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Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week. This most recent one prompted an Emergency Room visit. She also notes decreased appetite, possibly change in weight, but her clothes are looser than they had been.
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Evidence: tachy-brady syndrome
Condition: Sick sinus syndrome
HCC: I495
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: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week. This most recent one prompted an Emergency Room visit. She also notes decreased appetite, possibly change in weight, but her clothes are looser than they had been.
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Evidence: tachy-brady syndrome
Condition: Sick sinus syndrome
HCC: I495
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: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week.
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Evidence: tachy-brady syndrome
Condition: Sick sinus syndrome
HCC: I495
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: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week.
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Evidence: status post pacemaker
Condition: Sick sinus syndrome
HCC: I495
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: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats.
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Evidence: status post pacemaker
Condition: Sick sinus syndrome
HCC: I495
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: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats.
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Evidence: status post pacemaker
Condition: Sick sinus syndrome
HCC: I495
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: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week. This most recent one prompted an Emergency Room visit. She also notes decreased appetite, possibly change in weight, but her clothes are looser than they had been. She reports good compliance with her home anti-hypertensives, but does not measure her blood pressures.
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Evidence: tachy-brady syndrome
Condition: Sick sinus syndrome
HCC: I495
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: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week. This most recent one prompted an Emergency Room visit. She also notes decreased appetite, possibly change in weight, but her clothes are looser than they had been.
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Evidence: tachy-brady syndrome
Condition: Sick sinus syndrome
HCC: I495
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week.
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Evidence: tachy-brady syndrome
Condition: Sick sinus syndrome
HCC: I495
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 has seven more days to go to complete those. Her shortness of breath improved throughout her stay. She continued to use her incentive spirometer and eventually was weaned off nasal cannula and saturating well even with ambulation. She did not require oxygen for the last four days of her admission. 2. ESCHERICHIEAE COLI BACTEREMIA AND URINARY TRACT INFECTION: The patient had a few blood cultures positive for E.
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Evidence: shortness of breath improved throughout her stay
Condition: Unspecified diastolic congestive heart failure
HCC: I5030
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Her shortness of breath improved throughout her stay. She continued to use her incentive spirometer and eventually was weaned off nasal cannula and saturating well even with ambulation. She did not require oxygen for the last four days of her admission. 2. ESCHERICHIEAE COLI BACTEREMIA AND URINARY TRACT INFECTION: The patient had a few blood cultures positive for E. coli at time of admission as were her urine cultures.
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Evidence: weaned off nasal cannula and saturating well
Condition: Unspecified diastolic congestive heart failure
HCC: I5030
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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She continued to use her incentive spirometer and eventually was weaned off nasal cannula and saturating well even with ambulation. She did not require oxygen for the last four days of her admission. 2. ESCHERICHIEAE COLI BACTEREMIA AND URINARY TRACT INFECTION: The patient had a few blood cultures positive for E. coli at time of admission as were her urine cultures.
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Evidence: not requiring oxygen for the last four days of her admission
Condition: Unspecified diastolic congestive heart failure
HCC: I5030
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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9. Recent echocardiogram in [**Month (only) **] showed an ejection fraction of 60% with mild to moderate mitral regurgitation and aortic regurgitation, prolonged E wave deceleration, impaired relaxation, mild pulmonary artery systolic hypertension. MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 25 mg p.o. q.
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Evidence: Recent echocardiogram in [**Month (only) **] showed an ejection fraction of 60%
Condition: Unspecified diastolic congestive heart failure
HCC: I5030
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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9. Recent echocardiogram in [**Month (only) **] showed an ejection fraction of 60% with mild to moderate mitral regurgitation and aortic regurgitation, prolonged E wave deceleration, impaired relaxation, mild pulmonary artery systolic hypertension. MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 25 mg p.o. q. day. 2.
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Evidence: prolonged E wave deceleration, impaired relaxation
Condition: Unspecified diastolic congestive heart failure
HCC: I5030
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: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week. This most recent one prompted an Emergency Room visit. She also notes decreased appetite, possibly change in weight, but her clothes are looser than they had been. She reports good compliance with her home anti-hypertensives, but does not measure her blood pressures.
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Evidence: congestive heart failure
Condition: Unspecified diastolic congestive heart failure
HCC: I5030
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week. This most recent one prompted an Emergency Room visit. She also notes decreased appetite, possibly change in weight, but her clothes are looser than they had been. She reports good compliance with her home anti-hypertensives, but does not measure her blood pressures.
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Evidence: diastolic dysfunction
Condition: Unspecified diastolic congestive heart failure
HCC: I5030
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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PAST MEDICAL HISTORY: 1. Congestive heart failure with diastolic dysfunction. 2. Diabetes mellitus. 3. Coronary artery disease status post an myocardial infarction. 4. Hypertension with history of uncontrolled blood pressures in the 200s over 100s. 5.
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Evidence: Congestive heart failure with diastolic dysfunction
Condition: Unspecified diastolic congestive heart failure
HCC: I5030
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week.
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Evidence: congestive
heart failure
Condition: Unspecified diastolic congestive heart failure
HCC: I5030
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week. This most recent one prompted an Emergency Room visit. She also notes decreased appetite, possibly change in weight, but her clothes are looser than they had been.
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Evidence: diastolic dysfunction
Condition: Unspecified diastolic congestive heart failure
HCC: I5030
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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3. Diastolic congestive heart failure. 4. Urinary tract infection. 5.
