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Extract medical evidence from the following clinical text that supports medical condition coding:
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For treatment of her exacerbation, she was placed on oxygen 4L NC and started on prednisone 60 mg daily, ipratropium and albuterol nebulizers, mucinex 1200 mg [**Hospital1 **], and dextromethorphran 60 mg [**Hospital1 **]. She was transitioned to tiotropium bromide MDI daily and albuterol inhaler prn SOB and wheezing >24H prior to discharge with bedside teaching; her respiratory status remained stable with O2 requirement at 4L, O2 sats remained at low 90s. Attempt to taper O2 to 3L resulted with O2 sats to 88% at rest. Her prednisone was decreased to 40 mg at time of discharge. She was also started on calcium 1200 mg and vitamin D 800 units for osteoporosis prevention. She was discharged with home health services (O2 therapy, cardiopulmonary assessment, skilled nursing) and encouraged to follow up with outpatient pulmonary rehabilation. Patient was discharged with close PCP [**Last Name (NamePattern4) 702**]. We also scheduled follow up with pulmonary w/outpatient PFTs to evaluate the severity of her COPD. .
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Evidence: O2 requirement at 4L
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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For treatment of her exacerbation, she was placed on oxygen 4L NC and started on prednisone 60 mg daily, ipratropium and albuterol nebulizers, mucinex 1200 mg [**Hospital1 **], and dextromethorphran 60 mg [**Hospital1 **]. She was transitioned to tiotropium bromide MDI daily and albuterol inhaler prn SOB and wheezing >24H prior to discharge with bedside teaching; her respiratory status remained stable with O2 requirement at 4L, O2 sats remained at low 90s. Attempt to taper O2 to 3L resulted with O2 sats to 88% at rest. Her prednisone was decreased to 40 mg at time of discharge. She was also started on calcium 1200 mg and vitamin D 800 units for osteoporosis prevention. She was discharged with home health services (O2 therapy, cardiopulmonary assessment, skilled nursing) and encouraged to follow up with outpatient pulmonary rehabilation. Patient was discharged with close PCP [**Last Name (NamePattern4) 702**]. We also scheduled follow up with pulmonary w/outpatient PFTs to evaluate the severity of her COPD.
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Evidence: O2 sats
remained at low 90s
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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She was transitioned to tiotropium bromide MDI daily and albuterol inhaler prn SOB and wheezing >24H prior to discharge with bedside teaching; her respiratory status remained stable with O2 requirement at 4L, O2 sats remained at low 90s. Attempt to taper O2 to 3L resulted with O2 sats to 88% at rest. Her prednisone was decreased to 40 mg at time of discharge. She was also started on calcium 1200 mg and vitamin D 800 units for osteoporosis prevention. She was discharged with home health services (O2 therapy, cardiopulmonary assessment, skilled nursing) and encouraged to follow up with outpatient pulmonary rehabilation. Patient was discharged with close PCP [**Last Name (NamePattern4) 702**]. We also scheduled follow up with pulmonary w/outpatient PFTs to evaluate the severity of her COPD. . #.
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Evidence: O2
sats to 88% at rest
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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The patient is a retired post office worker and currently volunteers at [**Hospital1 392**] District Court in the probation department. Family History: - Mother (former smoker) died of lung cancer at 75, previous MI in her 60s - Father (former smoker) died of MI in his 60s, history of asthma since childhood - Maternal uncle with [**Name2 (NI) 499**] cancer age of diagnosis unknown Physical Exam: Admission Physical Exam Vitals: T: 97.5, BP: 86/50, P: 118, R: 16, O2: 86% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple Lungs: poor air movement, but clear to auscultation bilaterally, no wheezing, diminished breath sounds at the bases bilaterally CV: tachycardic, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: warm, well perfused; no cyanosis or edema Neuro: A+Ox3, CN II-XII intact, motor strength and sensory grossly equal and intact bilaterally. Physical Exam at Discharge VS: T 98.5 BP 120/50 (110-128/50-56) HR 88 (88-107) ....RR 24 (22-26), SpO2 94% on 4L NC(89-90% on 3L, 92-97% on 4L) Gen: NAD. Alert and oriented x3. Mood and affect appropriate. Pleasant and cooperative. Resting in bed.
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Evidence: poor air movement
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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The patient is a retired post office worker and currently volunteers at [**Hospital1 392**] District Court in the probation department. Family History: - Mother (former smoker) died of lung cancer at 75, previous MI in her 60s - Father (former smoker) died of MI in his 60s, history of asthma since childhood - Maternal uncle with [**Name2 (NI) 499**] cancer age of diagnosis unknown Physical Exam: Admission Physical Exam Vitals: T: 97.5, BP: 86/50, P: 118, R: 16, O2: 86% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple Lungs: poor air movement, but clear to auscultation bilaterally, no wheezing, diminished breath sounds at the bases bilaterally CV: tachycardic, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: warm, well perfused; no cyanosis or edema Neuro: A+Ox3, CN II-XII intact, motor strength and sensory grossly equal and intact bilaterally. Physical Exam at Discharge VS: T 98.5 BP 120/50 (110-128/50-56) HR 88 (88-107) ....RR 24 (22-26), SpO2 94% on 4L NC(89-90% on 3L, 92-97% on 4L) Gen: NAD. Alert and oriented x3. Mood and affect appropriate. Pleasant and cooperative.
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Evidence: diminished breath sounds at the bases bilaterally
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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No murmur, rubs, or gallops. Lungs: Breathing with pursed lips, with intermittent coughing, but able to complete full sentences. No accessory muscle use. CTAB. No wheezes or rhonchi. Abd: BS present.
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Evidence: Breathing with pursed lips, with intermittent coughing
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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No HSM detected. Ext: WWP, clubbing present. No edema. Distal pulses radial 2+, DP 2+, PT 2+. Pertinent Results: LABS ON ADMISSION: [**2198-1-13**] 03:15PM BLOOD WBC-22.0*# RBC-4.36 Hgb-13.4 Hct-40.1 MCV-92 MCH-30.7 MCHC-33.3 RDW-13.6 Plt Ct-476* [**2198-1-13**] 03:15PM BLOOD Glucose-112* UreaN-6 Creat-0.4 Na-131* K-4.0 Cl-87* HCO3-35* AnGap-13 . MICRO: [**2198-1-13**] 04:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG . Urine culture ([**2198-1-14**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. . Blood cultures ([**2198-1-13**]): NO GROWTH TO DATE.
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Evidence: clubbing present
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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She then became tachypneic to the 30s but was able to speak in full sentences. Her CXR showed hyperinflated lungs and a multifocal PNA. She received continuous albuterol nebs, 125mg IV Solumedrol, PR Tylenol, 750mg IV Levofloxacin, and Azithromycin 500mg IV. An EKG showed no ischemic changes. A UA was negative and an ABG was done which showed pH=7.36/pCO2=61/pO2=64. Upon transfer her vitals were HR=120, BP=109/44, RR=29, POx=93% on 8L FM. . On the floor, the patient appeared comfortable and was able to speak in full sentences despite being tachypneic. .
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Evidence: CXR showed
hyperinflated lungs and a multifocal PNA
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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. CXR ([**2198-1-13**]): Multifocal pneumonia superimposed on COPD and mild interstitial edema. . Ankle XRay ([**2198-1-15**]): Mild degenerative change at the right talonavicular articulation. No fracture or dislocation. Brief Hospital Course: This is a 72 year old female with PMH of moderate COPD with an FEV1 of 57% in [**3-17**] not on any home inhalers or O2, hypercholesterolemia, stable brain aneurysm, breast cancer (T2N0, ER positive) s/p right breast lumpectomy in [**2181**] without any recurrence, and s/p cecectomy in [**6-22**] for cecal volvulus who presented with fever, productive cough, and worsening shortness of breath for two weeks with findings most consistent with a COPD exacerbation in the setting of an acute PNA. During her admission she also sustained an ankle injury, which on Xray did not demonstrate any fractures or dislocation. .
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Evidence: Multifocal pneumonia superimposed on COPD
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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No fracture or dislocation. Brief Hospital Course: This is a 72 year old female with PMH of moderate COPD with an FEV1 of 57% in [**3-17**] not on any home inhalers or O2, hypercholesterolemia, stable brain aneurysm, breast cancer (T2N0, ER positive) s/p right breast lumpectomy in [**2181**] without any recurrence, and s/p cecectomy in [**6-22**] for cecal volvulus who presented with fever, productive cough, and worsening shortness of breath for two weeks with findings most consistent with a COPD exacerbation in the setting of an acute PNA. During her admission she also sustained an ankle injury, which on Xray did not demonstrate any fractures or dislocation. . #. COPD EXACERBATION: Pt with known history of COPD on no medications, last seen by Dr. [**Last Name (STitle) 575**] 5 years ago.
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Evidence: COPD exacerbation
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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#. COPD EXACERBATION: Pt with known history of COPD on no medications, last seen by Dr. [**Last Name (STitle) 575**] 5 years ago. Pt presented with dyspnea, hypoxia with worsening productive cough with fevers 1-2 weeks prior to presentation in setting of environmental exacerbations (saw dust in home) c/w community acquired pneumonia. Despite previous prescriptions for nebulizers, she has never taken any COPD medications and she continued to smoke 3 packs of cigarettes per day prior to her admission. For treatment of her exacerbation, she was placed on oxygen 4L NC and started on prednisone 60 mg daily, ipratropium and albuterol nebulizers, mucinex 1200 mg [**Hospital1 **], and dextromethorphran 60 mg [**Hospital1 **]. She was transitioned to tiotropium bromide MDI daily and albuterol inhaler prn SOB and wheezing >24H prior to discharge with bedside teaching; her respiratory status remained stable with O2 requirement at 4L, O2 sats remained at low 90s. Attempt to taper O2 to 3L resulted with O2 sats to 88% at rest. Her prednisone was decreased to 40 mg at time of discharge. She was also started on calcium 1200 mg and vitamin D 800 units for osteoporosis prevention. She was discharged with home health services (O2 therapy, cardiopulmonary assessment, skilled nursing) and encouraged to follow up with outpatient pulmonary rehabilation. Patient was discharged with close PCP [**Last Name (NamePattern4) 702**]. We also scheduled follow up with pulmonary w/outpatient PFTs to evaluate the severity of her COPD. . #. PNA: The patient's history of subjective fever, elevated WBC count to 22 on admission, and cough productive of a thick, yellowish sputum, together with CXR demonstrating multifocal opacifications, were suggestive of an acute community acquire PNA. She was started on a 7-day course of levofloxacin 750 mg daily, with an end date of [**2198-1-19**]. WBC started to trend down despite prednisone and she remained afebrile for >48H prior to discharge.
