Condition: Hyperlipidemia, unspecified
HCC: E785
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
2. Hyperlipidemia. 3. Type 2 diabetes, now insulin-dependent. 4. Coronary artery disease, status post myocardial infarction. 5. Status post kidney surgery, type unknown, as a child.
|
Evidence: Hyperlipidemia
Condition: Hyperlipidemia, unspecified
HCC: E785
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
13. Humalog sliding scale per the patient to maintain a blood sugar of 120 or less. DISPOSITION: The patient is to be discharged to home in stable condition. FOLLOW-UP: The patient is to follow-up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12491**], in one week for recheck of his amylase and lipase.
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Evidence: Humalog sliding scale per the patient to maintain a blood sugar of 120 or less
Condition: Type 2 diabetes mellitus without complications
HCC: E119
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
LABORATORY/RADIOLOGIC DATA: White blood cell count 7.7, hematocrit 40, platelet count 279,000. Sodium 135, potassium 4.4, chloride 98, bicarbonate 26, BUN 22, creatinine 1.0, glucose 120. AST 64, ALT 93, alkaline phosphatase 129, amylase 168, lipase 247, total bilirubin 2.1. DISCHARGE MEDICATIONS: 1. Lopressor 75 mg p.o. b.i.d. 2. Colace 100 mg p.o.
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Evidence: glucose 120
Condition: Type 2 diabetes mellitus without complications
HCC: E119
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
7. Insulin-dependent diabetes mellitus. CONDITION ON DISCHARGE: T maximum 98.6, pulse 90, sinus rhythm, blood pressure 106/60, respiratory rate 14, room air oxygen saturation 96%. The patient was awake, alert, oriented times three, ambulating independently with a nonfocal neurological examination. The heart revealed a regular rate and rhythm without rub or murmur. The lungs were clear bilaterally. The abdomen was with positive bowel sounds, soft, nontender, nondistended.
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Evidence: Insulin-dependent diabetes mellitus
Condition: Type 2 diabetes mellitus without complications
HCC: E119
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
7. NPH insulin 18 units subcutaneously b.i.d. 8. Humalog sliding scale. PREOPERATIVE LABORATORY DATA: Significant for a hematocrit of 40.7, potassium 4.5, BUN 18, creatinine 0.9.
|
Evidence: NPH insulin 18 units subcutaneously b.i.d.
Condition: Type 2 diabetes mellitus without complications
HCC: E119
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
8. Humalog sliding scale. PREOPERATIVE LABORATORY DATA: Significant for a hematocrit of 40.7, potassium 4.5, BUN 18, creatinine 0.9. HOSPITAL COURSE: The patient was taken to the Cardiac Catheterization Laboratory on [**2112-8-9**] where he was started on an Integrelin infusion and given a heparin bolus. During the cardiac catheterization, an attempted PCI of the LAD was undertaken. During the PCI, the patient began to develop chest pain and ST segment elevations. There was no flow through the LAD and no improvement in the flow with vasodilators. Due to the patient's continued chest pain, an intra-aortic balloon pump was inserted in the Cardiac Catheterization Laboratory and the patient was taken emergently to the Operating Room by Dr.
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Evidence: Humalog sliding scale
Condition: Type 2 diabetes mellitus without complications
HCC: E119
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
7. NPH insulin 18 units subcutaneously b.i.d. 8. Humalog sliding scale. PREOPERATIVE LABORATORY DATA: Significant for a hematocrit of 40.7, potassium 4.5, BUN 18, creatinine 0.9. HOSPITAL COURSE: The patient was taken to the Cardiac Catheterization Laboratory on [**2112-8-9**] where he was started on an Integrelin infusion and given a heparin bolus.
|
Evidence: NPH insulin 18 units subcutaneously b.i.d.
Condition: Type 2 diabetes mellitus without complications
HCC: E119
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
8. Humalog sliding scale. PREOPERATIVE LABORATORY DATA: Significant for a hematocrit of 40.7, potassium 4.5, BUN 18, creatinine 0.9. HOSPITAL COURSE: The patient was taken to the Cardiac Catheterization Laboratory on [**2112-8-9**] where he was started on an Integrelin infusion and given a heparin bolus. During the cardiac catheterization, an attempted PCI of the LAD was undertaken. During the PCI, the patient began to develop chest pain and ST segment elevations.
|
Evidence: Humalog sliding scale
Condition: Type 2 diabetes mellitus without complications
HCC: E119
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
3. Type 2 diabetes, now insulin-dependent. 4. Coronary artery disease, status post myocardial infarction. 5.
|
Evidence: Type 2 diabetes, now insulin-dependent
Condition: Type 2 diabetes mellitus without complications
HCC: E119
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
7. Insulin-dependent diabetes mellitus. CONDITION ON DISCHARGE: T maximum 98.6, pulse 90, sinus rhythm, blood pressure 106/60, respiratory rate 14, room air oxygen saturation 96%. The patient was awake, alert, oriented times three, ambulating independently with a nonfocal neurological examination. The heart revealed a regular rate and rhythm without rub or murmur. The lungs were clear bilaterally.