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Evidence: Diastolic congestive heart failure
Condition: Unspecified diastolic congestive heart failure
HCC: I5030
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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She received a dose of Lopressor and Diltiazem in the Emergency Room with good response. Also, she received 20 of intravenous Lasix, Nitroglycerin, digoxin and then had a CT scan of her chest done to evaluate for shortness of breath. She was noted to have some lymphadenopathy and diffuse nodules worse on the left than on the right. PAST MEDICAL HISTORY: 1. Congestive heart failure with diastolic dysfunction. 2. Diabetes mellitus.
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Evidence: received 20 of intravenous Lasix
Condition: Unspecified diastolic congestive heart failure
HCC: I5030
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: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week.
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Evidence: congestive heart failure
Condition: Unspecified diastolic congestive heart failure
HCC: I5030
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week.
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Evidence: diastolic dysfunction
Condition: Unspecified diastolic congestive heart failure
HCC: I5030
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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PAST MEDICAL HISTORY: 1. Congestive heart failure with diastolic dysfunction. 2. Diabetes mellitus. 3. Coronary artery disease status post an myocardial infarction.
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Evidence: Congestive heart failure with diastolic dysfunction
Condition: Unspecified diastolic congestive heart failure
HCC: I5030
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week. This most recent one prompted an Emergency Room visit. She also notes decreased appetite, possibly change in weight, but her clothes are looser than they had been.
|
Evidence: congestive
heart failure
Condition: Unspecified diastolic congestive heart failure
HCC: I5030
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week. This most recent one prompted an Emergency Room visit. She also notes decreased appetite, possibly change in weight, but her clothes are looser than they had been.
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Evidence: diastolic dysfunction
Condition: Unspecified diastolic congestive heart failure
HCC: I5030
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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3. Diastolic congestive heart failure. 4. Urinary tract infection. 5. Bacteremia. DISCHARGE MEDICATIONS: 1.
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Evidence: Diastolic congestive heart failure
Condition: Unspecified diastolic congestive heart failure
HCC: I5030
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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1. SHORTNESS OF BREATH: The patient was stable oxygen wise and was treated for pneumonia empirically with initially Ceftazidine and then switched over to Levofloxacin to complete a two week course; currently being discharged on day seven of two weeks. The day after admission the patient had a bronchoscopy done to evaluate airway disease. She had evidence of diffuse narrowing of her lower airways without occlusion. No endobronchial lesions were noted. No source of hemoptysis, but she had minimal non-purulent secretions.
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Evidence: stable
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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3. Coronary artery disease status post an myocardial infarction. 4. Hypertension with history of uncontrolled blood pressures in the 200s over 100s. 5. Hyperlipidemia. 6. Atrial fibrillation status post tachy-brady syndrome status post pacemaker. 7.
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Evidence: Coronary artery disease
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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3. Coronary artery disease status post an myocardial infarction. 4. Hypertension with history of uncontrolled blood pressures in the 200s over 100s. 5. Hyperlipidemia. 6. Atrial fibrillation status post tachy-brady syndrome status post pacemaker.
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Evidence: CORONARY ARTERY DISEASE
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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4. CORONARY ARTERY DISEASE: The patient was stable and continued on her metoprolol although her aspirin was held for procedures and can be restarted once her work-up for her lung cancer is completed. 5. DIABETES MELLITUS: She was overall well controlled on a sliding scale, however, her fingersticks remained between 112 and 130 during the course of her stay with minimal sliding scale requirements. She will continue at home off medications but advised to continue with diabetic diet.
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Evidence: continued on her metoprolol
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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4. CORONARY ARTERY DISEASE: The patient was stable and continued on her metoprolol although her aspirin was held for procedures and can be restarted once her work-up for her lung cancer is completed. 5. DIABETES MELLITUS: She was overall well controlled on a sliding scale, however, her fingersticks remained between 112 and 130 during the course of her stay with minimal sliding scale requirements. She will continue at home off medications but advised to continue with diabetic diet. This can continue to be followed as an outpatient.
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Evidence: aspirin was held for procedures and can be restarted
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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4. Aspirin 325 mg p.o. q. day. 5. Toprol XL 100 mg p.o. q. day. ALLERGIES: No known drug allergies.
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Evidence: Aspirin 325 mg p.o. q. day
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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5. Toprol XL 100 mg p.o. q. day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She lives with her son. She is divorced. She works as a cook. She quit tobacco in the 70s but had a previous 20 pack year history. Alcohol with history of heavy alcohol abuse but quit 30 to 40 years ago and no other illicit drugs.
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Evidence: Toprol XL 100 mg p.o. q. day
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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5. Toprol XL 100 mg p.o. q. day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She lives with her son. She is divorced.
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Evidence: Toprol XL 100 mg p.o. q. day
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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3. Coronary artery disease status post an myocardial infarction. 4. Hypertension with history of uncontrolled blood pressures in the 200s over 100s. 5. Hyperlipidemia.
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Evidence: Coronary artery disease
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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3. Coronary artery disease status post an myocardial infarction. 4. Hypertension with history of uncontrolled blood pressures in the 200s over 100s. 5. Hyperlipidemia. 6.
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Evidence: CORONARY ARTERY DISEASE
Condition: Atherosclerotic heart disease of native coronary artery without angina pectoris
HCC: I2510
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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9. Recent echocardiogram in [**Month (only) **] showed an ejection fraction of 60% with mild to moderate mitral regurgitation and aortic regurgitation, prolonged E wave deceleration, impaired relaxation, mild pulmonary artery systolic hypertension. MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 25 mg p.o. q.