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Evidence: COPD EXACERBATION: Pt with known history of COPD on no
medications, last seen by Dr. [**Last Name (STitle) 575**] 5 years ago. Pt
presented with dyspnea, hypoxia with worsening productive cough
with fevers 1-2 weeks prior to presentation in setting of
environmental exacerbations (saw dust in home) c/w community
acquired pneumonia. Despite previous prescriptions for
nebulizers, she has never taken any COPD medications and she
continued to smoke 3 packs of cigarettes per day prior to her
admission. For treatment of her exacerbation, she was placed on
oxygen 4L NC and started on prednisone 60 mg daily, ipratropium
and albuterol nebulizers, mucinex 1200 mg [**Hospital1 **], and
dextromethorphran 60 mg [**Hospital1 **]. She was transitioned to tiotropium
bromide MDI daily and albuterol inhaler prn SOB and wheezing
>24H prior to discharge with bedside teaching; her respiratory
status remained stable with O2 requirement at 4L, O2 sats
remained at low 90s. Attempt to taper O2 to 3L resulted with O2
sats to 88% at rest. Her prednisone was decreased to 40 mg at
time of discharge. She was also started on calcium 1200 mg and
vitamin D 800 units for osteoporosis prevention. She was
discharged with home health services (O2 therapy,
cardiopulmonary assessment, skilled nursing) and encouraged to
follow up with outpatient pulmonary rehabilation. Patient was
discharged with close PCP [**Last Name (NamePattern4) 702**]. We also scheduled follow up
with pulmonary w/outpatient PFTs to evaluate the severity of her
COPD.
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
No fracture or dislocation. Brief Hospital Course: This is a 72 year old female with PMH of moderate COPD with an FEV1 of 57% in [**3-17**] not on any home inhalers or O2, hypercholesterolemia, stable brain aneurysm, breast cancer (T2N0, ER positive) s/p right breast lumpectomy in [**2181**] without any recurrence, and s/p cecectomy in [**6-22**] for cecal volvulus who presented with fever, productive cough, and worsening shortness of breath for two weeks with findings most consistent with a COPD exacerbation in the setting of an acute PNA. During her admission she also sustained an ankle injury, which on Xray did not demonstrate any fractures or dislocation. . #. COPD EXACERBATION: Pt with known history of COPD on no medications, last seen by Dr. [**Last Name (STitle) 575**] 5 years ago. Pt presented with dyspnea, hypoxia with worsening productive cough with fevers 1-2 weeks prior to presentation in setting of environmental exacerbations (saw dust in home) c/w community acquired pneumonia. Despite previous prescriptions for nebulizers, she has never taken any COPD medications and she continued to smoke 3 packs of cigarettes per day prior to her admission.
|
Evidence: COPD exacerbation
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
2. PREDNISONE for your COPD - Prednisone two 20 mg tablets daily until you see your primary care doctor on [**2198-1-22**]. - You are being given a two week supply of this, but your primary care doctor may decrease it when he sees you on the 10th 3. TIOTROPIUM BROMIDE for COPD - Tiotropium bromide metered dose inhaler 1 capsule inhaled, daily 4. ALBUTEROL INHALER for any shortness of breath or wheezing - Albuterol inhaler 1-2 puffs as needed for wheezing or shortness of breath 5. OXYGEN for your breathing - Set the oxygen tank to 4 liters and use oxygen therapy at all times throughout the day and night to help with your breathing. 6. CALCIUM and VITAMIN D for osteoporosis prevention - You should take 500mg of calcium twice a day and 1000u vitamin D once a day Please continue all other medications as prescribed, which include 1. ATORVASTATIN 20 mg tablet daily 2. MULTIVITAMIN daily As we talked about, it is EXTREMELY important to stop smoking.
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Evidence: PREDNISONE for your COPD
- Prednisone two 20 mg tablets daily until you see your primary
care doctor on [**2198-1-22**].
- You are being given a two week supply of this, but your
primary care doctor may decrease it when he sees you on the 10th
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
- You are being given a two week supply of this, but your primary care doctor may decrease it when he sees you on the 10th 3. TIOTROPIUM BROMIDE for COPD - Tiotropium bromide metered dose inhaler 1 capsule inhaled, daily 4. ALBUTEROL INHALER for any shortness of breath or wheezing - Albuterol inhaler 1-2 puffs as needed for wheezing or shortness of breath 5. OXYGEN for your breathing - Set the oxygen tank to 4 liters and use oxygen therapy at all times throughout the day and night to help with your breathing. 6. CALCIUM and VITAMIN D for osteoporosis prevention - You should take 500mg of calcium twice a day and 1000u vitamin D once a day Please continue all other medications as prescribed, which include 1. ATORVASTATIN 20 mg tablet daily 2. MULTIVITAMIN daily As we talked about, it is EXTREMELY important to stop smoking. This is often very hard to do at home and you should talk to your PCP if you're having trouble.
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Evidence: TIOTROPIUM BROMIDE for COPD
- Tiotropium bromide metered dose inhaler 1 capsule inhaled,
daily
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
TIOTROPIUM BROMIDE for COPD - Tiotropium bromide metered dose inhaler 1 capsule inhaled, daily 4. ALBUTEROL INHALER for any shortness of breath or wheezing - Albuterol inhaler 1-2 puffs as needed for wheezing or shortness of breath 5. OXYGEN for your breathing - Set the oxygen tank to 4 liters and use oxygen therapy at all times throughout the day and night to help with your breathing. 6. CALCIUM and VITAMIN D for osteoporosis prevention - You should take 500mg of calcium twice a day and 1000u vitamin D once a day Please continue all other medications as prescribed, which include 1. ATORVASTATIN 20 mg tablet daily 2. MULTIVITAMIN daily As we talked about, it is EXTREMELY important to stop smoking. This is often very hard to do at home and you should talk to your PCP if you're having trouble.
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Evidence: ALBUTEROL INHALER for any shortness of breath or wheezing
- Albuterol inhaler 1-2 puffs as needed for wheezing or
shortness of breath
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
ALBUTEROL INHALER for any shortness of breath or wheezing - Albuterol inhaler 1-2 puffs as needed for wheezing or shortness of breath 5. OXYGEN for your breathing - Set the oxygen tank to 4 liters and use oxygen therapy at all times throughout the day and night to help with your breathing. 6. CALCIUM and VITAMIN D for osteoporosis prevention - You should take 500mg of calcium twice a day and 1000u vitamin D once a day Please continue all other medications as prescribed, which include 1. ATORVASTATIN 20 mg tablet daily 2.
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Evidence: OXYGEN for your breathing
- Set the oxygen tank to 4 liters and use oxygen therapy at all
times throughout the day and night to help with your breathing.
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
After they see you several times, you will be discharged from their services. After that you can call one of the pulmonary rehabilitation programs on the list you were given. It was a pleasure meeting you and participating in your care. Followup Instructions: Name: [**Last Name (LF) 9328**],[**First Name3 (LF) **] [**Doctor First Name 9329**] Address: [**Street Address(2) 9330**], [**Hospital1 **],[**Numeric Identifier 9331**] Phone: [**Telephone/Fax (1) 9332**] When: [**Last Name (LF) 766**], [**1-22**], 9:30AM Department: PULMONARY FUNCTION LAB When: TUESDAY [**2198-1-30**] at 8:10 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES/ Pulmonary When: TUESDAY [**2198-1-30**] at 8:30 AM With: DR. [**First Name (STitle) **] & DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
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Evidence: After that you can call
one of the pulmonary rehabilitation programs on the list you
were given.
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Patient was discharged with close PCP [**Last Name (NamePattern4) 702**]. We also scheduled follow up with pulmonary w/outpatient PFTs to evaluate the severity of her COPD. . #. PNA: The patient's history of subjective fever, elevated WBC count to 22 on admission, and cough productive of a thick, yellowish sputum, together with CXR demonstrating multifocal opacifications, were suggestive of an acute community acquire PNA. She was started on a 7-day course of levofloxacin 750 mg daily, with an end date of [**2198-1-19**]. WBC started to trend down despite prednisone and she remained afebrile for >48H prior to discharge. Her urine legionella antigen was negative and blood cultures demonstrated no growth to date at time of discharge. .
|
Evidence: We also scheduled follow up
with pulmonary w/outpatient PFTs to evaluate the severity of her
COPD.
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Despite previous prescriptions for nebulizers, she has never taken any COPD medications and she continued to smoke 3 packs of cigarettes per day prior to her admission. For treatment of her exacerbation, she was placed on oxygen 4L NC and started on prednisone 60 mg daily, ipratropium and albuterol nebulizers, mucinex 1200 mg [**Hospital1 **], and dextromethorphran 60 mg [**Hospital1 **]. She was transitioned to tiotropium bromide MDI daily and albuterol inhaler prn SOB and wheezing >24H prior to discharge with bedside teaching; her respiratory status remained stable with O2 requirement at 4L, O2 sats remained at low 90s. Attempt to taper O2 to 3L resulted with O2 sats to 88% at rest. Her prednisone was decreased to 40 mg at time of discharge.
|
Evidence: placed on
oxygen 4L NC
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Despite previous prescriptions for nebulizers, she has never taken any COPD medications and she continued to smoke 3 packs of cigarettes per day prior to her admission. For treatment of her exacerbation, she was placed on oxygen 4L NC and started on prednisone 60 mg daily, ipratropium and albuterol nebulizers, mucinex 1200 mg [**Hospital1 **], and dextromethorphran 60 mg [**Hospital1 **]. She was transitioned to tiotropium bromide MDI daily and albuterol inhaler prn SOB and wheezing >24H prior to discharge with bedside teaching; her respiratory status remained stable with O2 requirement at 4L, O2 sats remained at low 90s. Attempt to taper O2 to 3L resulted with O2 sats to 88% at rest. Her prednisone was decreased to 40 mg at time of discharge. She was also started on calcium 1200 mg and vitamin D 800 units for osteoporosis prevention. She was discharged with home health services (O2 therapy, cardiopulmonary assessment, skilled nursing) and encouraged to follow up with outpatient pulmonary rehabilation. Patient was discharged with close PCP [**Last Name (NamePattern4) 702**].
