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Extract medical evidence from the following clinical text that supports medical condition coding:
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2. Lisinopril 40 mg p.o. q. day. 3. Amlodipine 10 mg p.o. q. day. 4.
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Evidence: Lisinopril 40 mg p.o. q. day
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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3. Amlodipine 10 mg p.o. q. day. 4. Aspirin 325 mg p.o. q. day. 5.
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Evidence: Amlodipine 10 mg p.o. q. day
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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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: 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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6. 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. CONDITION ON DISCHARGE: Good. The patient is ambulated with the assistance of walker without difficulty.
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Evidence: continued on her
Hydrochlorothiazide, Metoprolol and Diltiazem
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. 3. Amlodipine 10 mg p.o. q. day. 4. Aspirin 325 mg p.o. q. day. 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. FAMILY HISTORY: Includes mother who died of breast cancer and an uncle with cancer. 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. Extremities with no cyanosis, clubbing or edema. Neurological examination: She was alert, oriented and appropriate, and moving all extremities. 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. The ST changes were resolved. A CT scan showed no evidence of pulmonary embolism, extensive hilar lymphadenopathy and multiple foci. 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. 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. 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: Hydrochlorothiazide 25 mg p.o. q. day times seven more days
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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4. Diltiazem 60 mg p.o. four times a day. 5. Ipratropium MDI, two puffs inhaled four times a day. 6. Toprol XL 100 mg p.o.
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Evidence: Diltiazem 60 mg p.o. four times a day
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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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.
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Evidence: Toprol XL 100 mg p.o. q. day
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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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: poorly controlled
hypertension
Condition: Essential (primary) hypertension
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: Hypertension
Condition: Essential (primary) hypertension
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.
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Evidence: HYPERTENSION
Condition: Essential (primary) hypertension
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. The ST changes were resolved. A CT scan showed no evidence of pulmonary embolism, extensive hilar lymphadenopathy and multiple foci.
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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. DISCHARGE STATUS: Discharged to home with services.
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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.
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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.
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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.
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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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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. 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.
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Evidence: her fingersticks remained between 112
and 130 during the course of her stay with minimal sliding
scale requirements
Condition: Type 2 diabetes mellitus without complications
HCC: E1122
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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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. The ST changes were resolved. A CT scan showed no evidence of pulmonary embolism, extensive hilar lymphadenopathy and multiple foci.
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Evidence: Glucose of 192
Condition: Type 2 diabetes mellitus without complications
HCC: E1122
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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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. 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.
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Evidence: diabetes mellitus is borderline diabetes
mellitus
Condition: Type 2 diabetes mellitus without complications
HCC: E1122
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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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. 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.
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Evidence: Diabetes mellitus
Condition: Type 2 diabetes mellitus without complications
HCC: E1122
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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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. 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.
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Evidence: DIABETES MELLITUS
Condition: Type 2 diabetes mellitus without complications
HCC: E1122
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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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. HYPERTENSION: She was continued on her Hydrochlorothiazide, Metoprolol and Diltiazem.
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Evidence: overall well controlled on a
sliding scale
Condition: Type 2 diabetes mellitus without complications
HCC: E1122
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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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. 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.
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Evidence: advised to continue with diabetic diet
Condition: Type 2 diabetes mellitus without complications
HCC: E1122
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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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. 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.
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Evidence: diabetes mellitus is borderline diabetes
mellitus
Condition: Type 2 diabetes mellitus without complications
HCC: E1122
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 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. 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.
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Evidence: Diabetes mellitus
Condition: Type 2 diabetes mellitus without complications
HCC: E1122
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 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. 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.
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Evidence: DIABETES MELLITUS
Condition: Type 2 diabetes mellitus without complications
HCC: E1122
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. 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. DISCHARGE STATUS: Discharged to home with services.
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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: E1122
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.
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Evidence: creatinine 1.7
Condition: Chronic kidney disease, unspecified
HCC: E1122
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: E1122
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.
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Evidence: Chronic renal insufficiency
Condition: Chronic kidney disease, unspecified
HCC: E1122
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: E1122
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.
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Evidence: Chronic renal insufficiency
Condition: Chronic kidney disease, unspecified
HCC: E1122
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. q.
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Evidence: CHRONIC RENAL INSUFFICIENCY
Condition: Chronic kidney disease, unspecified
HCC: E1122
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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IgG level wnl. Dr [**Last Name (STitle) **] followed patient closely. No plan for IVIG infusion. . # Diabetes. Last HgA1c: 9.0. Patient states she does not take any meds for diabetes and her daughter said she eats whatever she wants.
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Evidence: Dr [**Last Name (STitle) **] followed patient closely.
Condition: Chronic lymphocytic leukemia of B-cell type not having achieved remission
HCC: C9110
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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In the ED, initial VS: 99.3 81 118/46 20 96% NRB. Labs notable for WBC of 33.2, 61% lymphocytes; K: 5.2, creatinine 2.7, lactate 1.3. Blood cultures obtained. CXR performed which demonstrated interval increase in moderate - large right pleural effusion as well as opacity lateral to left hilum. Patient received PO Tylenol 650mg x1, IV Ceftriaxone and Levofloxacin.
