instruction string | input string | output string |
|---|---|---|
List all known allergies. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| Relafen |
Mention any medication or food allergies. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| Relafen |
State the main reason for hospital visit. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| Recurrence of lung cancer |
Describe the patient's chief complaint. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| Recurrence of lung cancer |
List major surgeries or procedures. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| [**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer. |
Mention any invasive procedures performed. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| [**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer. |
Summarize the present illness. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time. |
Describe how the illness developed. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time. |
List the patient's past medical issues. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema |
Mention previous health conditions. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema |
Document previous surgeries. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy |
List surgical history with dates. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy |
Include lifestyle habits affecting health. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient. |
Mention smoking, alcohol, or drug use. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient. |
Record any hereditary conditions. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| She has two daughters who are healthy. There is a history of
allergies and emphysema in her family. |
Mention illnesses in close family. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| She has two daughters who are healthy. There is a history of
allergies and emphysema in her family. |
Summarize physical examination findings. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE |
List key observations from physical exam. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE |
List important lab or test results. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema. |
Include key findings from diagnostics. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema. |
Summarize patient's hospital stay. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray. |
Describe key events during admission. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray. |
List medications the patient was on upon arrival. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| 1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY |
Mention all admission-time medications. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| 1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY |
Provide medications prescribed at discharge. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| 1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0 |
List drugs to be taken post-discharge. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| 1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0 |
State where the patient is discharged to. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| Home With Service |
Mention the discharge plan. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| Home With Service |
List final diagnosis at discharge. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| Recurrent lung cancer |
Mention what condition was treated. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| Recurrent lung cancer |
Describe the patient's status at discharge. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent. |
Mention the discharge health condition. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent. |
List instructions given to the patient upon discharge. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care. |
Summarize the care or precautions advised after leaving the hospital. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care. |
Mention any scheduled follow-up or outpatient care. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge. |
List follow-up appointments or recommendations. | Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**]
Date of Birth: [**2054-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Relafen
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Recurrence of lung cancer
Major Surgical or Invasive Procedure:
[**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and
decortication of lung, Wedge resection of right lower lobe lung
cancer.
History of Present Illness:
Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a
right thoracotomy, right lower lobe superior segmentectomy on
[**2125-7-27**]. The pathology revealed a 2.5cm, moderately
differentiated, adenocarcinoma with negative margins. The lymph
nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic
[**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET
showed an FDG-avid subpleural nodule in the right lower lobe,
compatible with recurrence as well as in the chest wall in
the region of the right 5th and 6th ribs is new from [**2125-7-3**]
and also concerning for recurrence. She underwent a core biopsy
[**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies
any symptoms at this time.
Past Medical History:
Hypertension
Hyperlipidemia
breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant
chemorads
Renal angiomyolipoma
Emphysema
PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring
partial resection via thoracotomy
Social History:
She quit smoking in [**2109**] and smoked 40 years 2 packs a day.
Denies alcohol use. Unfortunately, husband has terminal gastric
cancer, is hospitalized at the VA which greatly upsets patient.
Family History:
She has two daughters who are healthy. There is a history of
allergies and emphysema in her family.
Physical Exam:
Gen: NAD, anxious
Neck: no [**Doctor First Name **]
Chest: clear ausc, incisions c,d,i
Cor: RRR no murmur
Ext: no CCE
Pertinent Results:
ADMISSION LABS
[**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333
[**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-22 AnGap-16
[**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5*
DISCHARGE LABS
[**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455*
[**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-30 AnGap-14
[**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8
[**8-30**] CXR post op
Right pneumothorax post surgery with three chest tubes in place
[**9-7**] CXR
Interval removal of the right basilar chest tube. There
continues to be
some subcutaneous emphysema within the right lateral chest wall
soft tissues. Post-surgical changes of the right hemithorax and
lung are stable. Stable right lateral pleural thickening and
right basilar pleural thickening could be post-operative or
represent some pleural fluid. However, the appearance is
stable. No pneumothorax is seen. The left lung remains well
inflated and clear. Cardiac and mediastinal contours are
stable. Clips in the right upper quadrant are consistent with
cholecystectomy. No pulmonary edema.