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Evidence: started on prednisone 60 mg daily, ipratropium
and albuterol nebulizers, mucinex 1200 mg [**Hospital1 **], and
dextromethorphran 60 mg [**Hospital1 **]
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
For treatment of her exacerbation, she was placed on oxygen 4L NC and started on prednisone 60 mg daily, ipratropium and albuterol nebulizers, mucinex 1200 mg [**Hospital1 **], and dextromethorphran 60 mg [**Hospital1 **]. She was transitioned to tiotropium bromide MDI daily and albuterol inhaler prn SOB and wheezing >24H prior to discharge with bedside teaching; her respiratory status remained stable with O2 requirement at 4L, O2 sats remained at low 90s. Attempt to taper O2 to 3L resulted with O2 sats to 88% at rest. Her prednisone was decreased to 40 mg at time of discharge. She was also started on calcium 1200 mg and vitamin D 800 units for osteoporosis prevention. She was discharged with home health services (O2 therapy, cardiopulmonary assessment, skilled nursing) and encouraged to follow up with outpatient pulmonary rehabilation. Patient was discharged with close PCP [**Last Name (NamePattern4) 702**]. We also scheduled follow up with pulmonary w/outpatient PFTs to evaluate the severity of her COPD. .
|
Evidence: transitioned to tiotropium
bromide MDI daily and albuterol inhaler prn SOB and wheezing
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
[**Telephone/Fax (1) **]:*30 Tablet(s)* Refills:*2* 5. Home oxygen therapy 4L nasal cannula continuous. Diagnosis: COPD 6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). [**Telephone/Fax (1) **]:*QS 1 month Capsule* Refills:*2* 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath, wheezing. [**Telephone/Fax (1) **]:*QS 1 month Inhaler* Refills:*2* 8.
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Evidence: Home oxygen therapy
4L nasal cannula continuous
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Diagnosis: COPD 6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). [**Telephone/Fax (1) **]:*QS 1 month Capsule* Refills:*2* 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath, wheezing. [**Telephone/Fax (1) **]:*QS 1 month Inhaler* Refills:*2* 8. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days: last dose [**2198-1-19**].
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Evidence: tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
[**Telephone/Fax (1) **]:*QS 1 month Capsule* Refills:*2* 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath, wheezing. [**Telephone/Fax (1) **]:*QS 1 month Inhaler* Refills:*2* 8. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days: last dose [**2198-1-19**]. [**Year (4 digits) **]:*2 Tablet(s)* Refills:*0* 9. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 2 weeks: This drug will be adjusted as seen fit by your primary care doctor.
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Evidence: albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath, wheezing.
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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[**Year (4 digits) **]:*2 Tablet(s)* Refills:*0* 9. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 2 weeks: This drug will be adjusted as seen fit by your primary care doctor. [**Last Name (Titles) **]:*28 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary Diagnosis: 1. COPD exacerbation 2. Community acquired pneumonia Secondary Diagnosis: Tobacco abuse Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms.
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Evidence: prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 2 weeks
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2198-1-13**] Discharge Date: [**2198-1-17**] Date of Birth: [**2125-5-6**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 905**] Chief Complaint: fever Major Surgical or Invasive Procedure: None History of Present Illness: This is a 72 year old female with PMH of moderate COPD with an FEV1 of 57% in [**3-17**] not on any home inhalers or O2, hypercholesterolemia, stable brain aneurysm, breast cancer (T2N0, ER positive) s/p right breast lumpectomy in [**2181**] without any recurrence, and s/p cecectomy in [**6-22**] for cecal volvulus presenting with fever, productive cough, and worsening shortness of breath for 10 days. The patient has not measured her temperature at home, but reports feeling warm, sweaty, and having chills. The patient also reports that her cough has changed from being productive of thin, clear sputum to being productive of pale yellow, thick sputum over the last 10 days. She also reports having difficulty sleeping as of late because she has not been able to lay flat. She has been sleeping sitting up on her couch.
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Evidence: moderate COPD
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Denies rashes or skin changes. Past Medical History: - COPD (emphysema and chronic bronchitis, not on home O2) - Breast cancer (T2N0, ER positive in remission) - Brain aneurysm - Hypercholesterolemia . Past Surgical History: - s/p Right breast lumpectomy in [**2181**] - s/p Cecectomy for cecal volvulus in [**6-22**] Social History: Patient reports smoking 3 packs per day for 55 years. She acknowledges that she knows she needs to quit, but currently does not feel ready to do so. She drinks EtOH socially. The patient is a retired post office worker and currently volunteers at [**Hospital1 392**] District Court in the probation department. Family History: - Mother (former smoker) died of lung cancer at 75, previous MI in her 60s - Father (former smoker) died of MI in his 60s, history of asthma since childhood - Maternal uncle with [**Name2 (NI) 499**] cancer age of diagnosis unknown Physical Exam: Admission Physical Exam Vitals: T: 97.5, BP: 86/50, P: 118, R: 16, O2: 86% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple Lungs: poor air movement, but clear to auscultation bilaterally, no wheezing, diminished breath sounds at the bases bilaterally CV: tachycardic, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: warm, well perfused; no cyanosis or edema Neuro: A+Ox3, CN II-XII intact, motor strength and sensory grossly equal and intact bilaterally. Physical Exam at Discharge VS: T 98.5 BP 120/50 (110-128/50-56) HR 88 (88-107) ....RR 24 (22-26), SpO2 94% on 4L NC(89-90% on 3L, 92-97% on 4L) Gen: NAD.
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Evidence: COPD (emphysema and chronic bronchitis
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2198-1-13**] Discharge Date: [**2198-1-17**] Date of Birth: [**2125-5-6**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 905**] Chief Complaint: fever Major Surgical or Invasive Procedure: None History of Present Illness: This is a 72 year old female with PMH of moderate COPD with an FEV1 of 57% in [**3-17**] not on any home inhalers or O2, hypercholesterolemia, stable brain aneurysm, breast cancer (T2N0, ER positive) s/p right breast lumpectomy in [**2181**] without any recurrence, and s/p cecectomy in [**6-22**] for cecal volvulus presenting with fever, productive cough, and worsening shortness of breath for 10 days. The patient has not measured her temperature at home, but reports feeling warm, sweaty, and having chills. The patient also reports that her cough has changed from being productive of thin, clear sputum to being productive of pale yellow, thick sputum over the last 10 days. She also reports having difficulty sleeping as of late because she has not been able to lay flat. She has been sleeping sitting up on her couch.
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Evidence: COPD
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2198-1-13**] Discharge Date: [**2198-1-17**] Date of Birth: [**2125-5-6**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 905**] Chief Complaint: fever Major Surgical or Invasive Procedure: None History of Present Illness: This is a 72 year old female with PMH of moderate COPD with an FEV1 of 57% in [**3-17**] not on any home inhalers or O2, hypercholesterolemia, stable brain aneurysm, breast cancer (T2N0, ER positive) s/p right breast lumpectomy in [**2181**] without any recurrence, and s/p cecectomy in [**6-22**] for cecal volvulus presenting with fever, productive cough, and worsening shortness of breath for 10 days. The patient has not measured her temperature at home, but reports feeling warm, sweaty, and having chills. The patient also reports that her cough has changed from being productive of thin, clear sputum to being productive of pale yellow, thick sputum over the last 10 days. She also reports having difficulty sleeping as of late because she has not been able to lay flat. She has been sleeping sitting up on her couch. Her shortness of breath has also worsened.
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Evidence: moderate COPD
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2198-1-13**] Discharge Date: [**2198-1-17**] Date of Birth: [**2125-5-6**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 905**] Chief Complaint: fever Major Surgical or Invasive Procedure: None History of Present Illness: This is a 72 year old female with PMH of moderate COPD with an FEV1 of 57% in [**3-17**] not on any home inhalers or O2, hypercholesterolemia, stable brain aneurysm, breast cancer (T2N0, ER positive) s/p right breast lumpectomy in [**2181**] without any recurrence, and s/p cecectomy in [**6-22**] for cecal volvulus presenting with fever, productive cough, and worsening shortness of breath for 10 days. The patient has not measured her temperature at home, but reports feeling warm, sweaty, and having chills. The patient also reports that her cough has changed from being productive of thin, clear sputum to being productive of pale yellow, thick sputum over the last 10 days. She also reports having difficulty sleeping as of late because she has not been able to lay flat. She has been sleeping sitting up on her couch.
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Evidence: COPD
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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No fracture or dislocation. Brief Hospital Course: This is a 72 year old female with PMH of moderate COPD with an FEV1 of 57% in [**3-17**] not on any home inhalers or O2, hypercholesterolemia, stable brain aneurysm, breast cancer (T2N0, ER positive) s/p right breast lumpectomy in [**2181**] without any recurrence, and s/p cecectomy in [**6-22**] for cecal volvulus who presented with fever, productive cough, and worsening shortness of breath for two weeks with findings most consistent with a COPD exacerbation in the setting of an acute PNA. During her admission she also sustained an ankle injury, which on Xray did not demonstrate any fractures or dislocation. . #.