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Evidence: WBC of 33.2, 61% lymphocytes
Condition: Chronic lymphocytic leukemia of B-cell type not having achieved remission
HCC: C9110
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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ANAEROBIC CULTURE (Final [**2135-2-11**]): NO GROWTH. URINE CULTURE (Final [**2135-2-10**]): <10,000 organisms/ml Pleural Pathology: pending CT chest: FINDINGS: Bulky lymphadenopathy is present in the imaged portion of the lower neck, superior mediastinum, throughout the intrathoracic mediastinum, bilateral hila, and to a lesser extent within the axillary regions. Large right pleural effusion is dependent in location and measures simple fluid density. A small amount of loculated fluid is also present within the major fissure and in the anterolateral portion of the right lower chest. Extensive consolidation is present within the right lower and right middle lobes. Peribronchiolar abnormalities are present in both upper lobes with a combination of ground glass and consolidation accompanied by bronchial wall thickening and small peribronchial nodules. A dominant peribronchial nodule in the left upper lobe measures 2.2 cm and is surrounded by a halo of ground-glass opacity (26, series 3A). This corresponds to a rapidly growing focal opacity on serial chest x-rays between [**2135-2-8**] and [**2135-2-10**].
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Evidence: Bulky lymphadenopathy is present in the imaged portion
of the lower neck, superior mediastinum, throughout the
intrathoracic mediastinum, bilateral hila, and to a lesser
extent within the axillary regions
Condition: Chronic lymphocytic leukemia of B-cell type not having achieved remission
HCC: C9110
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Additional peribronchiolar abnormalities are present to a lesser extent within the left lower lobe. Exam was not tailored to evaluate the subdiaphragmatic region, but note is made of retroperitoneal or intra-abdominal lymphadenopathy as well as incompletely imaged splenomegaly. Lucent spine lesions within the lower thoracic spine (image 53, series 3A and image 48, series 3A) are probably hemangiomas. Degenerative changes are also noted at multiple levels throughout the spine. IMPRESSION: 1.
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Evidence: incompletely imaged splenomegaly
Condition: Chronic lymphocytic leukemia of B-cell type not having achieved remission
HCC: C9110
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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CC: cough, shortness of breath . HPI: 83yo female Russian with history of CLL presenting with respiratory distress. . Per patient she reports 6 days of productive cough and progressive dyspnea. She reports associated fevers up to 100.2 and sore throat. Two days prior to admission prescribed bactrim by her son who is a physician. [**Name10 (NameIs) **] [**Name11 (NameIs) 3010**] worsened and she presented to her PCP [**Name Initial (PRE) 3011**]. There vital signs notable for O2 sat 89% RA, improved to 92% on 2L NC.
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Evidence: CLL
Condition: Chronic lymphocytic leukemia of B-cell type not having achieved remission
HCC: C9110
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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CC: cough, shortness of breath . HPI: 83yo female Russian with history of CLL presenting with respiratory distress. . Per patient she reports 6 days of productive cough and progressive dyspnea. She reports associated fevers up to 100.2 and sore throat. Two days prior to admission prescribed bactrim by her son who is a physician. [**Name10 (NameIs) **] [**Name11 (NameIs) 3010**] worsened and she presented to her PCP [**Name Initial (PRE) 3011**]. There vital signs notable for O2 sat 89% RA, improved to 92% on 2L NC. CXR with right increased effusion and possible left sided infiltrate.
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Evidence: CLL
Condition: Chronic lymphocytic leukemia of B-cell type not having achieved remission
HCC: C9110
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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CC: cough, shortness of breath . HPI: 83yo female Russian with history of CLL presenting with respiratory distress. . Per patient she reports 6 days of productive cough and progressive dyspnea. She reports associated fevers up to 100.2 and sore throat. Two days prior to admission prescribed bactrim by her son who is a physician. [**Name10 (NameIs) **] [**Name11 (NameIs) 3010**] worsened and she presented to her PCP [**Name Initial (PRE) 3011**]. There vital signs notable for O2 sat 89% RA, improved to 92% on 2L NC.
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Evidence: CLL
Condition: Chronic lymphocytic leukemia of B-cell type not having achieved remission
HCC: C9110
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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ROS: +: as per HPI -: denies any chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, orthopnea, PND, lower extremity edema, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: Past Medical History: # Oncologic History Chronic Lymphocytic Leukemia - Diagnosed in [**2125**]: Rai stage 0 in [**2125**] - s/p 5 cycles of fludarabine ending in [**2130-5-29**]. - recurrent anemia and advancing peripheral blood lymphocytosis and lymphadenopathy, prompted 4 additional 3-day cycles of fludarabine from [**3-9**] to [**6-6**]. # PMH 1. Macular degeneration; legally blind. 2.
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Evidence: Chronic Lymphocytic Leukemia
Condition: Chronic lymphocytic leukemia of B-cell type not having achieved remission
HCC: C9110
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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CC: cough, shortness of breath . HPI: 83yo female Russian with history of CLL presenting with respiratory distress. . Per patient she reports 6 days of productive cough and progressive dyspnea. She reports associated fevers up to 100.2 and sore throat. Two days prior to admission prescribed bactrim by her son who is a physician. [**Name10 (NameIs) **] [**Name11 (NameIs) 3010**] worsened and she presented to her PCP [**Name Initial (PRE) 3011**]. There vital signs notable for O2 sat 89% RA, improved to 92% on 2L NC.