|
Evidence: Insulin-dependent diabetes mellitus
Condition: Type 2 diabetes mellitus without complications
HCC: E119
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
7. Insulin-dependent diabetes mellitus. CONDITION ON DISCHARGE: T maximum 98.6, pulse 90, sinus rhythm, blood pressure 106/60, respiratory rate 14, room air oxygen saturation 96%. The patient was awake, alert, oriented times three, ambulating independently with a nonfocal neurological examination. The heart revealed a regular rate and rhythm without rub or murmur. The lungs were clear bilaterally.
|
Evidence: Insulin-dependent diabetes mellitus
Condition: Long-term (current) use of insulin
HCC: Z794
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
3. Type 2 diabetes, now insulin-dependent. 4. Coronary artery disease, status post myocardial infarction. 5. Status post kidney surgery, type unknown, as a child. ALLERGIES: Penicillin.
|
Evidence: Insulin-dependent
Condition: Long-term (current) use of insulin
HCC: Z794
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
7. NPH insulin 18 units subcutaneously b.i.d. 8. Humalog sliding scale. PREOPERATIVE LABORATORY DATA: Significant for a hematocrit of 40.7, potassium 4.5, BUN 18, creatinine 0.9. HOSPITAL COURSE: The patient was taken to the Cardiac Catheterization Laboratory on [**2112-8-9**] where he was started on an Integrelin infusion and given a heparin bolus. During the cardiac catheterization, an attempted PCI of the LAD was undertaken. During the PCI, the patient began to develop chest pain and ST segment elevations. There was no flow through the LAD and no improvement in the flow with vasodilators.
|
Evidence: NPH insulin 18 units subcutaneously b.i.d.
Condition: Long-term (current) use of insulin
HCC: Z794
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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8. Humalog sliding scale. PREOPERATIVE LABORATORY DATA: Significant for a hematocrit of 40.7, potassium 4.5, BUN 18, creatinine 0.9. HOSPITAL COURSE: The patient was taken to the Cardiac Catheterization Laboratory on [**2112-8-9**] where he was started on an Integrelin infusion and given a heparin bolus. During the cardiac catheterization, an attempted PCI of the LAD was undertaken. During the PCI, the patient began to develop chest pain and ST segment elevations. There was no flow through the LAD and no improvement in the flow with vasodilators. Due to the patient's continued chest pain, an intra-aortic balloon pump was inserted in the Cardiac Catheterization Laboratory and the patient was taken emergently to the Operating Room by Dr.
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Evidence: Humalog sliding scale
Condition: Long-term (current) use of insulin
HCC: Z794
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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7. NPH insulin 18 units subcutaneously b.i.d. 8. Humalog sliding scale. PREOPERATIVE LABORATORY DATA: Significant for a hematocrit of 40.7, potassium 4.5, BUN 18, creatinine 0.9.
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Evidence: NPH insulin 18 units subcutaneously b.i.d.
Condition: Long-term (current) use of insulin
HCC: Z794
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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8. Humalog sliding scale. PREOPERATIVE LABORATORY DATA: Significant for a hematocrit of 40.7, potassium 4.5, BUN 18, creatinine 0.9. HOSPITAL COURSE: The patient was taken to the Cardiac Catheterization Laboratory on [**2112-8-9**] where he was started on an Integrelin infusion and given a heparin bolus. During the cardiac catheterization, an attempted PCI of the LAD was undertaken. During the PCI, the patient began to develop chest pain and ST segment elevations. There was no flow through the LAD and no improvement in the flow with vasodilators. Due to the patient's continued chest pain, an intra-aortic balloon pump was inserted in the Cardiac Catheterization Laboratory and the patient was taken emergently to the Operating Room by Dr.
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Evidence: Humalog sliding scale
Condition: Long-term (current) use of insulin
HCC: Z794
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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3. Type 2 diabetes, now insulin-dependent. 4. Coronary artery disease, status post myocardial infarction. 5. Status post kidney surgery, type unknown, as a child. ALLERGIES: Penicillin.
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Evidence: Type 2 diabetes, now insulin-dependent
Condition: Long-term (current) use of insulin
HCC: Z794
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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3. Type 2 diabetes, now insulin-dependent. 4. Coronary artery disease, status post myocardial infarction. 5. Status post kidney surgery, type unknown, as a child. ALLERGIES: Penicillin.
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Evidence: insulin-dependent
Condition: Long-term (current) use of insulin
HCC: Z794
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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7. Insulin-dependent diabetes mellitus. CONDITION ON DISCHARGE: T maximum 98.6, pulse 90, sinus rhythm, blood pressure 106/60, respiratory rate 14, room air oxygen saturation 96%. The patient was awake, alert, oriented times three, ambulating independently with a nonfocal neurological examination. The heart revealed a regular rate and rhythm without rub or murmur. The lungs were clear bilaterally.