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Evidence: COPD exacerbation
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2198-1-13**] Discharge Date: [**2198-1-17**] Date of Birth: [**2125-5-6**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 905**] Chief Complaint: fever Major Surgical or Invasive Procedure: None History of Present Illness: This is a 72 year old female with PMH of moderate COPD with an FEV1 of 57% in [**3-17**] not on any home inhalers or O2, hypercholesterolemia, stable brain aneurysm, breast cancer (T2N0, ER positive) s/p right breast lumpectomy in [**2181**] without any recurrence, and s/p cecectomy in [**6-22**] for cecal volvulus presenting with fever, productive cough, and worsening shortness of breath for 10 days. The patient has not measured her temperature at home, but reports feeling warm, sweaty, and having chills. The patient also reports that her cough has changed from being productive of thin, clear sputum to being productive of pale yellow, thick sputum over the last 10 days. She also reports having difficulty sleeping as of late because she has not been able to lay flat. She has been sleeping sitting up on her couch. Her shortness of breath has also worsened. At baseline, prior to [**Month (only) 359**], she says that she was able to climb 2 flights of stairs without stopping to rest.
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Evidence: COPD
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2198-1-13**] Discharge Date: [**2198-1-17**] Date of Birth: [**2125-5-6**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 905**] Chief Complaint: fever Major Surgical or Invasive Procedure: None History of Present Illness: This is a 72 year old female with PMH of moderate COPD with an FEV1 of 57% in [**3-17**] not on any home inhalers or O2, hypercholesterolemia, stable brain aneurysm, breast cancer (T2N0, ER positive) s/p right breast lumpectomy in [**2181**] without any recurrence, and s/p cecectomy in [**6-22**] for cecal volvulus presenting with fever, productive cough, and worsening shortness of breath for 10 days. The patient has not measured her temperature at home, but reports feeling warm, sweaty, and having chills. The patient also reports that her cough has changed from being productive of thin, clear sputum to being productive of pale yellow, thick sputum over the last 10 days. She also reports having difficulty sleeping as of late because she has not been able to lay flat. She has been sleeping sitting up on her couch. Her shortness of breath has also worsened.
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Evidence: COPD
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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No fracture or dislocation. Brief Hospital Course: This is a 72 year old female with PMH of moderate COPD with an FEV1 of 57% in [**3-17**] not on any home inhalers or O2, hypercholesterolemia, stable brain aneurysm, breast cancer (T2N0, ER positive) s/p right breast lumpectomy in [**2181**] without any recurrence, and s/p cecectomy in [**6-22**] for cecal volvulus who presented with fever, productive cough, and worsening shortness of breath for two weeks with findings most consistent with a COPD exacerbation in the setting of an acute PNA. During her admission she also sustained an ankle injury, which on Xray did not demonstrate any fractures or dislocation. . #. COPD EXACERBATION: Pt with known history of COPD on no medications, last seen by Dr. [**Last Name (STitle) 575**] 5 years ago. Pt presented with dyspnea, hypoxia with worsening productive cough with fevers 1-2 weeks prior to presentation in setting of environmental exacerbations (saw dust in home) c/w community acquired pneumonia. Despite previous prescriptions for nebulizers, she has never taken any COPD medications and she continued to smoke 3 packs of cigarettes per day prior to her admission.
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Evidence: COPD exacerbation
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2198-1-13**] Discharge Date: [**2198-1-17**] Date of Birth: [**2125-5-6**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 905**] Chief Complaint: fever Major Surgical or Invasive Procedure: None History of Present Illness: This is a 72 year old female with PMH of moderate COPD with an FEV1 of 57% in [**3-17**] not on any home inhalers or O2, hypercholesterolemia, stable brain aneurysm, breast cancer (T2N0, ER positive) s/p right breast lumpectomy in [**2181**] without any recurrence, and s/p cecectomy in [**6-22**] for cecal volvulus presenting with fever, productive cough, and worsening shortness of breath for 10 days. The patient has not measured her temperature at home, but reports feeling warm, sweaty, and having chills. The patient also reports that her cough has changed from being productive of thin, clear sputum to being productive of pale yellow, thick sputum over the last 10 days. She also reports having difficulty sleeping as of late because she has not been able to lay flat. She has been sleeping sitting up on her couch. Her shortness of breath has also worsened.
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Evidence: COPD
Condition: Chronic obstructive pulmonary disease with (acute) exacerbation
HCC: J440
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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She was started on a 7-day course of levofloxacin 750 mg daily, with an end date of [**2198-1-19**]. WBC started to trend down despite prednisone and she remained afebrile for >48H prior to discharge. Her urine legionella antigen was negative and blood cultures demonstrated no growth to date at time of discharge. . #.
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Evidence: WBC started to trend down despite prednisone and she remained afebrile for >48H prior to discharge
Condition: Pneumonia, unspecified organism
HCC: J440
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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She then became tachypneic to the 30s but was able to speak in full sentences. Her CXR showed hyperinflated lungs and a multifocal PNA. She received continuous albuterol nebs, 125mg IV Solumedrol, PR Tylenol, 750mg IV Levofloxacin, and Azithromycin 500mg IV. An EKG showed no ischemic changes. A UA was negative and an ABG was done which showed pH=7.36/pCO2=61/pO2=64. Upon transfer her vitals were HR=120, BP=109/44, RR=29, POx=93% on 8L FM. . On the floor, the patient appeared comfortable and was able to speak in full sentences despite being tachypneic.
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Evidence: CXR showed
hyperinflated lungs and a multifocal PNA
Condition: Pneumonia, unspecified organism
HCC: J440
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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. CXR ([**2198-1-13**]): Multifocal pneumonia superimposed on COPD and mild interstitial edema. . Ankle XRay ([**2198-1-15**]): Mild degenerative change at the right talonavicular articulation. No fracture or dislocation.
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Evidence: Multifocal pneumonia superimposed on COPD
Condition: Pneumonia, unspecified organism
HCC: J440
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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#. PNA: The patient's history of subjective fever, elevated WBC count to 22 on admission, and cough productive of a thick, yellowish sputum, together with CXR demonstrating multifocal opacifications, were suggestive of an acute community acquire PNA. She was started on a 7-day course of levofloxacin 750 mg daily, with an end date of [**2198-1-19**]. WBC started to trend down despite prednisone and she remained afebrile for >48H prior to discharge. Her urine legionella antigen was negative and blood cultures demonstrated no growth to date at time of discharge.
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Evidence: elevated WBC count to 22 on admission
Condition: Pneumonia, unspecified organism
HCC: J440
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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WBC started to trend down despite prednisone and she remained afebrile for >48H prior to discharge. Her urine legionella antigen was negative and blood cultures demonstrated no growth to date at time of discharge. . #. TOBACCO ABUSE: Patient extensively counseled on smoking cessation. Social work was consulted and multiple resources presented to patient to successfully quit smoking. . #. RIGHT MEDIAL MALLELOUS PAIN: Injury to bilateral lower extremities during admission from O2 tank.
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Evidence: Urine legionella antigen was negative
Condition: Pneumonia, unspecified organism
HCC: J440
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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WBC started to trend down despite prednisone and she remained afebrile for >48H prior to discharge. Her urine legionella antigen was negative and blood cultures demonstrated no growth to date at time of discharge. . #. TOBACCO ABUSE: Patient extensively counseled on smoking cessation. Social work was consulted and multiple resources presented to patient to successfully quit smoking. .
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Evidence: blood cultures demonstrated no growth to date at time of discharge
Condition: Pneumonia, unspecified organism
HCC: J440
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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#. PNA: The patient's history of subjective fever, elevated WBC count to 22 on admission, and cough productive of a thick, yellowish sputum, together with CXR demonstrating multifocal opacifications, were suggestive of an acute community acquire PNA. She was started on a 7-day course of levofloxacin 750 mg daily, with an end date of [**2198-1-19**]. WBC started to trend down despite prednisone and she remained afebrile for >48H prior to discharge. Her urine legionella antigen was negative and blood cultures demonstrated no growth to date at time of discharge. . #. TOBACCO ABUSE: Patient extensively counseled on smoking cessation.
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Evidence: CXR demonstrating multifocal
opacifications
Condition: Pneumonia, unspecified organism
HCC: J440
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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She then became tachypneic to the 30s but was able to speak in full sentences. Her CXR showed hyperinflated lungs and a multifocal PNA. She received continuous albuterol nebs, 125mg IV Solumedrol, PR Tylenol, 750mg IV Levofloxacin, and Azithromycin 500mg IV. An EKG showed no ischemic changes. A UA was negative and an ABG was done which showed pH=7.36/pCO2=61/pO2=64.
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Evidence: multifocal PNA
Condition: Pneumonia, unspecified organism
HCC: J440
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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. CXR ([**2198-1-13**]): Multifocal pneumonia superimposed on COPD and mild interstitial edema. . Ankle XRay ([**2198-1-15**]): Mild degenerative change at the right talonavicular articulation. No fracture or dislocation. Brief Hospital Course: This is a 72 year old female with PMH of moderate COPD with an FEV1 of 57% in [**3-17**] not on any home inhalers or O2, hypercholesterolemia, stable brain aneurysm, breast cancer (T2N0, ER positive) s/p right breast lumpectomy in [**2181**] without any recurrence, and s/p cecectomy in [**6-22**] for cecal volvulus who presented with fever, productive cough, and worsening shortness of breath for two weeks with findings most consistent with a COPD exacerbation in the setting of an acute PNA.
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Evidence: Multifocal pneumonia
Condition: Pneumonia, unspecified organism
HCC: J440
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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No fracture or dislocation. Brief Hospital Course: This is a 72 year old female with PMH of moderate COPD with an FEV1 of 57% in [**3-17**] not on any home inhalers or O2, hypercholesterolemia, stable brain aneurysm, breast cancer (T2N0, ER positive) s/p right breast lumpectomy in [**2181**] without any recurrence, and s/p cecectomy in [**6-22**] for cecal volvulus who presented with fever, productive cough, and worsening shortness of breath for two weeks with findings most consistent with a COPD exacerbation in the setting of an acute PNA. During her admission she also sustained an ankle injury, which on Xray did not demonstrate any fractures or dislocation. . #. COPD EXACERBATION: Pt with known history of COPD on no medications, last seen by Dr. [**Last Name (STitle) 575**] 5 years ago. Pt presented with dyspnea, hypoxia with worsening productive cough with fevers 1-2 weeks prior to presentation in setting of environmental exacerbations (saw dust in home) c/w community acquired pneumonia.