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Evidence: CLL
Condition: Chronic lymphocytic leukemia of B-cell type not having achieved remission
HCC: C9110
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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CC: cough, shortness of breath . HPI: 83yo female Russian with history of CLL presenting with respiratory distress. . Per patient she reports 6 days of productive cough and progressive dyspnea. She reports associated fevers up to 100.2 and sore throat. Two days prior to admission prescribed bactrim by her son who is a physician. [**Name10 (NameIs) **] [**Name11 (NameIs) 3010**] worsened and she presented to her PCP [**Name Initial (PRE) 3011**]. There vital signs notable for O2 sat 89% RA, improved to 92% on 2L NC. CXR with right increased effusion and possible left sided infiltrate.
|
Evidence: CLL
Condition: Chronic lymphocytic leukemia of B-cell type not having achieved remission
HCC: C9110
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
CC: cough, shortness of breath . HPI: 83yo female Russian with history of CLL presenting with respiratory distress. . Per patient she reports 6 days of productive cough and progressive dyspnea. She reports associated fevers up to 100.2 and sore throat. Two days prior to admission prescribed bactrim by her son who is a physician. [**Name10 (NameIs) **] [**Name11 (NameIs) 3010**] worsened and she presented to her PCP [**Name Initial (PRE) 3011**].
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Evidence: CLL
Condition: Chronic lymphocytic leukemia of B-cell type not having achieved remission
HCC: C9110
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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FeNa: 1.3. Creatinine slowly improved with IVF and was 2.3. at time of transfer to the medical floor. Trending daily. It was lowered to 1.7 prior to discharge. .
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Evidence: Creatinine slowly improved
Condition: Chronic kidney disease, stage 3a
HCC: N1831
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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at time of transfer to the medical floor. Trending daily. It was lowered to 1.7 prior to discharge. . # CLL. Patient diagnosed in [**2125**]. Patient last treated with fludarabine in [**2133-5-29**]. Labs notable for elevated WBC >20 since 4/[**2134**].
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Evidence: Trending daily.
Condition: Chronic kidney disease, stage 3a
HCC: N1831
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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2. Chronic renal failure: baseline creatinine 1.5 3. Hypothyroidism secondary to hemithyroidectomy on [**2121-2-26**] 4. Diabetes: last HgA1c: 7.0 5. Hypertension.
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Evidence: baseline creatinine 1.5
Condition: Chronic kidney disease, stage 3a
HCC: N1831
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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In the ED, initial VS: 99.3 81 118/46 20 96% NRB. Labs notable for WBC of 33.2, 61% lymphocytes; K: 5.2, creatinine 2.7, lactate 1.3. Blood cultures obtained. CXR performed which demonstrated interval increase in moderate - large right pleural effusion as well as opacity lateral to left hilum. Patient received PO Tylenol 650mg x1, IV Ceftriaxone and Levofloxacin. The patient was attempted to be weaned to NC, but desated to 90%. She was placed back on a NRB and transferred to [**Hospital Unit Name 153**] for further evaluation and management. .
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Evidence: creatinine 2.7
Condition: Chronic kidney disease, stage 3a
HCC: N1831
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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Patient with history of chronic renal insufficiency with baseline creatinine 1.5. Creatinine on admission 2.7. Etiology pre-renal, AIN in setting of recent bactrim usage. UA and urine culture without sign of infection. Urine eosinophils negative. FeNa: 1.3. Creatinine slowly improved with IVF and was 2.3. at time of transfer to the medical floor. Trending daily.
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Evidence: Creatinine on admission 2.7.
Condition: Chronic kidney disease, stage 3a
HCC: N1831
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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FeNa: 1.3. Creatinine slowly improved with IVF and was 2.3. at time of transfer to the medical floor. Trending daily. It was lowered to 1.7 prior to discharge. . # CLL. Patient diagnosed in [**2125**].
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Evidence: was 2.3. at
time of transfer to the medical floor.
Condition: Chronic kidney disease, stage 3a
HCC: N1831
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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Trending daily. It was lowered to 1.7 prior to discharge. . # CLL. Patient diagnosed in [**2125**]. Patient last treated with fludarabine in [**2133-5-29**]. Labs notable for elevated WBC >20 since 4/[**2134**]. Patient without anemia or thrombocytopenia.
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Evidence: It was
lowered to 1.7 prior to discharge.
Condition: Chronic kidney disease, stage 3a
HCC: N1831
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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Urine eosinophils negative. FeNa: 1.3. Creatinine slowly improved with IVF and was 2.3. at time of transfer to the medical floor. Trending daily.
|
Evidence: FeNa: 1.3.
Condition: Chronic kidney disease, stage 3a
HCC: N1831
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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2. Chronic renal failure: baseline creatinine 1.5 3. Hypothyroidism secondary to hemithyroidectomy on [**2121-2-26**] 4. Diabetes: last HgA1c: 7.0 5. Hypertension.