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Evidence: Recent echocardiogram in [**Month (only) **] showed... mild pulmonary artery systolic
hypertension
Condition: Secondary pulmonary arterial hypertension
HCC: I2721
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
9. Recent echocardiogram in [**Month (only) **] showed an ejection fraction of 60% with mild to moderate mitral regurgitation and aortic regurgitation, prolonged E wave deceleration, impaired relaxation, mild pulmonary artery systolic hypertension. MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 25 mg p.o. q.
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Evidence: mild pulmonary artery systolic
hypertension
Condition: Secondary pulmonary arterial hypertension
HCC: I2721
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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9. Recent echocardiogram in [**Month (only) **] showed an ejection fraction of 60% with mild to moderate mitral regurgitation and aortic regurgitation, prolonged E wave deceleration, impaired relaxation, mild pulmonary artery systolic hypertension. MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 25 mg p.o. q.
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Evidence: mild pulmonary artery systolic
hypertension
Condition: Secondary pulmonary arterial hypertension
HCC: I2721
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
She has seven more days to go to complete those. Her shortness of breath improved throughout her stay. She continued to use her incentive spirometer and eventually was weaned off nasal cannula and saturating well even with ambulation. She did not require oxygen for the last four days of her admission. 2. ESCHERICHIEAE COLI BACTEREMIA AND URINARY TRACT INFECTION: The patient had a few blood cultures positive for E. coli at time of admission as were her urine cultures.
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Evidence: shortness of breath improved throughout her stay
Condition: Abscess of lung and mediastinum as complication following procedure
HCC: J852
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Her shortness of breath improved throughout her stay. She continued to use her incentive spirometer and eventually was weaned off nasal cannula and saturating well even with ambulation. She did not require oxygen for the last four days of her admission. 2. ESCHERICHIEAE COLI BACTEREMIA AND URINARY TRACT INFECTION: The patient had a few blood cultures positive for E.
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Evidence: weaned off nasal cannula and saturating well
Condition: Abscess of lung and mediastinum as complication following procedure
HCC: J852
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
She continued to use her incentive spirometer and eventually was weaned off nasal cannula and saturating well even with ambulation. She did not require oxygen for the last four days of her admission. 2. ESCHERICHIEAE COLI BACTEREMIA AND URINARY TRACT INFECTION: The patient had a few blood cultures positive for E. coli at time of admission as were her urine cultures.
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Evidence: not requiring oxygen for the last four days of her admission
Condition: Abscess of lung and mediastinum as complication following procedure
HCC: J852
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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Areas of nodular density consistent with metastatic foci. Positive post obstructive pneumonia. HOSPITAL COURSE: This is a 78 year old woman with history of atrial fibrillation with rapid ventricular response, tachy-brady syndrome, status post pacemaker, with congestive heart failure, diastolic dysfunction, who presented with shortness of breath. She was initially admitted to the Intensive Care Unit for better monitoring. 1. SHORTNESS OF BREATH: The patient was stable oxygen wise and was treated for pneumonia empirically with initially Ceftazidine and then switched over to Levofloxacin to complete a two week course; currently being discharged on day seven of two weeks. The day after admission the patient had a bronchoscopy done to evaluate airway disease. She had evidence of diffuse narrowing of her lower airways without occlusion. No endobronchial lesions were noted.
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Evidence: CT scan showed... Positive post
obstructive pneumonia
Condition: Abscess of lung and mediastinum as complication following procedure
HCC: J852
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Areas of nodular density consistent with metastatic foci. Positive post obstructive pneumonia. HOSPITAL COURSE: This is a 78 year old woman with history of atrial fibrillation with rapid ventricular response, tachy-brady syndrome, status post pacemaker, with congestive heart failure, diastolic dysfunction, who presented with shortness of breath. She was initially admitted to the Intensive Care Unit for better monitoring. 1.
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Evidence: post
obstructive pneumonia
Condition: Abscess of lung and mediastinum as complication following procedure
HCC: J852
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Areas of nodular density consistent with metastatic foci. Positive post obstructive pneumonia. HOSPITAL COURSE: This is a 78 year old woman with history of atrial fibrillation with rapid ventricular response, tachy-brady syndrome, status post pacemaker, with congestive heart failure, diastolic dysfunction, who presented with shortness of breath. She was initially admitted to the Intensive Care Unit for better monitoring. 1. SHORTNESS OF BREATH: The patient was stable oxygen wise and was treated for pneumonia empirically with initially Ceftazidine and then switched over to Levofloxacin to complete a two week course; currently being discharged on day seven of two weeks. The day after admission the patient had a bronchoscopy done to evaluate airway disease. She had evidence of diffuse narrowing of her lower airways without occlusion. No endobronchial lesions were noted.
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Evidence: post obstructive pneumonia
Condition: Abscess of lung and mediastinum as complication following procedure
HCC: J852
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Areas of nodular density consistent with metastatic foci. Positive post obstructive pneumonia. HOSPITAL COURSE: This is a 78 year old woman with history of atrial fibrillation with rapid ventricular response, tachy-brady syndrome, status post pacemaker, with congestive heart failure, diastolic dysfunction, who presented with shortness of breath. She was initially admitted to the Intensive Care Unit for better monitoring. 1. SHORTNESS OF BREATH: The patient was stable oxygen wise and was treated for pneumonia empirically with initially Ceftazidine and then switched over to Levofloxacin to complete a two week course; currently being discharged on day seven of two weeks. The day after admission the patient had a bronchoscopy done to evaluate airway disease. She had evidence of diffuse narrowing of her lower airways without occlusion.