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Evidence: acute PNA
Condition: Pneumonia, unspecified organism
HCC: J440
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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[**Last Name (STitle) 575**] 5 years ago. Pt presented with dyspnea, hypoxia with worsening productive cough with fevers 1-2 weeks prior to presentation in setting of environmental exacerbations (saw dust in home) c/w community acquired pneumonia. Despite previous prescriptions for nebulizers, she has never taken any COPD medications and she continued to smoke 3 packs of cigarettes per day prior to her admission. For treatment of her exacerbation, she was placed on oxygen 4L NC and started on prednisone 60 mg daily, ipratropium and albuterol nebulizers, mucinex 1200 mg [**Hospital1 **], and dextromethorphran 60 mg [**Hospital1 **]. She was transitioned to tiotropium bromide MDI daily and albuterol inhaler prn SOB and wheezing >24H prior to discharge with bedside teaching; her respiratory status remained stable with O2 requirement at 4L, O2 sats remained at low 90s.
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Evidence: community
acquired pneumonia
Condition: Pneumonia, unspecified organism
HCC: J440
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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#. PNA: The patient's history of subjective fever, elevated WBC count to 22 on admission, and cough productive of a thick, yellowish sputum, together with CXR demonstrating multifocal opacifications, were suggestive of an acute community acquire PNA. She was started on a 7-day course of levofloxacin 750 mg daily, with an end date of [**2198-1-19**]. WBC started to trend down despite prednisone and she remained afebrile for >48H prior to discharge. Her urine legionella antigen was negative and blood cultures demonstrated no growth to date at time of discharge. . #. TOBACCO ABUSE: Patient extensively counseled on smoking cessation. Social work was consulted and multiple resources presented to patient to successfully quit smoking. .
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Evidence: PNA: The patient's history of subjective fever, elevated WBC
count to 22 on admission, and cough productive of a thick,
yellowish sputum, together with CXR demonstrating multifocal
opacifications, were suggestive of an acute community acquire
PNA. She was started on a 7-day course of levofloxacin 750 mg
daily, with an end date of [**2198-1-19**]. WBC started to trend down
despite prednisone and she remained afebrile for >48H prior to
discharge. Her urine legionella antigen was negative and blood
cultures demonstrated no growth to date at time of discharge.
Condition: Pneumonia, unspecified organism
HCC: J440
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
|
#. PNA: The patient's history of subjective fever, elevated WBC count to 22 on admission, and cough productive of a thick, yellowish sputum, together with CXR demonstrating multifocal opacifications, were suggestive of an acute community acquire PNA. She was started on a 7-day course of levofloxacin 750 mg daily, with an end date of [**2198-1-19**]. WBC started to trend down despite prednisone and she remained afebrile for >48H prior to discharge. Her urine legionella antigen was negative and blood cultures demonstrated no growth to date at time of discharge.
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Evidence: acute community acquire
PNA
Condition: Pneumonia, unspecified organism
HCC: J440
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
|
[**Last Name (STitle) 575**] 5 years ago. Pt presented with dyspnea, hypoxia with worsening productive cough with fevers 1-2 weeks prior to presentation in setting of environmental exacerbations (saw dust in home) c/w community acquired pneumonia. Despite previous prescriptions for nebulizers, she has never taken any COPD medications and she continued to smoke 3 packs of cigarettes per day prior to her admission. For treatment of her exacerbation, she was placed on oxygen 4L NC and started on prednisone 60 mg daily, ipratropium and albuterol nebulizers, mucinex 1200 mg [**Hospital1 **], and dextromethorphran 60 mg [**Hospital1 **]. She was transitioned to tiotropium bromide MDI daily and albuterol inhaler prn SOB and wheezing >24H prior to discharge with bedside teaching; her respiratory status remained stable with O2 requirement at 4L, O2 sats remained at low 90s. Attempt to taper O2 to 3L resulted with O2 sats to 88% at rest. Her prednisone was decreased to 40 mg at time of discharge. She was also started on calcium 1200 mg and vitamin D 800 units for osteoporosis prevention. She was discharged with home health services (O2 therapy, cardiopulmonary assessment, skilled nursing) and encouraged to follow up with outpatient pulmonary rehabilation.
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Evidence: Community acquired pneumonia
Condition: Pneumonia, unspecified organism
HCC: J440
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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You were admitted because you had difficulty breathing. It was noted that you have a lung infection. This likely worsened your COPD. You also had an ankle injury during your admission; X-rays of your ankles showed that you did not have any fractures or serious injury. Your pain was controlled with Advil. The following medication changes have been made: ADDED: 1. LEVOFLOXACIN for your lung infection - 1 tablet of levofloxacin (750 mg) daily, your last dose will be on Friday, [**2198-1-19**]. 2.
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Evidence: lung infection
Condition: Pneumonia, unspecified organism
HCC: J440
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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The following medication changes have been made: ADDED: 1. LEVOFLOXACIN for your lung infection - 1 tablet of levofloxacin (750 mg) daily, your last dose will be on Friday, [**2198-1-19**]. 2. PREDNISONE for your COPD - Prednisone two 20 mg tablets daily until you see your primary care doctor on [**2198-1-22**]. - You are being given a two week supply of this, but your primary care doctor may decrease it when he sees you on the 10th 3.
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Evidence: LEVOFLOXACIN for your lung infection
- 1 tablet of levofloxacin (750 mg) daily, your last dose will
be on Friday, [**2198-1-19**].
Condition: Pneumonia, unspecified organism
HCC: J440
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Her CXR showed hyperinflated lungs and a multifocal PNA. She received continuous albuterol nebs, 125mg IV Solumedrol, PR Tylenol, 750mg IV Levofloxacin, and Azithromycin 500mg IV. An EKG showed no ischemic changes. A UA was negative and an ABG was done which showed pH=7.36/pCO2=61/pO2=64. Upon transfer her vitals were HR=120, BP=109/44, RR=29, POx=93% on 8L FM. . On the floor, the patient appeared comfortable and was able to speak in full sentences despite being tachypneic. .
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Evidence: 750mg IV Levofloxacin, and Azithromycin 500mg IV
Condition: Pneumonia, unspecified organism
HCC: J440
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
|
PNA: The patient's history of subjective fever, elevated WBC count to 22 on admission, and cough productive of a thick, yellowish sputum, together with CXR demonstrating multifocal opacifications, were suggestive of an acute community acquire PNA. She was started on a 7-day course of levofloxacin 750 mg daily, with an end date of [**2198-1-19**]. WBC started to trend down despite prednisone and she remained afebrile for >48H prior to discharge. Her urine legionella antigen was negative and blood cultures demonstrated no growth to date at time of discharge. . #. TOBACCO ABUSE: Patient extensively counseled on smoking cessation. Social work was consulted and multiple resources presented to patient to successfully quit smoking.
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Evidence: started on a 7-day course of levofloxacin 750 mg
daily
Condition: Pneumonia, unspecified organism
HCC: J440
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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[**Telephone/Fax (1) **]:*QS 1 month Inhaler* Refills:*2* 8. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days: last dose [**2198-1-19**]. [**Year (4 digits) **]:*2 Tablet(s)* Refills:*0* 9. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 2 weeks: This drug will be adjusted as seen fit by your primary care doctor. [**Last Name (Titles) **]:*28 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary Diagnosis: 1. COPD exacerbation 2.
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Evidence: levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 days: last dose [**2198-1-19**].
Condition: Pneumonia, unspecified organism
HCC: J440
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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She then became tachypneic to the 30s but was able to speak in full sentences. Her CXR showed hyperinflated lungs and a multifocal PNA. She received continuous albuterol nebs, 125mg IV Solumedrol, PR Tylenol, 750mg IV Levofloxacin, and Azithromycin 500mg IV. An EKG showed no ischemic changes. A UA was negative and an ABG was done which showed pH=7.36/pCO2=61/pO2=64. Upon transfer her vitals were HR=120, BP=109/44, RR=29, POx=93% on 8L FM. .
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Evidence: multifocal PNA
Condition: Pneumonia, unspecified organism
HCC: J440
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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. CXR ([**2198-1-13**]): Multifocal pneumonia superimposed on COPD and mild interstitial edema. . Ankle XRay ([**2198-1-15**]): Mild degenerative change at the right talonavicular articulation. No fracture or dislocation. Brief Hospital Course: This is a 72 year old female with PMH of moderate COPD with an FEV1 of 57% in [**3-17**] not on any home inhalers or O2, hypercholesterolemia, stable brain aneurysm, breast cancer (T2N0, ER positive) s/p right breast lumpectomy in [**2181**] without any recurrence, and s/p cecectomy in [**6-22**] for cecal volvulus who presented with fever, productive cough, and worsening shortness of breath for two weeks with findings most consistent with a COPD exacerbation in the setting of an acute PNA. During her admission she also sustained an ankle injury, which on Xray did not demonstrate any fractures or dislocation.
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Evidence: Multifocal pneumonia
Condition: Pneumonia, unspecified organism
HCC: J440
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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No fracture or dislocation. Brief Hospital Course: This is a 72 year old female with PMH of moderate COPD with an FEV1 of 57% in [**3-17**] not on any home inhalers or O2, hypercholesterolemia, stable brain aneurysm, breast cancer (T2N0, ER positive) s/p right breast lumpectomy in [**2181**] without any recurrence, and s/p cecectomy in [**6-22**] for cecal volvulus who presented with fever, productive cough, and worsening shortness of breath for two weeks with findings most consistent with a COPD exacerbation in the setting of an acute PNA. During her admission she also sustained an ankle injury, which on Xray did not demonstrate any fractures or dislocation. . #. COPD EXACERBATION: Pt with known history of COPD on no medications, last seen by Dr. [**Last Name (STitle) 575**] 5 years ago. Pt presented with dyspnea, hypoxia with worsening productive cough with fevers 1-2 weeks prior to presentation in setting of environmental exacerbations (saw dust in home) c/w community acquired pneumonia.