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Evidence: Chronic renal failure
Condition: Chronic kidney disease, stage 3a
HCC: N1831
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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# [**Last Name (un) **]. Patient with history of chronic renal insufficiency with baseline creatinine 1.5. Creatinine on admission 2.7. Etiology pre-renal, AIN in setting of recent bactrim usage. UA and urine culture without sign of infection.
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Evidence: chronic renal insufficiency
Condition: Chronic kidney disease, stage 3a
HCC: N1831
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: Community acquired pneumonia with parapneumonic effusion Chronic kidney disease stage III CLL Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for treatment for severe pneumonia as well as fluid in the lung.
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Evidence: Chronic kidney disease stage III
Condition: Chronic kidney disease, stage 3a
HCC: N1831
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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2. Chronic renal failure: baseline creatinine 1.5 3. Hypothyroidism secondary to hemithyroidectomy on [**2121-2-26**] 4. Diabetes: last HgA1c: 7.0 5. Hypertension.
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Evidence: Chronic renal failure
Condition: Chronic kidney disease, stage 3a
HCC: N1831
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
# [**Last Name (un) **]. Patient with history of chronic renal insufficiency with baseline creatinine 1.5. Creatinine on admission 2.7. Etiology pre-renal, AIN in setting of recent bactrim usage. UA and urine culture without sign of infection.
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Evidence: chronic renal insufficiency
Condition: Chronic kidney disease, stage 3a
HCC: N1831
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: Community acquired pneumonia with parapneumonic effusion Chronic kidney disease stage III CLL Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for treatment for severe pneumonia as well as fluid in the lung. The fluid in the lung was sampled. You were started on antibiotics with improvement in your symptoms.
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Evidence: Chronic kidney disease stage III
Condition: Chronic kidney disease, stage 3a
HCC: N1831
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Chronic renal failure: baseline creatinine 1.5 3. Hypothyroidism secondary to hemithyroidectomy on [**2121-2-26**] 4. Diabetes: last HgA1c: 7.0 5. Hypertension. 6. In [**2133-6-29**], she was admitted to hospital with respiratory infection due to H1N1 influenza A.
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Evidence: Hypothyroid
Condition: Postprocedural hypothyroidism
HCC: E890
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Chronic renal failure: baseline creatinine 1.5 3. Hypothyroidism secondary to hemithyroidectomy on [**2121-2-26**] 4. Diabetes: last HgA1c: 7.0 5. Hypertension. 6.
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Evidence: Hypothyroidism
Condition: Postprocedural hypothyroidism
HCC: E890
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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# Hypothyroid. Continued Synthroid . # FEN: IVF, replete prn, diabetic/cardiac diet . # Access: PIV . # PPx: subQ heparin, home PPI .
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Evidence: Continued Synthroid
Condition: Postprocedural hypothyroidism
HCC: E890
Category: Treatment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO BID (2 times a day). 5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*0* 6. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 2 doses. Disp:*2 Tablet(s)* Refills:*0* 7.
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Evidence: levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Condition: Postprocedural hypothyroidism
HCC: E890
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Chronic renal failure: baseline creatinine 1.5 3. Hypothyroidism secondary to hemithyroidectomy on [**2121-2-26**] 4. Diabetes: last HgA1c: 7.0 5. Hypertension. 6. In [**2133-6-29**], she was admitted to hospital with respiratory infection due to H1N1 influenza A. She received 6 days of Tamiflu and Levaquin with improvement in symptoms.
|
Evidence: Hypothyroidism secondary to hemithyroidectomy
Condition: Postprocedural hypothyroidism
HCC: E890
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Chronic renal failure: baseline creatinine 1.5 3. Hypothyroidism secondary to hemithyroidectomy on [**2121-2-26**] 4. Diabetes: last HgA1c: 7.0 5. Hypertension. 6.
|
Evidence: Hypothyroid
Condition: Postprocedural hypothyroidism
HCC: E890
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Chronic renal failure: baseline creatinine 1.5 3. Hypothyroidism secondary to hemithyroidectomy on [**2121-2-26**] 4. Diabetes: last HgA1c: 7.0 5. Hypertension. 6. In [**2133-6-29**], she was admitted to hospital with respiratory infection due to H1N1 influenza A.
|
Evidence: Hypothyroidism
Condition: Postprocedural hypothyroidism
HCC: E890
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size and wall thickness with preserved global and regional biventricular systolic function. No clinically significant valvular regurgitation. Borderline pulmonary artery systolic hypertension. An area of echodensity measuring 7.4 cm x 4.9 cm (clip [**Clip Number (Radiology) **]) is seen that appears to be contained within a small right pleural effusion. Clinical correlation and consideration of a chest CT for further characterization suggested.
|
Evidence: borderline pulmonary artery systolic hypertension
Condition: Primary pulmonary hypertension
HCC: I270
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size and wall thickness with preserved global and regional biventricular systolic function. No clinically significant valvular regurgitation. Borderline pulmonary artery systolic hypertension. An area of echodensity measuring 7.4 cm x 4.9 cm (clip [**Clip Number (Radiology) **]) is seen that appears to be contained within a small right pleural effusion. Clinical correlation and consideration of a chest CT for further characterization suggested.