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Evidence: Post obstructive pneumonia
Condition: Abscess of lung and mediastinum as complication following procedure
HCC: J852
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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1. SHORTNESS OF BREATH: The patient was stable oxygen wise and was treated for pneumonia empirically with initially Ceftazidine and then switched over to Levofloxacin to complete a two week course; currently being discharged on day seven of two weeks. The day after admission the patient had a bronchoscopy done to evaluate airway disease. She had evidence of diffuse narrowing of her lower airways without occlusion. No endobronchial lesions were noted. No source of hemoptysis, but she had minimal non-purulent secretions. She did have three sets of samples sent of for pathology and cytology which eventually, on the day prior to discharge, returned as highly suspicious for non-small cell carcinoma. The patient was advised of these findings and referred to the Thoracic Multi-Disciplinary Oncology Center for further follow-up and further staging.
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Evidence: treated for pneumonia empirically with initially
Ceftazidine and then switched over to Levofloxacin
Condition: Abscess of lung and mediastinum as complication following procedure
HCC: J852
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Otherwise, the patient's shortness of breath was likely exacerbated by a post obstructive pneumonia. Eventually, Flagyl was added on for better anaerobic coverage and the patient is to complete a ten day course of this. She has seven more days to go to complete those. Her shortness of breath improved throughout her stay. She continued to use her incentive spirometer and eventually was weaned off nasal cannula and saturating well even with ambulation. She did not require oxygen for the last four days of her admission.
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Evidence: Flagyl was added on for better anaerobic coverage
Condition: Abscess of lung and mediastinum as complication following procedure
HCC: J852
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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2. Levofloxacin 250 mg p.o. q. day times seven more days. 3. Flagyl 500 mg p.o. three times a day times seven more days. 4.
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Evidence: Levofloxacin 250 mg p.o. q. day times seven more days
Condition: Abscess of lung and mediastinum as complication following procedure
HCC: J852
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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3. Flagyl 500 mg p.o. three times a day times seven more days. 4. Diltiazem 60 mg p.o. four times a day. 5. Ipratropium MDI, two puffs inhaled four times a day. 6.
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Evidence: Flagyl 500 mg p.o. three times a day times seven more
days
Condition: Abscess of lung and mediastinum as complication following procedure
HCC: J852
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Areas of nodular density consistent with metastatic foci. Positive post obstructive pneumonia. HOSPITAL COURSE: This is a 78 year old woman with history of atrial fibrillation with rapid ventricular response, tachy-brady syndrome, status post pacemaker, with congestive heart failure, diastolic dysfunction, who presented with shortness of breath. She was initially admitted to the Intensive Care Unit for better monitoring. 1. SHORTNESS OF BREATH: The patient was stable oxygen wise and was treated for pneumonia empirically with initially Ceftazidine and then switched over to Levofloxacin to complete a two week course; currently being discharged on day seven of two weeks. The day after admission the patient had a bronchoscopy done to evaluate airway disease.
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Evidence: post
obstructive pneumonia
Condition: Abscess of lung and mediastinum as complication following procedure
HCC: J852
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Areas of nodular density consistent with metastatic foci. Positive post obstructive pneumonia. HOSPITAL COURSE: This is a 78 year old woman with history of atrial fibrillation with rapid ventricular response, tachy-brady syndrome, status post pacemaker, with congestive heart failure, diastolic dysfunction, who presented with shortness of breath. She was initially admitted to the Intensive Care Unit for better monitoring. 1. SHORTNESS OF BREATH: The patient was stable oxygen wise and was treated for pneumonia empirically with initially Ceftazidine and then switched over to Levofloxacin to complete a two week course; currently being discharged on day seven of two weeks. The day after admission the patient had a bronchoscopy done to evaluate airway disease. She had evidence of diffuse narrowing of her lower airways without occlusion. No endobronchial lesions were noted.
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Evidence: post obstructive pneumonia
Condition: Abscess of lung and mediastinum as complication following procedure
HCC: J852
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Areas of nodular density consistent with metastatic foci. Positive post obstructive pneumonia. HOSPITAL COURSE: This is a 78 year old woman with history of atrial fibrillation with rapid ventricular response, tachy-brady syndrome, status post pacemaker, with congestive heart failure, diastolic dysfunction, who presented with shortness of breath. She was initially admitted to the Intensive Care Unit for better monitoring. 1. SHORTNESS OF BREATH: The patient was stable oxygen wise and was treated for pneumonia empirically with initially Ceftazidine and then switched over to Levofloxacin to complete a two week course; currently being discharged on day seven of two weeks. The day after admission the patient had a bronchoscopy done to evaluate airway disease. She had evidence of diffuse narrowing of her lower airways without occlusion.
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Evidence: Post obstructive pneumonia
Condition: Abscess of lung and mediastinum as complication following procedure
HCC: J852
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 source of hemoptysis, but she had minimal non-purulent secretions. She did have three sets of samples sent of for pathology and cytology which eventually, on the day prior to discharge, returned as highly suspicious for non-small cell carcinoma. The patient was advised of these findings and referred to the Thoracic Multi-Disciplinary Oncology Center for further follow-up and further staging. The patient is aware of diagnosis as is her family were advised of condition and the patient defers treatment and plans for treatment to her physicians as she feels they know more appropriately what is involved. When asked about her wishes, she also defers to her son. They are prepared to continue with the treatment and arrangements have been made to set up initial visit on day of discharge with Dr.