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Evidence: acute PNA
Condition: Pneumonia, unspecified organism
HCC: J440
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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[**Last Name (STitle) 575**] 5 years ago. Pt presented with dyspnea, hypoxia with worsening productive cough with fevers 1-2 weeks prior to presentation in setting of environmental exacerbations (saw dust in home) c/w community acquired pneumonia. Despite previous prescriptions for nebulizers, she has never taken any COPD medications and she continued to smoke 3 packs of cigarettes per day prior to her admission. For treatment of her exacerbation, she was placed on oxygen 4L NC and started on prednisone 60 mg daily, ipratropium and albuterol nebulizers, mucinex 1200 mg [**Hospital1 **], and dextromethorphran 60 mg [**Hospital1 **]. She was transitioned to tiotropium bromide MDI daily and albuterol inhaler prn SOB and wheezing >24H prior to discharge with bedside teaching; her respiratory status remained stable with O2 requirement at 4L, O2 sats remained at low 90s. Attempt to taper O2 to 3L resulted with O2 sats to 88% at rest.
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Evidence: community
acquired pneumonia
Condition: Pneumonia, unspecified organism
HCC: J440
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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She then became tachypneic to the 30s but was able to speak in full sentences. Her CXR showed hyperinflated lungs and a multifocal PNA. She received continuous albuterol nebs, 125mg IV Solumedrol, PR Tylenol, 750mg IV Levofloxacin, and Azithromycin 500mg IV. An EKG showed no ischemic changes. A UA was negative and an ABG was done which showed pH=7.36/pCO2=61/pO2=64. Upon transfer her vitals were HR=120, BP=109/44, RR=29, POx=93% on 8L FM. . On the floor, the patient appeared comfortable and was able to speak in full sentences despite being tachypneic.
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Evidence: PNA
Condition: Pneumonia, unspecified organism
HCC: J440
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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#. PNA: The patient's history of subjective fever, elevated WBC count to 22 on admission, and cough productive of a thick, yellowish sputum, together with CXR demonstrating multifocal opacifications, were suggestive of an acute community acquire PNA. She was started on a 7-day course of levofloxacin 750 mg daily, with an end date of [**2198-1-19**]. WBC started to trend down despite prednisone and she remained afebrile for >48H prior to discharge. Her urine legionella antigen was negative and blood cultures demonstrated no growth to date at time of discharge. . #. TOBACCO ABUSE: Patient extensively counseled on smoking cessation. Social work was consulted and multiple resources presented to patient to successfully quit smoking.
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Evidence: acute community acquire
PNA
Condition: Pneumonia, unspecified organism
HCC: J440
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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[**Last Name (STitle) 575**] 5 years ago. Pt presented with dyspnea, hypoxia with worsening productive cough with fevers 1-2 weeks prior to presentation in setting of environmental exacerbations (saw dust in home) c/w community acquired pneumonia. Despite previous prescriptions for nebulizers, she has never taken any COPD medications and she continued to smoke 3 packs of cigarettes per day prior to her admission. For treatment of her exacerbation, she was placed on oxygen 4L NC and started on prednisone 60 mg daily, ipratropium and albuterol nebulizers, mucinex 1200 mg [**Hospital1 **], and dextromethorphran 60 mg [**Hospital1 **]. She was transitioned to tiotropium bromide MDI daily and albuterol inhaler prn SOB and wheezing >24H prior to discharge with bedside teaching; her respiratory status remained stable with O2 requirement at 4L, O2 sats remained at low 90s. Attempt to taper O2 to 3L resulted with O2 sats to 88% at rest. Her prednisone was decreased to 40 mg at time of discharge. She was also started on calcium 1200 mg and vitamin D 800 units for osteoporosis prevention. She was discharged with home health services (O2 therapy, cardiopulmonary assessment, skilled nursing) and encouraged to follow up with outpatient pulmonary rehabilation.
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Evidence: Community acquired pneumonia
Condition: Pneumonia, unspecified organism
HCC: J440
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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You were admitted because you had difficulty breathing. It was noted that you have a lung infection. This likely worsened your COPD. You also had an ankle injury during your admission; X-rays of your ankles showed that you did not have any fractures or serious injury. Your pain was controlled with Advil. The following medication changes have been made: ADDED: 1. LEVOFLOXACIN for your lung infection - 1 tablet of levofloxacin (750 mg) daily, your last dose will be on Friday, [**2198-1-19**]. 2.
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Evidence: lung infection
Condition: Pneumonia, unspecified organism
HCC: J440
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 PLAN: It is recommended that the patient receive ventilatory support at night in a pulmonary rehabilitation facility. Her pneumonia is resolving, and she is continuing on a course of Vancomycin and Meropenem IV via her PICC line for three weeks. DISCHARGE DIAGNOSIS: 1. Aspiration pneumonia. 2.
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Evidence: pneumonia is resolving
Condition: Pneumonitis due to inhalation of food and vomit
HCC: J690
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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She had two bronchoscopies on [**2-20**] and 17 to clear secretions and evaluate her further. The secretions were purulent with 4+ PNS and were positive on culture with MRSA and Enterobacter which was sensitive to Meropenem and Gentamicin. On the Cardiovascular Service, she became somnolescent on [**2-23**], and a repeat arterial blood gas revealed a pCO2 of 133. She was seen by the Infectious Disease Service and started on Vancomycin 1 g per day and also Meropenem. For ventilatory support, she was transferred to the MICU, where her arterial blood gas improved to a pH of 7.49 and pCO2 of 71. She tolerated a trach mask by [**2-24**] and was transferred back to Cardiovascular Surgery on [**2-26**]; however, after that, she became progressively short of breath with worsening cough and increased secretions which were yellowish.
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Evidence: secretions were
purulent
Condition: Pneumonitis due to inhalation of food and vomit
HCC: J690
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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She had two bronchoscopies on [**2-20**] and 17 to clear secretions and evaluate her further. The secretions were purulent with 4+ PNS and were positive on culture with MRSA and Enterobacter which was sensitive to Meropenem and Gentamicin. On the Cardiovascular Service, she became somnolescent on [**2-23**], and a repeat arterial blood gas revealed a pCO2 of 133. She was seen by the Infectious Disease Service and started on Vancomycin 1 g per day and also Meropenem. For ventilatory support, she was transferred to the MICU, where her arterial blood gas improved to a pH of 7.49 and pCO2 of 71. She tolerated a trach mask by [**2-24**] and was transferred back to Cardiovascular Surgery on [**2-26**]; however, after that, she became progressively short of breath with worsening cough and increased secretions which were yellowish. She also became more confused, and her little pCO2 rose to 92, so she was transferred back to the MICU on [**3-2**] for additional ventilatory support. Although decortication procedure on the right lung, previously performed on the left in [**2139-6-7**], was considered, it was felt that the patient must first recover from this bout of aspiration pneumonia and be optimized in terms of her ventilatory support at a rehabilitation facility prior to this procedure. PAST MEDICAL HISTORY: 1.
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Evidence: positive on culture with MRSA
and Enterobacter
Condition: Pneumonitis due to inhalation of food and vomit
HCC: J690
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2139-3-2**] Discharge Date: [**2139-3-4**] Date of Birth: [**2085-1-5**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old woman with restrictive lung disease and radiation fibrosis secondary to previous radiation therapy for Hodgkin's disease in the [**2106**] and recurrent episodes and admissions for aspiration pneumonia. She was most recently admitted to the Cardiothoracic Service on [**2139-2-20**], for recurrent aspiration pneumonia and hypercarbia and consideration of decortication surgery on her right lung. She had worsening shortness of breath, chest tightness, weakness fatigue, and mild cough on admission, which are typical symptoms of her exacerbations. Her initial arterial blood gas was a pH of 7.24, pCO2 126, and her white count was 8.3 with 3% bands; however, she was afebrile with stable vitals signs and was initially with an oxygen saturation of 96% on 4 L supplemental oxygen.
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Evidence: Aspiration pneumonia
Condition: Pneumonitis due to inhalation of food and vomit
HCC: J690
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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DISCHARGE PLAN: It is recommended that the patient receive ventilatory support at night in a pulmonary rehabilitation facility. Her pneumonia is resolving, and she is continuing on a course of Vancomycin and Meropenem IV via her PICC line for three weeks. DISCHARGE DIAGNOSIS: 1. Aspiration pneumonia. 2. Restrictive lung disease with radiation fibrosis. 3. Congestive heart failure. 4.
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Evidence: pneumonia is resolving
Condition: Pneumonitis due to inhalation of food and vomit
HCC: J690
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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On the Cardiovascular Service, she became somnolescent on [**2-23**], and a repeat arterial blood gas revealed a pCO2 of 133. She was seen by the Infectious Disease Service and started on Vancomycin 1 g per day and also Meropenem. For ventilatory support, she was transferred to the MICU, where her arterial blood gas improved to a pH of 7.49 and pCO2 of 71. She tolerated a trach mask by [**2-24**] and was transferred back to Cardiovascular Surgery on [**2-26**]; however, after that, she became progressively short of breath with worsening cough and increased secretions which were yellowish. She also became more confused, and her little pCO2 rose to 92, so she was transferred back to the MICU on [**3-2**] for additional ventilatory support. Although decortication procedure on the right lung, previously performed on the left in [**2139-6-7**], was considered, it was felt that the patient must first recover from this bout of aspiration pneumonia and be optimized in terms of her ventilatory support at a rehabilitation facility prior to this procedure. PAST MEDICAL HISTORY: 1. Hodgkin's disease in the [**2106**].
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Evidence: started on Vancomycin 1 g per day and also Meropenem
Condition: Pneumonitis due to inhalation of food and vomit
HCC: J690
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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DISCHARGE PLAN: It is recommended that the patient receive ventilatory support at night in a pulmonary rehabilitation facility. Her pneumonia is resolving, and she is continuing on a course of Vancomycin and Meropenem IV via her PICC line for three weeks. DISCHARGE DIAGNOSIS: 1. Aspiration pneumonia. 2. Restrictive lung disease with radiation fibrosis. 3. Congestive heart failure.