Brief Hospital Course:
Patient was admitted on [**2126-8-30**] to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray.
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
2. Nortriptyline 30 mg PO HS
3. Pravastatin 40 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
twice a day Rinse mouth after use
4. Nortriptyline 30 mg PO HS
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
10. Metoprolol Tartrate 12.5 mg PO BID HTN
Hold for SBP < 100 or HR < 60
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Recurrent lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgery on your lung. You
have done well after the procedure and may return home to
continue your recovery.
There is a dressing over the site of your chest tube- this may
be removed in 24 hours. You can leave the incision open to air
after that. You may shower with the dressing in place.
Please take the prescribed pain medication as needed.
Constipation can be a problem with narcotic use, therefore drink
plenty of fluid to stay well hydrated and use a stool softener
while taking narcotics. Do NOT drive while taking narcotic pain
medications.
While in the hospital, you were noticed to have a heart rhythm
called atrial fibrillation. We were able to convert the rhythm
back to normal using medication; please ask your primary care
doctor if you need further tests or treatment. We also started
you on a new medication called Metoprolol for your high blood
pressure and new dysrhythmia, please ask your primary care
doctor if you need to continue it.
If you develop any chest pain, shortness of breath or any other
symptoms that concern you, please call your surgeon or go to the
nearest Emergency Room.
Thank you for allowing us to participate in your care.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge.
| Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call
[**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with
a chest x ray.
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest x-ray.
Please follow up with your primary care doctor within a week
from discharge. |
Extract the ICD-10-CM code assigned to each clinical condition mentioned in the discharge summary. | Admission Date: [**2169-1-9**] Discharge Date: [**2169-1-15**]
Date of Birth: [**2087-9-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Asymptomatic valve and coronary artery disease
Major Surgical or Invasive Procedure:
[**2169-1-10**] - AVR (21mm [**Company 1543**] Mosaic Porcine Valve); CABGx3 (Left
internal mammary->Left anterior descending artery, Vein->Obtuse
marginal artery, vein->right coronary artery)
History of Present Illness:
81 y/o female with known aortic stenosis which has been followed
by serial echocardiograms. Her most recent echocardiogram showed
severe aortic stenosis with dilation of her left atrium and left
ventricle. She underwent an elective cardiac catheterization
which revealed severe three vessel disease.
Past Medical History:
AS
CAD
Cataracts
Anemia
GI Bleed
AV malformation s/p Cauterization
Arthritis
TIA
Social History:
Retired book keeper. Kves with spouse. 30 pack year smoking
history quit 30 years ago. Drinks 1 glass of red wine daily.
Family History:
Father died of MI at age 63
Physical Exam:
60 sr 18 170/64 172/65 63" 125
GEN: NAD
SKIN: Unremarkable
HEENT: EOMI, PERRL, OP Benign
NECK: Supple, FROM, No LAD
LUNGS: CTA
HEART: RRR, 3/6 SEM
ABD: S/NT/ND/NABS
EXT: Warm, well perfused, no edema
NEURO: Grossly intact
Pertinent Results:
[**2169-1-9**] 02:45PM PT-12.7 PTT-26.7 INR(PT)-1.1
[**2169-1-9**] 02:45PM WBC-5.0 RBC-3.46* HGB-11.6* HCT-33.8* MCV-98
MCH-33.6* MCHC-34.4 RDW-13.8
[**2169-1-9**] 02:45PM ALT(SGPT)-25 AST(SGOT)-35 LD(LDH)-196 ALK
PHOS-80 AMYLASE-93 TOT BILI-0.3
[**2169-1-9**] 02:45PM GLUCOSE-104 UREA N-15 CREAT-0.8 SODIUM-144
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-33* ANION GAP-8
[**2169-1-10**] ECHO
PRE-CPB:1. The left atrium is moderately dilated. No thrombus is
seen in the left atrial appendage.