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Evidence: three sets of samples sent of for pathology and cytology which eventually, on the day prior to
discharge, returned as highly suspicious for non-small cell
carcinoma
Condition: Malignant neoplasm of unspecified part of unspecified bronchus or lung
HCC: C3490
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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No source of hemoptysis, but she had minimal non-purulent secretions. She did have three sets of samples sent of for pathology and cytology which eventually, on the day prior to discharge, returned as highly suspicious for non-small cell carcinoma. The patient was advised of these findings and referred to the Thoracic Multi-Disciplinary Oncology Center for further follow-up and further staging. The patient is aware of diagnosis as is her family were advised of condition and the patient defers treatment and plans for treatment to her physicians as she feels they know more appropriately what is involved. When asked about her wishes, she also defers to her son. They are prepared to continue with the treatment and arrangements have been made to set up initial visit on day of discharge with Dr. [**Last Name (STitle) **].
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Evidence: non-small cell
carcinoma
Condition: Malignant neoplasm of unspecified part of unspecified bronchus or lung
HCC: C3490
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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4. CORONARY ARTERY DISEASE: The patient was stable and continued on her metoprolol although her aspirin was held for procedures and can be restarted once her work-up for her lung cancer is completed. 5. DIABETES MELLITUS: She was overall well controlled on a sliding scale, however, her fingersticks remained between 112 and 130 during the course of her stay with minimal sliding scale requirements. She will continue at home off medications but advised to continue with diabetic diet. This can continue to be followed as an outpatient. 6.
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Evidence: lung
cancer
Condition: Malignant neoplasm of unspecified part of unspecified bronchus or lung
HCC: C3490
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
No source of hemoptysis, but she had minimal non-purulent secretions. She did have three sets of samples sent of for pathology and cytology which eventually, on the day prior to discharge, returned as highly suspicious for non-small cell carcinoma. The patient was advised of these findings and referred to the Thoracic Multi-Disciplinary Oncology Center for further follow-up and further staging. The patient is aware of diagnosis as is her family were advised of condition and the patient defers treatment and plans for treatment to her physicians as she feels they know more appropriately what is involved. When asked about her wishes, she also defers to her son. They are prepared to continue with the treatment and arrangements have been made to set up initial visit on day of discharge with Dr. [**Last Name (STitle) **]. Otherwise, the patient's shortness of breath was likely exacerbated by a post obstructive pneumonia.
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Evidence: Non-small cell carcinoma
Condition: Malignant neoplasm of unspecified part of unspecified bronchus or lung
HCC: C3490
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
She did have three sets of samples sent of for pathology and cytology which eventually, on the day prior to discharge, returned as highly suspicious for non-small cell carcinoma. The patient was advised of these findings and referred to the Thoracic Multi-Disciplinary Oncology Center for further follow-up and further staging. The patient is aware of diagnosis as is her family were advised of condition and the patient defers treatment and plans for treatment to her physicians as she feels they know more appropriately what is involved. When asked about her wishes, she also defers to her son. They are prepared to continue with the treatment and arrangements have been made to set up initial visit on day of discharge with Dr. [**Last Name (STitle) **]. Otherwise, the patient's shortness of breath was likely exacerbated by a post obstructive pneumonia. Eventually, Flagyl was added on for better anaerobic coverage and the patient is to complete a ten day course of this.
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Evidence: referred to the Thoracic Multi-Disciplinary Oncology Center for further follow-up and further staging
Condition: Malignant neoplasm of unspecified part of unspecified bronchus or lung
HCC: C3490
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
|
When asked about her wishes, she also defers to her son. They are prepared to continue with the treatment and arrangements have been made to set up initial visit on day of discharge with Dr. [**Last Name (STitle) **]. Otherwise, the patient's shortness of breath was likely exacerbated by a post obstructive pneumonia. Eventually, Flagyl was added on for better anaerobic coverage and the patient is to complete a ten day course of this. She has seven more days to go to complete those. Her shortness of breath improved throughout her stay.
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Evidence: arrangements have been made to set up initial visit on day of discharge
Condition: Malignant neoplasm of unspecified part of unspecified bronchus or lung
HCC: C3490
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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DISCHARGE INSTRUCTIONS: 1. The patient is to follow-up with Dr. [**Last Name (STitle) **] in the Multispecialty Thoracic Clinic at 03:30 on [**4-19**]. 2. The patient is to follow-up with her nurse practitioner, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2114-4-25**]. 3. The patient is to follow-up with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**2114-5-22**]. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D.
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Evidence: The patient is to follow-up with Dr. [**Last Name (STitle) **] in the
Multispecialty Thoracic Clinic
Condition: Malignant neoplasm of unspecified part of unspecified bronchus or lung
HCC: C3490
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
|
No source of hemoptysis, but she had minimal non-purulent secretions. She did have three sets of samples sent of for pathology and cytology which eventually, on the day prior to discharge, returned as highly suspicious for non-small cell carcinoma. The patient was advised of these findings and referred to the Thoracic Multi-Disciplinary Oncology Center for further follow-up and further staging. The patient is aware of diagnosis as is her family were advised of condition and the patient defers treatment and plans for treatment to her physicians as she feels they know more appropriately what is involved. When asked about her wishes, she also defers to her son. They are prepared to continue with the treatment and arrangements have been made to set up initial visit on day of discharge with Dr.
|
Evidence: non-small cell
carcinoma
Condition: Malignant neoplasm of unspecified part of unspecified bronchus or lung
HCC: C3490
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
4. CORONARY ARTERY DISEASE: The patient was stable and continued on her metoprolol although her aspirin was held for procedures and can be restarted once her work-up for her lung cancer is completed. 5. DIABETES MELLITUS: She was overall well controlled on a sliding scale, however, her fingersticks remained between 112 and 130 during the course of her stay with minimal sliding scale requirements. She will continue at home off medications but advised to continue with diabetic diet. This can continue to be followed as an outpatient.
|
Evidence: lung
cancer
Condition: Malignant neoplasm of unspecified part of unspecified bronchus or lung
HCC: C3490
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
No source of hemoptysis, but she had minimal non-purulent secretions. She did have three sets of samples sent of for pathology and cytology which eventually, on the day prior to discharge, returned as highly suspicious for non-small cell carcinoma. The patient was advised of these findings and referred to the Thoracic Multi-Disciplinary Oncology Center for further follow-up and further staging. The patient is aware of diagnosis as is her family were advised of condition and the patient defers treatment and plans for treatment to her physicians as she feels they know more appropriately what is involved. When asked about her wishes, she also defers to her son. They are prepared to continue with the treatment and arrangements have been made to set up initial visit on day of discharge with Dr. [**Last Name (STitle) **].