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Evidence: continuing on a course of Vancomycin and Meropenem IV
Condition: Pneumonitis due to inhalation of food and vomit
HCC: J690
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2139-3-2**] Discharge Date: [**2139-3-4**] Date of Birth: [**2085-1-5**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old woman with restrictive lung disease and radiation fibrosis secondary to previous radiation therapy for Hodgkin's disease in the [**2106**] and recurrent episodes and admissions for aspiration pneumonia. She was most recently admitted to the Cardiothoracic Service on [**2139-2-20**], for recurrent aspiration pneumonia and hypercarbia and consideration of decortication surgery on her right lung. She had worsening shortness of breath, chest tightness, weakness fatigue, and mild cough on admission, which are typical symptoms of her exacerbations. Her initial arterial blood gas was a pH of 7.24, pCO2 126, and her white count was 8.3 with 3% bands; however, she was afebrile with stable vitals signs and was initially with an oxygen saturation of 96% on 4 L supplemental oxygen. She had no fever or chills at that time. She has chronic difficulty with clearing her secretions, and she was given suction treatment repeatedly on the CT Service through her tracheostomy which was placed last summer for suctioning and intermittent ventilatory support as needed.
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Evidence: aspiration pneumonia
Condition: Pneumonitis due to inhalation of food and vomit
HCC: J690
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2139-3-2**] Discharge Date: [**2139-3-4**] Date of Birth: [**2085-1-5**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old woman with restrictive lung disease and radiation fibrosis secondary to previous radiation therapy for Hodgkin's disease in the [**2106**] and recurrent episodes and admissions for aspiration pneumonia. She was most recently admitted to the Cardiothoracic Service on [**2139-2-20**], for recurrent aspiration pneumonia and hypercarbia and consideration of decortication surgery on her right lung. She had worsening shortness of breath, chest tightness, weakness fatigue, and mild cough on admission, which are typical symptoms of her exacerbations. Her initial arterial blood gas was a pH of 7.24, pCO2 126, and her white count was 8.3 with 3% bands; however, she was afebrile with stable vitals signs and was initially with an oxygen saturation of 96% on 4 L supplemental oxygen. She had no fever or chills at that time. She has chronic difficulty with clearing her secretions, and she was given suction treatment repeatedly on the CT Service through her tracheostomy which was placed last summer for suctioning and intermittent ventilatory support as needed. She had two bronchoscopies on [**2-20**] and 17 to clear secretions and evaluate her further. The secretions were purulent with 4+ PNS and were positive on culture with MRSA and Enterobacter which was sensitive to Meropenem and Gentamicin. On the Cardiovascular Service, she became somnolescent on [**2-23**], and a repeat arterial blood gas revealed a pCO2 of 133.
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Evidence: recurrent aspiration pneumonia
Condition: Pneumonitis due to inhalation of food and vomit
HCC: J690
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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She also became more confused, and her little pCO2 rose to 92, so she was transferred back to the MICU on [**3-2**] for additional ventilatory support. Although decortication procedure on the right lung, previously performed on the left in [**2139-6-7**], was considered, it was felt that the patient must first recover from this bout of aspiration pneumonia and be optimized in terms of her ventilatory support at a rehabilitation facility prior to this procedure. PAST MEDICAL HISTORY: 1. Hodgkin's disease in the [**2106**]. Stage IIB, treated with chest and abdominal radiation. Status post splenectomy in [**2110**]. 2.
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Evidence: bout of aspiration pneumonia
Condition: Pneumonitis due to inhalation of food and vomit
HCC: J690
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. History of multiple episodes of aspiration pneumonia. She has a known risk of aspiration. A video fluoroscopic swallowing study in [**2139-6-7**] revealed difficulty with thin liquids and aspiration risk. The patient has frequently been positive for MRSA and Enterobacter on previous bronchoalveolar lavages.
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Evidence: multiple
episodes of aspiration pneumonia
Condition: Pneumonitis due to inhalation of food and vomit
HCC: J690
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Electrocardiogram on [**2-24**]: Sinus tachycardia at 110 with normal intervals and diffuse ST abnormalities without Q-waves. HOSPITAL COURSE: This 54-year-old woman with chronic restrictive lung disease came to the MICU for ventilatory support in the setting of worsening hypercarbia and recent aspiration pneumonia. 1. Cardiovascular: Her systolic blood pressure was declining from about 100 to the 70s during her hospitalization; however, she responded to increased fluid intake once her mental status improved and she began to take p.o. fluids. Her systolic blood pressure rose to an average of 100 at discharge.
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Evidence: recent
aspiration pneumonia
Condition: Pneumonitis due to inhalation of food and vomit
HCC: J690
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 PLAN: It is recommended that the patient receive ventilatory support at night in a pulmonary rehabilitation facility. Her pneumonia is resolving, and she is continuing on a course of Vancomycin and Meropenem IV via her PICC line for three weeks. DISCHARGE DIAGNOSIS: 1. Aspiration pneumonia. 2.
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Evidence: pneumonia is resolving
Condition: Pneumonitis due to inhalation of food and vomit
HCC: J690
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2139-3-2**] Discharge Date: [**2139-3-4**] Date of Birth: [**2085-1-5**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old woman with restrictive lung disease and radiation fibrosis secondary to previous radiation therapy for Hodgkin's disease in the [**2106**] and recurrent episodes and admissions for aspiration pneumonia. She was most recently admitted to the Cardiothoracic Service on [**2139-2-20**], for recurrent aspiration pneumonia and hypercarbia and consideration of decortication surgery on her right lung. She had worsening shortness of breath, chest tightness, weakness fatigue, and mild cough on admission, which are typical symptoms of her exacerbations. Her initial arterial blood gas was a pH of 7.24, pCO2 126, and her white count was 8.3 with 3% bands; however, she was afebrile with stable vitals signs and was initially with an oxygen saturation of 96% on 4 L supplemental oxygen.
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Evidence: Aspiration pneumonia
Condition: Pneumonitis due to inhalation of food and vomit
HCC: J690
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Restrictive lung disease with mediastinal radiation fibrosis. Her status has worsened over the past several years with increasing dyspnea on exertion. For two years she has been dependent on a minimum of 2 L oxygen by nasal cannula, but she frequently requires hospitalization for ventilatory support. She was forced to retire last summer from her job as a [**Year (4 digits) 9929**] professor due to her illness. At her best she has three-pillow orthopnea and can climb one flight of stairs on oxygen. 3. Status post decortication of her left lung in [**2138-6-7**]. Initially the patient felt that her shortness of breath was improved but now feels that her status has returned to its previous level at baseline before the procedure.
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Evidence: worsened over the past several years
Condition: Chronic respiratory conditions due to radiation
HCC: J701
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
|
2. Restrictive lung disease with mediastinal radiation fibrosis. Her status has worsened over the past several years with increasing dyspnea on exertion. For two years she has been dependent on a minimum of 2 L oxygen by nasal cannula, but she frequently requires hospitalization for ventilatory support. She was forced to retire last summer from her job as a [**Year (4 digits) 9929**] professor due to her illness. At her best she has three-pillow orthopnea and can climb one flight of stairs on oxygen.
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Evidence: Restrictive lung
disease with mediastinal radiation fibrosis
Condition: Chronic respiratory conditions due to radiation
HCC: J701
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Chest CT on [**2-23**]: Small bilateral pleural effusion and pleural thickening. Paramediastinal volume loss and radiation fibrosis with traction bronchiectasis. Dependent ground glass opacification in the expiratory phase and septal thickening. No endobronchial lesions. Electrocardiogram on [**2-24**]: Sinus tachycardia at 110 with normal intervals and diffuse ST abnormalities without Q-waves. HOSPITAL COURSE: This 54-year-old woman with chronic restrictive lung disease came to the MICU for ventilatory support in the setting of worsening hypercarbia and recent aspiration pneumonia. 1. Cardiovascular: Her systolic blood pressure was declining from about 100 to the 70s during her hospitalization; however, she responded to increased fluid intake once her mental status improved and she began to take p.o.
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Evidence: radiation fibrosis with traction bronchiectasis
Condition: Chronic respiratory conditions due to radiation
HCC: J701
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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2. Restrictive lung disease with radiation fibrosis. 3. Congestive heart failure. 4. Depression. 5.
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Evidence: Restrictive lung disease with radiation fibrosis
Condition: Chronic respiratory conditions due to radiation
HCC: J701
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2139-3-2**] Discharge Date: [**2139-3-4**] Date of Birth: [**2085-1-5**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old woman with restrictive lung disease and radiation fibrosis secondary to previous radiation therapy for Hodgkin's disease in the [**2106**] and recurrent episodes and admissions for aspiration pneumonia. She was most recently admitted to the Cardiothoracic Service on [**2139-2-20**], for recurrent aspiration pneumonia and hypercarbia and consideration of decortication surgery on her right lung. She had worsening shortness of breath, chest tightness, weakness fatigue, and mild cough on admission, which are typical symptoms of her exacerbations. Her initial arterial blood gas was a pH of 7.24, pCO2 126, and her white count was 8.3 with 3% bands; however, she was afebrile with stable vitals signs and was initially with an oxygen saturation of 96% on 4 L supplemental oxygen. She had no fever or chills at that time. She has chronic difficulty with clearing her secretions, and she was given suction treatment repeatedly on the CT Service through her tracheostomy which was placed last summer for suctioning and intermittent ventilatory support as needed. She had two bronchoscopies on [**2-20**] and 17 to clear secretions and evaluate her further.
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Evidence: radiation fibrosis
secondary to previous radiation therapy for Hodgkin's disease
Condition: Chronic respiratory conditions due to radiation
HCC: J701
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
2. Restrictive lung disease with mediastinal radiation fibrosis. Her status has worsened over the past several years with increasing dyspnea on exertion. For two years she has been dependent on a minimum of 2 L oxygen by nasal cannula, but she frequently requires hospitalization for ventilatory support. She was forced to retire last summer from her job as a [**Year (4 digits) 9929**] professor due to her illness.