2. The right atrium is moderately dilated. No spontaneous echo
contrast is seen in the body of the right atrium. A prominent
eustacian valve is seen.
3. No atrial septal defect is seen by 2D or color Doppler.
4. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Transmitral Doppler and
tissue velocity imaging are consistent with Grade I (mild) LV
diastolic dysfunction.
5. Right ventricular chamber size and free wall motion are
normal.
6. The ascending aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta.
7. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened and show limited movement. No
masses or vegetations are seen on the aortic valve. There is
moderate to severe aortic valve stenosis (area 0.8-1.0cm2).
Moderate (2+) aortic regurgitation is seen.
8. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
9. There is a trivial/physiologic pericardial effusion.
POST-CPB: On infusion of
Brief Hospital Course:
Mrs. [**Known lastname 10019**] was admitted to the [**Hospital1 18**] on [**2169-1-9**] for elective
surgical management of her coronary artery and aortic valve
disease. On [**2169-1-10**] Mrs. [**Known lastname 10019**] was taken to the operating room
where she underwent coronary artery bypass grafting to three
vessels and an aortic valve replacement using a 21mm [**Company **]
mosaic porcine valve. Postoperatively she was taken to the
intensive care unit for monitoring. On postoperative day one,
Mrs. [**Known lastname 10019**] awoke neurologically intact and was extubated.
Aspirin, beta blockade and a statin were resumed. She was then
transferred to the step down unit for further recovery. She was
gently diuresed towards her preoperative weight. The physical
therapy service was consulted for assistance with her
postoperative strength and mobility.
Mrs. [**Known lastname 10019**] continued to make steady progress and was discharged
to home with VNA services. She will follow-up with Dr.
[**Last Name (STitle) 1290**], her cardiologist and her primary care physician as an
outpatient.
Medications on Admission:
Aspirin 81mg daily
Lipitor 10mg daily
Multivitamin
Caltrate 600mg daily
Fish oil
B-12
Ocuvite
Protonix 20mg daily
Ferosol 45mg daily
Colace 100mg daily
Calcium and vitamin D
Discharge Medications:
1. [**Last Name (un) 1724**]
[**Last Name (un) 1724**] ASA 81', lipitor 10', mvi', caltrate 600', fish oil 1200'
b12 1000', vit d 400', colace 100", feosol 45', protonix 20'
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 6 days.
Disp:*12 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. other Vitamins
Your other vitamins are ok to take / caltrate / fishoil etc
14. Feosol 45 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
CAD/AS s/p CABG/AVR [**2169-1-10**]
Hyperlipidemia
Anemia
Cataracts
GI bleed d/t AV Malformation
Arthritis
TIA
Hyperthyroid
Discharge Condition:
Stable
Discharge Instructions:
1) Please monitor wounds for signs of infection. These include
redness, drainage or increased pain. Please contact surgeon at
([**Telephone/Fax (1) 1504**] with any wound issues.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lifting greater then 10 pounds for 10 weeks.
5) No driving for 1 month.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 120**] in 2 weeks.
Follow-up with Dr. [**Last Name (STitle) 10020**] in 2 weeks. ([**Telephone/Fax (1) 10021**]
Completed by:[**2169-1-15**] | {
"clinical_findings": {
"I2510": [
{
"icd_10_cm_code": "I25.10",
"icd_10_cm_code_description": "Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Monitoring": [],
"Evaluation": [
{
"text": "severe three vessel disease",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "CAD",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "CABGx3 (Left\ninternal mammary->Left anterior descending artery, Vein->Obtuse\nmarginal artery, vein->right coronary artery)",
"page_numbers": [
1
]
},
{
"text": "s/p CABG/AVR",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "severe three vessel disease",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I25.10 is assigned for Atherosclerotic heart disease of native coronary artery. MEAT criteria are met with Evaluation evidence from the cardiac catheterization showing 'severe three vessel disease', Assessment evidence from the Discharge Diagnosis listing 'CAD', and Treatment evidence from the Major Surgical Procedure and Discharge Diagnosis indicating 'CABGx3' and 's/p CABG/AVR'."