|
Evidence: Borderline pulmonary artery systolic
hypertension
Condition: Primary pulmonary hypertension
HCC: I270
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size and wall thickness with preserved global and regional biventricular systolic function. No clinically significant valvular regurgitation. Borderline pulmonary artery systolic hypertension.
|
Evidence: borderline pulmonary artery systolic hypertension
Condition: Primary pulmonary hypertension
HCC: I270
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size and wall thickness with preserved global and regional biventricular systolic function. No clinically significant valvular regurgitation. Borderline pulmonary artery systolic hypertension.
|
Evidence: Borderline pulmonary artery systolic
hypertension
Condition: Primary pulmonary hypertension
HCC: I270
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
FeNa: 1.3. Creatinine slowly improved with IVF and was 2.3. at time of transfer to the medical floor. Trending daily. It was lowered to 1.7 prior to discharge. . # CLL.
|
Evidence: Creatinine slowly improved
Condition: Chronic kidney disease, stage 3a
HCC: E1122
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
at time of transfer to the medical floor. Trending daily. It was lowered to 1.7 prior to discharge. . # CLL. Patient diagnosed in [**2125**]. Patient last treated with fludarabine in [**2133-5-29**].
|
Evidence: Trending daily.
Condition: Chronic kidney disease, stage 3a
HCC: E1122
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
2. Chronic renal failure: baseline creatinine 1.5 3. Hypothyroidism secondary to hemithyroidectomy on [**2121-2-26**] 4. Diabetes: last HgA1c: 7.0 5. Hypertension. 6. In [**2133-6-29**], she was admitted to hospital with respiratory infection due to H1N1 influenza A. She received 6 days of Tamiflu and Levaquin with improvement in symptoms.
|
Evidence: baseline creatinine 1.5
Condition: Chronic kidney disease, stage 3a
HCC: E1122
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
In the ED, initial VS: 99.3 81 118/46 20 96% NRB. Labs notable for WBC of 33.2, 61% lymphocytes; K: 5.2, creatinine 2.7, lactate 1.3. Blood cultures obtained. CXR performed which demonstrated interval increase in moderate - large right pleural effusion as well as opacity lateral to left hilum. Patient received PO Tylenol 650mg x1, IV Ceftriaxone and Levofloxacin. The patient was attempted to be weaned to NC, but desated to 90%. She was placed back on a NRB and transferred to [**Hospital Unit Name 153**] for further evaluation and management.
|
Evidence: creatinine 2.7
Condition: Chronic kidney disease, stage 3a
HCC: E1122
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Patient with history of chronic renal insufficiency with baseline creatinine 1.5. Creatinine on admission 2.7. Etiology pre-renal, AIN in setting of recent bactrim usage. UA and urine culture without sign of infection. Urine eosinophils negative. FeNa: 1.3. Creatinine slowly improved with IVF and was 2.3.
|
Evidence: Creatinine on admission 2.7.
Condition: Chronic kidney disease, stage 3a
HCC: E1122
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
FeNa: 1.3. Creatinine slowly improved with IVF and was 2.3. at time of transfer to the medical floor. Trending daily. It was lowered to 1.7 prior to discharge. .
|
Evidence: was 2.3. at
time of transfer to the medical floor.
Condition: Chronic kidney disease, stage 3a
HCC: E1122
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Trending daily. It was lowered to 1.7 prior to discharge. . # CLL. Patient diagnosed in [**2125**]. Patient last treated with fludarabine in [**2133-5-29**]. Labs notable for elevated WBC >20 since 4/[**2134**]. Patient without anemia or thrombocytopenia.
|
Evidence: It was
lowered to 1.7 prior to discharge.
Condition: Chronic kidney disease, stage 3a
HCC: E1122
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Urine eosinophils negative. FeNa: 1.3. Creatinine slowly improved with IVF and was 2.3. at time of transfer to the medical floor. Trending daily. It was lowered to 1.7 prior to discharge. . # CLL. Patient diagnosed in [**2125**].
|
Evidence: FeNa: 1.3.
Condition: Chronic kidney disease, stage 3a
HCC: E1122
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
2. Chronic renal failure: baseline creatinine 1.5 3. Hypothyroidism secondary to hemithyroidectomy on [**2121-2-26**] 4. Diabetes: last HgA1c: 7.0 5. Hypertension. 6. In [**2133-6-29**], she was admitted to hospital with respiratory infection due to H1N1 influenza A.
|
Evidence: Chronic renal failure
Condition: Chronic kidney disease, stage 3a
HCC: E1122
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
# [**Last Name (un) **]. Patient with history of chronic renal insufficiency with baseline creatinine 1.5. Creatinine on admission 2.7. Etiology pre-renal, AIN in setting of recent bactrim usage. UA and urine culture without sign of infection. Urine eosinophils negative.
|
Evidence: chronic renal insufficiency
Condition: Chronic kidney disease, stage 3a
HCC: E1122
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: Community acquired pneumonia with parapneumonic effusion Chronic kidney disease stage III CLL Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for treatment for severe pneumonia as well as fluid in the lung. The fluid in the lung was sampled. You were started on antibiotics with improvement in your symptoms. Please continue your antibiotics to complete the full course. Please take all other medications as prescribed.