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Evidence: Non-small cell carcinoma
Condition: Malignant neoplasm of unspecified part of unspecified bronchus or lung
HCC: C3490
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
She was not on Coumadin secondary to fall risk and a question of compliance, and otherwise remained stable and asymptomatic. The patient's elevated troponins on admission were likely secondary to the demand ischemia secondary to her atrial fibrillation with rapid ventricular response. 4. CORONARY ARTERY DISEASE: The patient was stable and continued on her metoprolol although her aspirin was held for procedures and can be restarted once her work-up for her lung cancer is completed. 5. DIABETES MELLITUS: She was overall well controlled on a sliding scale, however, her fingersticks remained between 112 and 130 during the course of her stay with minimal sliding scale requirements. She will continue at home off medications but advised to continue with diabetic diet. This can continue to be followed as an outpatient. 6.
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Evidence: elevated troponins on admission
Condition: Other forms of acute ischemic heart disease
HCC: I248
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
She was not on Coumadin secondary to fall risk and a question of compliance, and otherwise remained stable and asymptomatic. The patient's elevated troponins on admission were likely secondary to the demand ischemia secondary to her atrial fibrillation with rapid ventricular response. 4. CORONARY ARTERY DISEASE: The patient was stable and continued on her metoprolol although her aspirin was held for procedures and can be restarted once her work-up for her lung cancer is completed. 5. DIABETES MELLITUS: She was overall well controlled on a sliding scale, however, her fingersticks remained between 112 and 130 during the course of her stay with minimal sliding scale requirements.
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Evidence: demand ischemia
Condition: Other forms of acute ischemic heart disease
HCC: I248
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
She was not on Coumadin secondary to fall risk and a question of compliance, and otherwise remained stable and asymptomatic. The patient's elevated troponins on admission were likely secondary to the demand ischemia secondary to her atrial fibrillation with rapid ventricular response. 4. CORONARY ARTERY DISEASE: The patient was stable and continued on her metoprolol although her aspirin was held for procedures and can be restarted once her work-up for her lung cancer is completed. 5.
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Evidence: demand ischemia
Condition: Other forms of acute ischemic heart disease
HCC: I248
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
She has seven more days to go to complete those. Her shortness of breath improved throughout her stay. She continued to use her incentive spirometer and eventually was weaned off nasal cannula and saturating well even with ambulation. She did not require oxygen for the last four days of her admission. 2. ESCHERICHIEAE COLI BACTEREMIA AND URINARY TRACT INFECTION: The patient had a few blood cultures positive for E. coli at time of admission as were her urine cultures.
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Evidence: shortness of breath improved throughout her stay
Condition: Unspecified diastolic congestive heart failure
HCC: I130
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Her shortness of breath improved throughout her stay. She continued to use her incentive spirometer and eventually was weaned off nasal cannula and saturating well even with ambulation. She did not require oxygen for the last four days of her admission. 2. ESCHERICHIEAE COLI BACTEREMIA AND URINARY TRACT INFECTION: The patient had a few blood cultures positive for E. coli at time of admission as were her urine cultures. It was likely that the patient had a urinary source of her urinary tract infection but her E. coli was pan sensitive and the patient was continued on Levofloxacin for her urinary tract infection and her E.
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Evidence: weaned off nasal cannula and saturating well
Condition: Unspecified diastolic congestive heart failure
HCC: I130
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
She continued to use her incentive spirometer and eventually was weaned off nasal cannula and saturating well even with ambulation. She did not require oxygen for the last four days of her admission. 2. ESCHERICHIEAE COLI BACTEREMIA AND URINARY TRACT INFECTION: The patient had a few blood cultures positive for E. coli at time of admission as were her urine cultures.
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Evidence: not requiring oxygen for the last four days of her admission
Condition: Unspecified diastolic congestive heart failure
HCC: I130
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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9. Recent echocardiogram in [**Month (only) **] showed an ejection fraction of 60% with mild to moderate mitral regurgitation and aortic regurgitation, prolonged E wave deceleration, impaired relaxation, mild pulmonary artery systolic hypertension. MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 25 mg p.o. q.
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Evidence: Recent echocardiogram in [**Month (only) **] showed an ejection fraction of 60%
Condition: Unspecified diastolic congestive heart failure
HCC: I130
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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9. Recent echocardiogram in [**Month (only) **] showed an ejection fraction of 60% with mild to moderate mitral regurgitation and aortic regurgitation, prolonged E wave deceleration, impaired relaxation, mild pulmonary artery systolic hypertension. MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 25 mg p.o. q. day.
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Evidence: prolonged E wave deceleration, impaired relaxation
Condition: Unspecified diastolic congestive heart failure
HCC: I130
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week. This most recent one prompted an Emergency Room visit. She also notes decreased appetite, possibly change in weight, but her clothes are looser than they had been. She reports good compliance with her home anti-hypertensives, but does not measure her blood pressures.