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Evidence: Insulin-dependent diabetes mellitus
Condition: Long-term (current) use of insulin
HCC: Z794
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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3. Type 2 diabetes, now insulin-dependent. 4. Coronary artery disease, status post myocardial infarction. 5.
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Evidence: Insulin-dependent
Condition: Long-term (current) use of insulin
HCC: Z794
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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During the cardiac catheterization, an attempted PCI of the LAD was undertaken. During the PCI, the patient began to develop chest pain and ST segment elevations. There was no flow through the LAD and no improvement in the flow with vasodilators. Due to the patient's continued chest pain, an intra-aortic balloon pump was inserted in the Cardiac Catheterization Laboratory and the patient was taken emergently to the Operating Room by Dr. [**Last Name (STitle) **] for coronary artery bypass.
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Evidence: patient began to develop
chest pain
Condition: Atherosclerotic cardiovascular disease of native coronary artery without angina pectoris
HCC: I2510
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
During the cardiac catheterization, an attempted PCI of the LAD was undertaken. During the PCI, the patient began to develop chest pain and ST segment elevations. There was no flow through the LAD and no improvement in the flow with vasodilators. Due to the patient's continued chest pain, an intra-aortic balloon pump was inserted in the Cardiac Catheterization Laboratory and the patient was taken emergently to the Operating Room by Dr. [**Last Name (STitle) **] for coronary artery bypass.
|
Evidence: ST segment elevations
Condition: Atherosclerotic cardiovascular disease of native coronary artery without angina pectoris
HCC: I2510
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
There was no flow through the LAD and no improvement in the flow with vasodilators. Due to the patient's continued chest pain, an intra-aortic balloon pump was inserted in the Cardiac Catheterization Laboratory and the patient was taken emergently to the Operating Room by Dr. [**Last Name (STitle) **] for coronary artery bypass. In the Operating Room, the patient underwent a CABG times three with SVG to LAD, SVG to diagonal, and SVG to OM. Due to the patient's coagulation status preoperatively with the patient being on Plavix and Integrelin, the patient had a large amount of chest tube output in the Operating Room and postoperatively. The patient was transferred to the Intensive Care Unit on a large amount of pressors due to a low blood pressure. In the Intensive Care Unit, the patient had approximately 2 liters of chest tube drainage in the first hour in the Intensive Care Unit. The patient was quickly taken back to the Operating Room. In the Operating Room, there were found only small areas of bleeding which were repaired.
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Evidence: continued chest pain
Condition: Atherosclerotic cardiovascular disease of native coronary artery without angina pectoris
HCC: I2510
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
On the evening of postoperative day number one, the patient required large amounts of blood products. The patient continued on his intra-aortic balloon pump. It was elected to keep the patient intubated on the night of postoperative day number one. The patient's chest tube output was considerably decreased. The patient was moderately hypoxic. The chest x-ray showed volume overload. By postoperative day number two, the patient's coagulopathy had been corrected and he was hemodynamically stable. The intra-aortic balloon pump was removed without complications. The patient required large amounts of diuresis over the next several days for the patient's oxygenation and enable the patient to wean on the ventilator. On postoperative day number three, it was noted that the patient had a large right-sided pleural effusion. A right pleural chest tube was inserted with 1,500 cc of old dark blood and improvement in the patient's chest x-ray. After the chest tube was inserted, the patient began complaining of the sensation of shortness of breath and became tachypneic. A repeat chest x-ray was performed which showed no pneumothorax, no effusion; however, the patient's endotracheal tube was noted to be high. This was advanced. However, the patient continued to remain anxious. The patient's oxygenation improved with sedation. By postoperative day number four, the patient had been weaned off of his pressors and was started on a low-dose beta blocker. The patient was noted to have a dropping platelet count. A heparin antibody test was sent which was subsequently negative. The patient had been started on Plavix as he still had a stent to his RCA. It was recommended by Dr. [**Last Name (STitle) **] that the patient be transfused platelets and given Plavix as the concern for keeping the stent patent. On the evening of postoperative day number four, the patient began draining large amounts of bloody fluid from his sternal incision which was thought to be a liquefying hematoma. On postoperative day number five, the patient continued to have a large amount of drainage and Dr. [**Last Name (STitle) **] decided to return the patient to the Operating Room for tightening of the sternal wires as he thought the drainage was due to a sternal dehiscence. The patient tolerated this procedure well and returned to the Intensive Care Unit and remained intubated throughout. On the evening of postoperative day number five, the patient was weaned and extubated from mechanical ventilation and required vigorous chest PT to maintain oxygen saturation, had a moderate productive cough.
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Evidence: patient continued on Plavix as he still had a stent to his RCA
Condition: Atherosclerotic cardiovascular disease of native coronary artery without angina pectoris
HCC: I2510
Category: Monitoring
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