|
Evidence: Chronic kidney disease stage III
Condition: Chronic kidney disease, stage 3a
HCC: E1122
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
2. Chronic renal failure: baseline creatinine 1.5 3. Hypothyroidism secondary to hemithyroidectomy on [**2121-2-26**] 4. Diabetes: last HgA1c: 7.0 5. Hypertension. 6. In [**2133-6-29**], she was admitted to hospital with respiratory infection due to H1N1 influenza A. She received 6 days of Tamiflu and Levaquin with improvement in symptoms.
|
Evidence: Chronic renal failure
Condition: Chronic kidney disease, stage 3a
HCC: E1122
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
# [**Last Name (un) **]. Patient with history of chronic renal insufficiency with baseline creatinine 1.5. Creatinine on admission 2.7. Etiology pre-renal, AIN in setting of recent bactrim usage. UA and urine culture without sign of infection. Urine eosinophils negative. FeNa: 1.3. Creatinine slowly improved with IVF and was 2.3. at time of transfer to the medical floor.
|
Evidence: chronic renal insufficiency
Condition: Chronic kidney disease, stage 3a
HCC: E1122
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: Community acquired pneumonia with parapneumonic effusion Chronic kidney disease stage III CLL Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for treatment for severe pneumonia as well as fluid in the lung. The fluid in the lung was sampled. You were started on antibiotics with improvement in your symptoms. Please continue your antibiotics to complete the full course. Please take all other medications as prescribed.
|
Evidence: Chronic kidney disease stage III
Condition: Chronic kidney disease, stage 3a
HCC: E1122
Category: condition_evidence
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Patient states she does not take any meds for diabetes and her daughter said she eats whatever she wants. Monitoring QID FS, ISS. . # Hypothyroid. Continued Synthroid . # FEN: IVF, replete prn, diabetic/cardiac diet . # Access: PIV .
|
Evidence: Monitoring QID FS, ISS.
Condition: Type 2 diabetes mellitus without complications
HCC: E1122
Category: Monitoring
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Hypothyroidism secondary to hemithyroidectomy on [**2121-2-26**] 4. Diabetes: last HgA1c: 7.0 5. Hypertension. 6. In [**2133-6-29**], she was admitted to hospital with respiratory infection due to H1N1 influenza A.
|
Evidence: last HgA1c: 7.0
Condition: Type 2 diabetes mellitus without complications
HCC: E1122
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
# Diabetes. Last HgA1c: 9.0. Patient states she does not take any meds for diabetes and her daughter said she eats whatever she wants. Monitoring QID FS, ISS. . # Hypothyroid.
|
Evidence: Last HgA1c: 9.0.
Condition: Type 2 diabetes mellitus without complications
HCC: E1122
Category: Evaluation
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Hypothyroidism secondary to hemithyroidectomy on [**2121-2-26**] 4. Diabetes: last HgA1c: 7.0 5. Hypertension. 6. In [**2133-6-29**], she was admitted to hospital with respiratory infection due to H1N1 influenza A.
|
Evidence: Diabetes
Condition: Type 2 diabetes mellitus without complications
HCC: E1122
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Hypothyroidism secondary to hemithyroidectomy on [**2121-2-26**] 4. Diabetes: last HgA1c: 7.0 5. Hypertension. 6. In [**2133-6-29**], she was admitted to hospital with respiratory infection due to H1N1 influenza A. She received 6 days of Tamiflu and Levaquin with improvement in symptoms.
|
Evidence: Diabetes
Condition: Type 2 diabetes mellitus without complications
HCC: E1122
Category: Assessment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
Continued Synthroid . # FEN: IVF, replete prn, diabetic/cardiac diet . # Access: PIV . # PPx: subQ heparin, home PPI . Medications on Admission: See [**Hospital Unit Name 153**] admission note Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO Q12H (every 12 hours). 2. tramadol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
|
Evidence: diabetic/cardiac diet
Condition: Type 2 diabetes mellitus without complications
HCC: E1122
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
|
dx: pleural effusion 8. metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: Community acquired pneumonia with parapneumonic effusion Chronic kidney disease stage III CLL Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for treatment for severe pneumonia as well as fluid in the lung. The fluid in the lung was sampled. You were started on antibiotics with improvement in your symptoms. Please continue your antibiotics to complete the full course.
|
Evidence: metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
Condition: Type 2 diabetes mellitus without complications
HCC: E1122
Category: Treatment
|
Extract medical evidence from the following clinical text that supports medical condition coding:
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Hypothyroidism secondary to hemithyroidectomy on [**2121-2-26**] 4. Diabetes: last HgA1c: 7.0 5. Hypertension. 6. In [**2133-6-29**], she was admitted to hospital with respiratory infection due to H1N1 influenza A. She received 6 days of Tamiflu and Levaquin with improvement in symptoms.