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Evidence: congestive heart failure
Condition: Unspecified diastolic congestive heart failure
HCC: I130
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week. This most recent one prompted an Emergency Room visit.
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Evidence: diastolic dysfunction
Condition: Unspecified diastolic congestive heart failure
HCC: I130
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
PAST MEDICAL HISTORY: 1. Congestive heart failure with diastolic dysfunction. 2. Diabetes mellitus. 3. Coronary artery disease status post an myocardial infarction. 4.
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Evidence: Congestive heart failure with diastolic dysfunction
Condition: Unspecified diastolic congestive heart failure
HCC: I130
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week. This most recent one prompted an Emergency Room visit. She also notes decreased appetite, possibly change in weight, but her clothes are looser than they had been. She reports good compliance with her home anti-hypertensives, but does not measure her blood pressures.
|
Evidence: congestive
heart failure
Condition: Unspecified diastolic congestive heart failure
HCC: I130
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week. This most recent one prompted an Emergency Room visit. She also notes decreased appetite, possibly change in weight, but her clothes are looser than they had been.
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Evidence: diastolic dysfunction
Condition: Unspecified diastolic congestive heart failure
HCC: I130
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
3. Diastolic congestive heart failure. 4. Urinary tract infection. 5.
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Evidence: Diastolic congestive heart failure
Condition: Unspecified diastolic congestive heart failure
HCC: I130
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
She received a dose of Lopressor and Diltiazem in the Emergency Room with good response. Also, she received 20 of intravenous Lasix, Nitroglycerin, digoxin and then had a CT scan of her chest done to evaluate for shortness of breath. She was noted to have some lymphadenopathy and diffuse nodules worse on the left than on the right. PAST MEDICAL HISTORY: 1. Congestive heart failure with diastolic dysfunction. 2. Diabetes mellitus. 3. Coronary artery disease status post an myocardial infarction.
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Evidence: received 20 of intravenous Lasix
Condition: Unspecified diastolic congestive heart failure
HCC: I130
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week. This most recent one prompted an Emergency Room visit. She also notes decreased appetite, possibly change in weight, but her clothes are looser than they had been. She reports good compliance with her home anti-hypertensives, but does not measure her blood pressures.
|
Evidence: congestive heart failure
Condition: Unspecified diastolic congestive heart failure
HCC: I130
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week. This most recent one prompted an Emergency Room visit. She also notes decreased appetite, possibly change in weight, but her clothes are looser than they had been.
|
Evidence: diastolic dysfunction
Condition: Unspecified diastolic congestive heart failure
HCC: I130
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
PAST MEDICAL HISTORY: 1. Congestive heart failure with diastolic dysfunction. 2. Diabetes mellitus. 3. Coronary artery disease status post an myocardial infarction. 4.
|
Evidence: Congestive heart failure with diastolic dysfunction
Condition: Unspecified diastolic congestive heart failure
HCC: I130
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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Admission Date: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week.
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Evidence: congestive
heart failure
Condition: Unspecified diastolic congestive heart failure
HCC: I130
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: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week. This most recent one prompted an Emergency Room visit. She also notes decreased appetite, possibly change in weight, but her clothes are looser than they had been. She reports good compliance with her home anti-hypertensives, but does not measure her blood pressures.
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Evidence: diastolic dysfunction
Condition: Unspecified diastolic congestive heart failure
HCC: I130
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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3. Diastolic congestive heart failure. 4. Urinary tract infection. 5.
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Evidence: Diastolic congestive heart failure
Condition: Unspecified diastolic congestive heart failure
HCC: I130
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. CHRONIC RENAL INSUFFICIENCY: Her creatinine was elevated on admission at 1.7 and back down to her baseline of 1.1 and 1.2 at time of discharge. Likely this was slightly prerenal dehydration on admission. CONDITION ON DISCHARGE: Good. The patient is ambulated with the assistance of walker without difficulty.
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Evidence: Her creatinine was elevated on admission at 1.7 and back down to her baseline of 1.1 and 1.2 at time of discharge
Condition: Chronic kidney disease, unspecified
HCC: I130
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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LABORATORY: On admission, white blood cell count 13.6, hematocrit 34, platelets of 209 and differential with 70% neutrophils, 15% bands, 12% lymphs. Hematocrit 139, potassium 3.7, chloride 105, bicarbonate 18, BUN 31, creatinine 1.7, gap of 16. Glucose of 192. CK of 240; CK MB of 5, troponin of 0.01. Blood gas with pH of 7.33, pCO2 of 33, pO2 of 63, lactate of 5. On admission EKG she had atrial fibrillation with rapid ventricular response, diffuse ST depression, and then follow-up EKG had sinus tachycardia at a rate of 112, normal axis, normal intervals.
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Evidence: creatinine 1.7
Condition: Chronic kidney disease, unspecified
HCC: I130
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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7. CHRONIC RENAL INSUFFICIENCY: Her creatinine was elevated on admission at 1.7 and back down to her baseline of 1.1 and 1.2 at time of discharge. Likely this was slightly prerenal dehydration on admission. CONDITION ON DISCHARGE: Good. The patient is ambulated with the assistance of walker without difficulty. The patient is sitting up in a chair without difficulty. The patient is not requiring oxygen. The patient aware of diagnosis although unsure if understands complete complications and associated issues associated with her diagnosis.