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Evidence: Restrictive lung
disease with mediastinal radiation fibrosis
Condition: Chronic respiratory conditions due to radiation
HCC: J701
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2139-3-2**] Discharge Date: [**2139-3-4**] Date of Birth: [**2085-1-5**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old woman with restrictive lung disease and radiation fibrosis secondary to previous radiation therapy for Hodgkin's disease in the [**2106**] and recurrent episodes and admissions for aspiration pneumonia. She was most recently admitted to the Cardiothoracic Service on [**2139-2-20**], for recurrent aspiration pneumonia and hypercarbia and consideration of decortication surgery on her right lung. She had worsening shortness of breath, chest tightness, weakness fatigue, and mild cough on admission, which are typical symptoms of her exacerbations. Her initial arterial blood gas was a pH of 7.24, pCO2 126, and her white count was 8.3 with 3% bands; however, she was afebrile with stable vitals signs and was initially with an oxygen saturation of 96% on 4 L supplemental oxygen. She had no fever or chills at that time. She has chronic difficulty with clearing her secretions, and she was given suction treatment repeatedly on the CT Service through her tracheostomy which was placed last summer for suctioning and intermittent ventilatory support as needed. She had two bronchoscopies on [**2-20**] and 17 to clear secretions and evaluate her further.
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Evidence: radiation fibrosis
Condition: Chronic respiratory conditions due to radiation
HCC: J701
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
2. Restrictive lung disease with radiation fibrosis. 3. Congestive heart failure. 4. Depression. 5.
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Evidence: Restrictive lung disease with radiation fibrosis
Condition: Chronic respiratory conditions due to radiation
HCC: J701
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
1. Cardiovascular: Her systolic blood pressure was declining from about 100 to the 70s during her hospitalization; however, she responded to increased fluid intake once her mental status improved and she began to take p.o. fluids. Her systolic blood pressure rose to an average of 100 at discharge. She was kept on her standing dose of Lasix at 20 mg p.o. q.d. during her hospital stay, and additional diuresis was not required.
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Evidence: systolic blood pressure was
declining from about 100 to the 70s during her
hospitalization; however, she responded to increased fluid
intake
Condition: Heart failure, unspecified
HCC: I509
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
fluids. Her systolic blood pressure rose to an average of 100 at discharge. She was kept on her standing dose of Lasix at 20 mg p.o. q.d. during her hospital stay, and additional diuresis was not required. An electrocardiogram was performed in the MICU which was essentially unchanged from her [**2-24**] study. She was also continued on Lopressor 25 mg p.o.
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Evidence: systolic blood pressure rose to an average
of 100 at discharge
Condition: Heart failure, unspecified
HCC: I509
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Her systolic blood pressure rose to an average of 100 at discharge. She was kept on her standing dose of Lasix at 20 mg p.o. q.d. during her hospital stay, and additional diuresis was not required. An electrocardiogram was performed in the MICU which was essentially unchanged from her [**2-24**] study. She was also continued on Lopressor 25 mg p.o. b.i.d., but it was frequently held when her blood pressure was below 90. 2.
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Evidence: She was kept on her standing dose of
Lasix at 20 mg p.o. q.d. during her hospital stay
Condition: Heart failure, unspecified
HCC: I509
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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Congestive heart failure. Ejection fraction of 35-40% on her last cardiac echocardiogram on [**2138-10-21**], with severe anterior, septal, and apical hypokinesis. The patient denied history of angina. 5. Status post pericardectomy for restrictive pericarditis secondary to radiation therapy in the [**2116**]. 6. Status post hysterectomy in [**2113**] for cervical cancer.
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Evidence: Ejection fraction
of 35-40% on her last cardiac echocardiogram
Condition: Heart failure, unspecified
HCC: I509
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Congestive heart failure. Ejection fraction of 35-40% on her last cardiac echocardiogram on [**2138-10-21**], with severe anterior, septal, and apical hypokinesis. The patient denied history of angina. 5. Status post pericardectomy for restrictive pericarditis secondary to radiation therapy in the [**2116**]. 6. Status post hysterectomy in [**2113**] for cervical cancer. 7. History of multiple episodes of aspiration pneumonia.
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Evidence: severe anterior, septal, and apical hypokinesis
Condition: Heart failure, unspecified
HCC: I509
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
4. Congestive heart failure. Ejection fraction of 35-40% on her last cardiac echocardiogram on [**2138-10-21**], with severe anterior, septal, and apical hypokinesis. The patient denied history of angina. 5. Status post pericardectomy for restrictive pericarditis secondary to radiation therapy in the [**2116**].
|
Evidence: Congestive heart failure
Condition: Heart failure, unspecified
HCC: I509
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
q.h.s., Lansoprazole 30 mg p.o. q.d., Lasix 20 mg p.o. q.d., .................... 60 mg subcutaneous b.i.d. because of her PICC line begun during this admission, Lopressor 25 mg p.o. b.i.d.
|
Evidence: Lasix 20 mg p.o.
q.d.
Condition: Heart failure, unspecified
HCC: I509
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
60 mg subcutaneous b.i.d. because of her PICC line begun during this admission, Lopressor 25 mg p.o. b.i.d. ALLERGIES: ANAPHYLAXIS TO IODINE DYE. PHYSICAL EXAMINATION: General: On transfer to the MICU she could speak in full sentences with some difficulty. Vital signs: Temperature 98.1??????, heart rate 95, blood pressure 90/40, respirations 16, oxygen saturation 100% on AC volume support with tidal volume 300, PEEP 5, FIO2 30%.
|
Evidence: Lopressor 25 mg p.o.
b.i.d.
Condition: Heart failure, unspecified
HCC: I509
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Her systolic blood pressure rose to an average of 100 at discharge. She was kept on her standing dose of Lasix at 20 mg p.o. q.d. during her hospital stay, and additional diuresis was not required. An electrocardiogram was performed in the MICU which was essentially unchanged from her [**2-24**] study. She was also continued on Lopressor 25 mg p.o. b.i.d., but it was frequently held when her blood pressure was below 90. 2.
|
Evidence: kept on her standing dose of
Lasix at 20 mg p.o. q.d.
Condition: Heart failure, unspecified
HCC: I509
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
An electrocardiogram was performed in the MICU which was essentially unchanged from her [**2-24**] study. She was also continued on Lopressor 25 mg p.o. b.i.d., but it was frequently held when her blood pressure was below 90. 2. Pulmonary: She was initially placed on volume-assist control with a tidal volume of 300 at respiration 14 with PEEP of 5 and FIO2 of 50%. Initially, she breathed at respiration rates above 30 on these settings and became somewhat confused. A venous blood gas showed a pH of 7.52, and pCO2 of 60. It was felt that given her chronic metabolic alkalosis with total CO2 of approximately 40 at baseline, that her mental status changes may have resulted from alkalemia, and the goal for her pCO2 was set for 60-70, which is likely her baseline. On the second hospital day, her ventilatory support was changed to pressure support at 10 cm; however, the pressure support was increased to 15 because of tidal volumes below 200.
|
Evidence: continued on Lopressor 25 mg p.o. b.i.d.
Condition: Heart failure, unspecified
HCC: I509
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
q.h.s., Lansoprazole 30 mg p.o. q.d., Lasix 20 mg p.o. q.d., .................... 60 mg subcutaneous b.i.d. because of her PICC line begun during this admission, Lopressor 25 mg p.o. b.i.d. ALLERGIES: ANAPHYLAXIS TO IODINE DYE.
|
Evidence: Lasix 20 mg p.o.
q.d.
Condition: Heart failure, unspecified
HCC: I509
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
q.d., Reglan 10 mg p.o. q.d., Lopressor 25 mg p.o. q.d., Lansoprazole 30 mg p.o. q.d., Levothyroxine 125 p.o. q.d., Meropenem 1 g IV q.8 hours [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Last Name (NamePattern1) 9936**] MEDQUIST36 D: [**2139-3-4**] 15:12 T: [**2139-3-4**] 15:19 JOB#: [**Job Number 9937**]
|
Evidence: Lopressor 25 mg
p.o. q.d.
Condition: Heart failure, unspecified
HCC: I509
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
4. Congestive heart failure. Ejection fraction of 35-40% on her last cardiac echocardiogram on [**2138-10-21**], with severe anterior, septal, and apical hypokinesis. The patient denied history of angina. 5. Status post pericardectomy for restrictive pericarditis secondary to radiation therapy in the [**2116**]. 6.
|
Evidence: Congestive heart failure
Condition: Heart failure, unspecified
HCC: I509
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
4. Congestive heart failure. Ejection fraction of 35-40% on her last cardiac echocardiogram on [**2138-10-21**], with severe anterior, septal, and apical hypokinesis. The patient denied history of angina. 5. Status post pericardectomy for restrictive pericarditis secondary to radiation therapy in the [**2116**]. 6. Status post hysterectomy in [**2113**] for cervical cancer.
|
Evidence: Congestive heart failure
Condition: Heart failure, unspecified
HCC: I509
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Congestive heart failure. Ejection fraction of 35-40% on her last cardiac echocardiogram on [**2138-10-21**], with severe anterior, septal, and apical hypokinesis. The patient denied history of angina. 5. Status post pericardectomy for restrictive pericarditis secondary to radiation therapy in the [**2116**]. 6. Status post hysterectomy in [**2113**] for cervical cancer. 7. History of multiple episodes of aspiration pneumonia.
|
Evidence: severe anterior, septal, and apical hypokinesis
Condition: Myocarditis, unspecified
HCC: I514
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Congestive heart failure. Ejection fraction of 35-40% on her last cardiac echocardiogram on [**2138-10-21**], with severe anterior, septal, and apical hypokinesis. The patient denied history of angina. 5. Status post pericardectomy for restrictive pericarditis secondary to radiation therapy in the [**2116**]. 6. Status post hysterectomy in [**2113**] for cervical cancer. 7.
|
Evidence: severe anterior, septal, and apical hypokinesis
Condition: Myocarditis, unspecified
HCC: I514
Category: condition_evidence
|
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