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Evidence: Diabetes
Condition: Type 2 diabetes mellitus without complications
HCC: E1122
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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Hypothyroidism secondary to hemithyroidectomy on [**2121-2-26**] 4. Diabetes: last HgA1c: 7.0 5. Hypertension. 6. In [**2133-6-29**], she was admitted to hospital with respiratory infection due to H1N1 influenza A. She received 6 days of Tamiflu and Levaquin with improvement in symptoms. Myelosuppression during her viral illness improved. . SURGICAL HISTORY: Hysterectomy at age 43.
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Evidence: Diabetes
Condition: Type 2 diabetes mellitus without complications
HCC: E1122
Category: condition_evidence
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Extract medical evidence from the following clinical text that supports medical condition coding:
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A central line was placed. She was placed on BiPAP with improvment of ABG to 7.31/56/61 on FiO2 40%.CT scan showed bilateral lower lobe opacities. She was given levofloxacin and Zosyn. She was transiently hypopensive to 70s systolic and was given a total of 3L of normal saline. Past Medical History: Dementia Diabetes with peripheral neuropathy Hypothyroidism Anxiety Depression Irritable bowel syndrome GERD Laryngeal cancer, status post radiotherapy Multiple skin cancers Right hip replacement due to osteoarthritis, pelvic fracture Social History: Ambien 10 mg po qd Seroquel 25 mg [**Hospital1 **] Ativan 2 mg QAM and 0.75 mg tid Remeron 45 mg qd Synthroid 125 mcg qd Trazodone 100mg po q6h Lisinopril 10 mg po qd Imdur 15 mg qd Ethacrynic 25 mg tid Atorvastatin 20 mg qd ASA 325 daily Albuterol nebs Pantoprazole 40 mg qd Bethanechol 20 mg tid colace flonase Tylenol 975 mg q8H Gabapentin 300 mg qd Tigan 300mg TID Allergies: Sulfa, chlorpromazine, codiene, benadryl Social Hx: Lives at [**Hospital 100**] rehab. Physical Exam: T 99 HR 100 BP 98/60 RR 24 86% on 4L NC General: sleepy, arousable only to physical stimulation HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs w/ bilaterally decreased bs at bases Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: 1+edema, 2+ radial, DP and PT pulses b/l.
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Evidence: ABG to 7.31/56/61 on FiO2 40%
Condition: Acute hypercapnic respiratory failure
HCC: J9602
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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She indicated that she did not want to use the Bipap. Due to her continued hypotension she required multiple fluid boluses and her respiratory status worsened. Her daughter was at the bedside throughout most of the stay. Pt's mental status was waxing and [**Doctor Last Name 688**] for the first 24 hours in the MICU. When she was clear, she stated that she did not want to use any sort of non invasive ventillation, and she confirmed with her daughter that she did not want "agressive treatment" meaning central lines or pressors.
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Evidence: her respiratory status worsened
Condition: Acute hypercapnic respiratory failure
HCC: J9602
Category: Monitoring
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Extract medical evidence from the following clinical text that supports medical condition coding:
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In the ED, initial vitals were T 99.9 HR 81 BP 106/96 RR 24 98% on NRB. ABG showed hypercarbic respiratory failure with pH on 7.27 and pCO2 66. A central line was placed. She was placed on BiPAP with improvment of ABG to 7.31/56/61 on FiO2 40%.CT scan showed bilateral lower lobe opacities. She was given levofloxacin and Zosyn. She was transiently hypopensive to 70s systolic and was given a total of 3L of normal saline. Past Medical History: Dementia Diabetes with peripheral neuropathy Hypothyroidism Anxiety Depression Irritable bowel syndrome GERD Laryngeal cancer, status post radiotherapy Multiple skin cancers Right hip replacement due to osteoarthritis, pelvic fracture Social History: Ambien 10 mg po qd Seroquel 25 mg [**Hospital1 **] Ativan 2 mg QAM and 0.75 mg tid Remeron 45 mg qd Synthroid 125 mcg qd Trazodone 100mg po q6h Lisinopril 10 mg po qd Imdur 15 mg qd Ethacrynic 25 mg tid Atorvastatin 20 mg qd ASA 325 daily Albuterol nebs Pantoprazole 40 mg qd Bethanechol 20 mg tid colace flonase Tylenol 975 mg q8H Gabapentin 300 mg qd Tigan 300mg TID Allergies: Sulfa, chlorpromazine, codiene, benadryl Social Hx: Lives at [**Hospital 100**] rehab. Physical Exam: T 99 HR 100 BP 98/60 RR 24 86% on 4L NC General: sleepy, arousable only to physical stimulation HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs w/ bilaterally decreased bs at bases Cardiac: RRR, nl.