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Evidence: Her creatinine was elevated on admission at 1.7 and back down to her baseline of 1.1 and 1.2 at time of discharge
Condition: Chronic kidney disease, unspecified
HCC: I130
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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7. Chronic renal insufficiency. 8. Arthritis. 9. Recent echocardiogram in [**Month (only) **] showed an ejection fraction of 60% with mild to moderate mitral regurgitation and aortic regurgitation, prolonged E wave deceleration, impaired relaxation, mild pulmonary artery systolic hypertension. MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 25 mg p.o. q.
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Evidence: Chronic renal insufficiency
Condition: Chronic kidney disease, unspecified
HCC: I130
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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7. Chronic renal insufficiency. 8. Arthritis. 9. Recent echocardiogram in [**Month (only) **] showed an ejection fraction of 60% with mild to moderate mitral regurgitation and aortic regurgitation, prolonged E wave deceleration, impaired relaxation, mild pulmonary artery systolic hypertension. MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 25 mg p.o. q.
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Evidence: CHRONIC RENAL INSUFFICIENCY
Condition: Chronic kidney disease, unspecified
HCC: I130
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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7. Chronic renal insufficiency. 8. Arthritis. 9. Recent echocardiogram in [**Month (only) **] showed an ejection fraction of 60% with mild to moderate mitral regurgitation and aortic regurgitation, prolonged E wave deceleration, impaired relaxation, mild pulmonary artery systolic hypertension. MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 25 mg p.o. q.
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Evidence: Chronic renal insufficiency
Condition: Chronic kidney disease, unspecified
HCC: I130
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. Chronic renal insufficiency. 8. Arthritis. 9. Recent echocardiogram in [**Month (only) **] showed an ejection fraction of 60% with mild to moderate mitral regurgitation and aortic regurgitation, prolonged E wave deceleration, impaired relaxation, mild pulmonary artery systolic hypertension. MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 25 mg p.o.
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Evidence: CHRONIC RENAL INSUFFICIENCY
Condition: Chronic kidney disease, unspecified
HCC: I130
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Father with history unknown. PHYSICAL EXAMINATION: On admission, temperature 99.8 F.; pulse of 129; blood pressure 166/71; respiratory saturation of 92% on room air; respiratory rate of 20. In general, she is an elderly woman sitting up, tripoding with moderate respiratory distress. HEENT: Normocephalic, atraumatic. Pupils are equal, round and reactive to light on the left; right side with clouding of her cornea. Neck was supple. Cardiovascular is tachycardic. Pulmonary examination with bilateral coarse expiratory wheezes and diffuse crackles throughout, left greater than right. Abdomen was soft, nontender, nondistended, active bowel sounds.
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Evidence: blood pressure 166/71
Condition: Essential (primary) hypertension
HCC: I130
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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HYPERTENSION: She was continued on her Hydrochlorothiazide, Metoprolol and Diltiazem. She had fairly good control on this regimen, with occasional episodes of hypertension throughout the course of her stay which resolved quickly. 7. CHRONIC RENAL INSUFFICIENCY: Her creatinine was elevated on admission at 1.7 and back down to her baseline of 1.1 and 1.2 at time of discharge. Likely this was slightly prerenal dehydration on admission.
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Evidence: fairly good control on this regimen, with occasional episodes of hypertension throughout the course of her stay which resolved quickly
Condition: Essential (primary) hypertension
HCC: I130
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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Father with history unknown. PHYSICAL EXAMINATION: On admission, temperature 99.8 F.; pulse of 129; blood pressure 166/71; respiratory saturation of 92% on room air; respiratory rate of 20. In general, she is an elderly woman sitting up, tripoding with moderate respiratory distress. HEENT: Normocephalic, atraumatic. Pupils are equal, round and reactive to light on the left; right side with clouding of her cornea. Neck was supple. Cardiovascular is tachycardic.
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Evidence: blood pressure 166/71
Condition: Essential (primary) hypertension
HCC: I130
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats.
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Evidence: poorly controlled
hypertension
Condition: Essential (primary) hypertension
HCC: I130
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week.
|
Evidence: Hypertension
Condition: Essential (primary) hypertension
HCC: I130
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Admission Date: [**2114-4-12**] Discharge Date: [**2114-4-19**] Service: [**Company 191**] MEDICI HISTORY OF PRESENT ILLNESS: This is a 79 year old woman with a history of atrial fibrillation with rapid ventricular rate status post pharmacologic conversion and status post pacemaker for tachy-brady syndrome with congestive heart failure, diastolic dysfunction, and poorly controlled hypertension, who presented with shortness of breath. The patient reports a three to four week history of "a cold" with cough productive of yellow thick sputum, occasionally blood. She admits to fevers, chills, which have been intermittent over the past few weeks but she did not take an actual temperature. No night sweats. She does admit to shortness of breath, especially with some severe spells over the last week.
|
Evidence: HYPERTENSION
Condition: Essential (primary) hypertension
HCC: I130
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
She also notes decreased appetite, possibly change in weight, but her clothes are looser than they had been. She reports good compliance with her home anti-hypertensives, but does not measure her blood pressures. She says her diabetes mellitus is borderline diabetes mellitus but not on any medications nor does she check fingersticks at home. She denied any chest pain but was with tachycardia on arrival at the Emergency Room. She received a dose of Lopressor and Diltiazem in the Emergency Room with good response.
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Evidence: reports good compliance with her home anti-hypertensives
Condition: Essential (primary) hypertension
HCC: I130
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 25 mg p.o. q. day. 2. Lisinopril 40 mg p.o. q. day.
|
Evidence: Hydrochlorothiazide 25 mg p.o. q. day
Condition: Essential (primary) hypertension
HCC: I130
Category: Treatment
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