}
],
"I422": [
{
"icd_10_cm_code": "I42.2",
"icd_10_cm_code_description": "Other hypertrophic cardiomyopathy",
"Monitoring": [],
"Evaluation": [
{
"text": "mild symmetric left ventricular hypertrophy",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild symmetric left ventricular hypertrophy",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I42.2 is assigned for Other hypertrophic cardiomyopathy, which includes symmetric left ventricular hypertrophy. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'mild symmetric left ventricular hypertrophy'."
}
],
"I5084": [
{
"icd_10_cm_code": "I50.84",
"icd_10_cm_code_description": "Diastolic heart failure",
"Monitoring": [],
"Evaluation": [
{
"text": "Grade I (mild) LV diastolic dysfunction",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "Grade I (mild) LV diastolic dysfunction",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I50.84 is assigned for Diastolic heart failure, as diastolic dysfunction is a component. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'Grade I (mild) LV diastolic dysfunction'. ICD-10-CM guidelines indicate to code also any associated underlying condition such as hypertrophic cardiomyopathy (I42.2), which is also coded and supported by MEAT."
}
],
"I7121": [
{
"icd_10_cm_code": "I71.21",
"icd_10_cm_code_description": "Aortic aneurysm of ascending aorta, without rupture",
"Monitoring": [],
"Evaluation": [
{
"text": "ascending aorta is mildly dilated",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ascending aorta is mildly dilated",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I71.21 is assigned for Aortic aneurysm of ascending aorta, without rupture, as dilation of the aorta is typically coded as an aneurysm or ectasia. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'ascending aorta is mildly dilated'."
}
],
"E785": [
{
"icd_10_cm_code": "E78.5",
"icd_10_cm_code_description": "Hyperlipidemia, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hyperlipidemia",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "Lipitor 10mg daily",
"page_numbers": [
1
]
},
{
"text": "Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "Hyperlipidemia",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code E78.5 is assigned for Hyperlipidemia, unspecified. MEAT criteria are met with Assessment evidence from the Discharge Diagnosis listing 'Hyperlipidemia' and Treatment evidence from the medication list showing 'Lipitor 10mg daily' and 'Atorvastatin 10 mg Tablet'."
}
]
}
} |
Extract the ICD-10-CM code description for each clinical condition mentioned in the discharge summary. | Admission Date: [**2169-1-9**] Discharge Date: [**2169-1-15**]
Date of Birth: [**2087-9-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Asymptomatic valve and coronary artery disease
Major Surgical or Invasive Procedure:
[**2169-1-10**] - AVR (21mm [**Company 1543**] Mosaic Porcine Valve); CABGx3 (Left
internal mammary->Left anterior descending artery, Vein->Obtuse
marginal artery, vein->right coronary artery)
History of Present Illness:
81 y/o female with known aortic stenosis which has been followed
by serial echocardiograms. Her most recent echocardiogram showed
severe aortic stenosis with dilation of her left atrium and left
ventricle. She underwent an elective cardiac catheterization
which revealed severe three vessel disease.
Past Medical History:
AS
CAD
Cataracts
Anemia
GI Bleed
AV malformation s/p Cauterization
Arthritis
TIA
Social History:
Retired book keeper. Kves with spouse. 30 pack year smoking
history quit 30 years ago. Drinks 1 glass of red wine daily.