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Evidence: ABG showed hypercarbic respiratory failure with pH on 7.27 and pCO2 66
Condition: Acute hypercapnic respiratory failure
HCC: J9602
Category: Evaluation
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Extract medical evidence from the following clinical text that supports medical condition coding:
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A central line was placed. She was placed on BiPAP with improvment of ABG to 7.31/56/61 on FiO2 40%.CT scan showed bilateral lower lobe opacities. She was given levofloxacin and Zosyn. She was transiently hypopensive to 70s systolic and was given a total of 3L of normal saline. Past Medical History: Dementia Diabetes with peripheral neuropathy Hypothyroidism Anxiety Depression Irritable bowel syndrome GERD Laryngeal cancer, status post radiotherapy Multiple skin cancers Right hip replacement due to osteoarthritis, pelvic fracture Social History: Ambien 10 mg po qd Seroquel 25 mg [**Hospital1 **] Ativan 2 mg QAM and 0.75 mg tid Remeron 45 mg qd Synthroid 125 mcg qd Trazodone 100mg po q6h Lisinopril 10 mg po qd Imdur 15 mg qd Ethacrynic 25 mg tid Atorvastatin 20 mg qd ASA 325 daily Albuterol nebs Pantoprazole 40 mg qd Bethanechol 20 mg tid colace flonase Tylenol 975 mg q8H Gabapentin 300 mg qd Tigan 300mg TID Allergies: Sulfa, chlorpromazine, codiene, benadryl Social Hx: Lives at [**Hospital 100**] rehab. Physical Exam: T 99 HR 100 BP 98/60 RR 24 86% on 4L NC General: sleepy, arousable only to physical stimulation HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs w/ bilaterally decreased bs at bases Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: 1+edema, 2+ radial, DP and PT pulses b/l. Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted.
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Evidence: ABG to 7.31/56/61 on FiO2 40%
Condition: Acute hypercapnic respiratory failure
HCC: J9602
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: [**2170-3-25**] Discharge Date: [**2170-3-26**] Service: MEDICINE Allergies: Sulfonamides Attending:[**First Name3 (LF) 338**] Chief Complaint: Hypercarbic and hypoxic respiratory failure Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **] YOF resident of [**Hospital 100**] rehab who presented to the ED with increased respiratory distress for the past several days. Pt is on standing ethacrynic acid tid for CHF, had recently started Levofloxacin and Tamiflu on [**2170-3-22**] for concern of pneumonia and possible flu. Additionally, pt had been asking staff at nursing home for increased doses of her pain medication (for OA) and of her Ativan. Nursing staff there noted that she was increasingly lethargic, but that she was insistent that they give her the medications so that she could be comfortable. As had been increasingly sedated, she concurrently developed low grade fever and productive cough for 2 days. . In the ED, initial vitals were T 99.9 HR 81 BP 106/96 RR 24 98% on NRB. ABG showed hypercarbic respiratory failure with pH on 7.27 and pCO2 66.
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Evidence: Hypercarbic and hypoxic respiratory failure
Condition: Acute hypercapnic respiratory failure
HCC: J9602
Category: Assessment
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Extract medical evidence from the following clinical text that supports medical condition coding:
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A central line was placed. She was placed on BiPAP with improvment of ABG to 7.31/56/61 on FiO2 40%.CT scan showed bilateral lower lobe opacities. She was given levofloxacin and Zosyn. She was transiently hypopensive to 70s systolic and was given a total of 3L of normal saline. Past Medical History: Dementia Diabetes with peripheral neuropathy Hypothyroidism Anxiety Depression Irritable bowel syndrome GERD Laryngeal cancer, status post radiotherapy Multiple skin cancers Right hip replacement due to osteoarthritis, pelvic fracture Social History: Ambien 10 mg po qd Seroquel 25 mg [**Hospital1 **] Ativan 2 mg QAM and 0.75 mg tid Remeron 45 mg qd Synthroid 125 mcg qd Trazodone 100mg po q6h Lisinopril 10 mg po qd Imdur 15 mg qd Ethacrynic 25 mg tid Atorvastatin 20 mg qd ASA 325 daily Albuterol nebs Pantoprazole 40 mg qd Bethanechol 20 mg tid colace flonase Tylenol 975 mg q8H Gabapentin 300 mg qd Tigan 300mg TID Allergies: Sulfa, chlorpromazine, codiene, benadryl Social Hx: Lives at [**Hospital 100**] rehab. Physical Exam: T 99 HR 100 BP 98/60 RR 24 86% on 4L NC General: sleepy, arousable only to physical stimulation HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs w/ bilaterally decreased bs at bases Cardiac: RRR, nl.
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Evidence: She was placed on BiPAP
Condition: Acute hypercapnic respiratory failure
HCC: J9602
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: [**2170-3-25**] Discharge Date: [**2170-3-26**] Service: MEDICINE Allergies: Sulfonamides Attending:[**First Name3 (LF) 338**] Chief Complaint: Hypercarbic and hypoxic respiratory failure Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **] YOF resident of [**Hospital 100**] rehab who presented to the ED with increased respiratory distress for the past several days. Pt is on standing ethacrynic acid tid for CHF, had recently started Levofloxacin and Tamiflu on [**2170-3-22**] for concern of pneumonia and possible flu. Additionally, pt had been asking staff at nursing home for increased doses of her pain medication (for OA) and of her Ativan. Nursing staff there noted that she was increasingly lethargic, but that she was insistent that they give her the medications so that she could be comfortable. As had been increasingly sedated, she concurrently developed low grade fever and productive cough for 2 days. . In the ED, initial vitals were T 99.9 HR 81 BP 106/96 RR 24 98% on NRB.
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Evidence: Hypercarbic and hypoxic respiratory failure
Condition: Acute hypercapnic respiratory failure
HCC: J9602
Category: condition_evidence
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