Family History:
Father died of MI at age 63
Physical Exam:
60 sr 18 170/64 172/65 63" 125
GEN: NAD
SKIN: Unremarkable
HEENT: EOMI, PERRL, OP Benign
NECK: Supple, FROM, No LAD
LUNGS: CTA
HEART: RRR, 3/6 SEM
ABD: S/NT/ND/NABS
EXT: Warm, well perfused, no edema
NEURO: Grossly intact
Pertinent Results:
[**2169-1-9**] 02:45PM PT-12.7 PTT-26.7 INR(PT)-1.1
[**2169-1-9**] 02:45PM WBC-5.0 RBC-3.46* HGB-11.6* HCT-33.8* MCV-98
MCH-33.6* MCHC-34.4 RDW-13.8
[**2169-1-9**] 02:45PM ALT(SGPT)-25 AST(SGOT)-35 LD(LDH)-196 ALK
PHOS-80 AMYLASE-93 TOT BILI-0.3
[**2169-1-9**] 02:45PM GLUCOSE-104 UREA N-15 CREAT-0.8 SODIUM-144
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-33* ANION GAP-8
[**2169-1-10**] ECHO
PRE-CPB:1. The left atrium is moderately dilated. No thrombus is
seen in the left atrial appendage.
2. The right atrium is moderately dilated. No spontaneous echo
contrast is seen in the body of the right atrium. A prominent
eustacian valve is seen.
3. No atrial septal defect is seen by 2D or color Doppler.
4. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Transmitral Doppler and
tissue velocity imaging are consistent with Grade I (mild) LV
diastolic dysfunction.
5. Right ventricular chamber size and free wall motion are
normal.
6. The ascending aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta.
7. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened and show limited movement. No
masses or vegetations are seen on the aortic valve. There is
moderate to severe aortic valve stenosis (area 0.8-1.0cm2).
Moderate (2+) aortic regurgitation is seen.
8. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
9. There is a trivial/physiologic pericardial effusion.
POST-CPB: On infusion of
Brief Hospital Course:
Mrs. [**Known lastname 10019**] was admitted to the [**Hospital1 18**] on [**2169-1-9**] for elective
surgical management of her coronary artery and aortic valve
disease. On [**2169-1-10**] Mrs. [**Known lastname 10019**] was taken to the operating room
where she underwent coronary artery bypass grafting to three
vessels and an aortic valve replacement using a 21mm [**Company **]
mosaic porcine valve. Postoperatively she was taken to the
intensive care unit for monitoring. On postoperative day one,
Mrs. [**Known lastname 10019**] awoke neurologically intact and was extubated.
Aspirin, beta blockade and a statin were resumed. She was then
transferred to the step down unit for further recovery. She was
gently diuresed towards her preoperative weight. The physical
therapy service was consulted for assistance with her
postoperative strength and mobility.
Mrs. [**Known lastname 10019**] continued to make steady progress and was discharged
to home with VNA services. She will follow-up with Dr.
[**Last Name (STitle) 1290**], her cardiologist and her primary care physician as an
outpatient.
Medications on Admission:
Aspirin 81mg daily
Lipitor 10mg daily
Multivitamin
Caltrate 600mg daily
Fish oil
B-12
Ocuvite
Protonix 20mg daily
Ferosol 45mg daily
Colace 100mg daily
Calcium and vitamin D
Discharge Medications:
1. [**Last Name (un) 1724**]
[**Last Name (un) 1724**] ASA 81', lipitor 10', mvi', caltrate 600', fish oil 1200'
b12 1000', vit d 400', colace 100", feosol 45', protonix 20'
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 6 days.
Disp:*12 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. other Vitamins
Your other vitamins are ok to take / caltrate / fishoil etc
14. Feosol 45 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
CAD/AS s/p CABG/AVR [**2169-1-10**]
Hyperlipidemia
Anemia
Cataracts
GI bleed d/t AV Malformation
Arthritis
TIA
Hyperthyroid
Discharge Condition:
Stable
Discharge Instructions:
1) Please monitor wounds for signs of infection. These include
redness, drainage or increased pain. Please contact surgeon at
([**Telephone/Fax (1) 1504**] with any wound issues.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lifting greater then 10 pounds for 10 weeks.
5) No driving for 1 month.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 120**] in 2 weeks.
Follow-up with Dr. [**Last Name (STitle) 10020**] in 2 weeks. ([**Telephone/Fax (1) 10021**]
Completed by:[**2169-1-15**] | {
"clinical_findings": {
"I2510": [
{
"icd_10_cm_code": "I25.10",
"icd_10_cm_code_description": "Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Monitoring": [],
"Evaluation": [
{
"text": "severe three vessel disease",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "CAD",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "CABGx3 (Left\ninternal mammary->Left anterior descending artery, Vein->Obtuse\nmarginal artery, vein->right coronary artery)",
"page_numbers": [
1
]
},
{
"text": "s/p CABG/AVR",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "severe three vessel disease",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I25.10 is assigned for Atherosclerotic heart disease of native coronary artery. MEAT criteria are met with Evaluation evidence from the cardiac catheterization showing 'severe three vessel disease', Assessment evidence from the Discharge Diagnosis listing 'CAD', and Treatment evidence from the Major Surgical Procedure and Discharge Diagnosis indicating 'CABGx3' and 's/p CABG/AVR'."
}
],
"I422": [
{
"icd_10_cm_code": "I42.2",
"icd_10_cm_code_description": "Other hypertrophic cardiomyopathy",
"Monitoring": [],
"Evaluation": [
{
"text": "mild symmetric left ventricular hypertrophy",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild symmetric left ventricular hypertrophy",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I42.2 is assigned for Other hypertrophic cardiomyopathy, which includes symmetric left ventricular hypertrophy. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'mild symmetric left ventricular hypertrophy'."
}
],
"I5084": [
{
"icd_10_cm_code": "I50.84",
"icd_10_cm_code_description": "Diastolic heart failure",
"Monitoring": [],
"Evaluation": [
{
"text": "Grade I (mild) LV diastolic dysfunction",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "Grade I (mild) LV diastolic dysfunction",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I50.84 is assigned for Diastolic heart failure, as diastolic dysfunction is a component. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'Grade I (mild) LV diastolic dysfunction'. ICD-10-CM guidelines indicate to code also any associated underlying condition such as hypertrophic cardiomyopathy (I42.2), which is also coded and supported by MEAT."
}
],
"I7121": [
{
"icd_10_cm_code": "I71.21",
"icd_10_cm_code_description": "Aortic aneurysm of ascending aorta, without rupture",
"Monitoring": [],
"Evaluation": [
{
"text": "ascending aorta is mildly dilated",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ascending aorta is mildly dilated",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I71.21 is assigned for Aortic aneurysm of ascending aorta, without rupture, as dilation of the aorta is typically coded as an aneurysm or ectasia. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'ascending aorta is mildly dilated'."
}
],
"E785": [
{
"icd_10_cm_code": "E78.5",
"icd_10_cm_code_description": "Hyperlipidemia, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hyperlipidemia",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "Lipitor 10mg daily",
"page_numbers": [
1
]
},
{
"text": "Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "Hyperlipidemia",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code E78.5 is assigned for Hyperlipidemia, unspecified. MEAT criteria are met with Assessment evidence from the Discharge Diagnosis listing 'Hyperlipidemia' and Treatment evidence from the medication list showing 'Lipitor 10mg daily' and 'Atorvastatin 10 mg Tablet'."
}
]
}
} |
Extract only the monitoring information related to each clinical condition, such as vital signs, labs, or telemetry data. | Admission Date: [**2169-1-9**] Discharge Date: [**2169-1-15**]
Date of Birth: [**2087-9-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Asymptomatic valve and coronary artery disease
Major Surgical or Invasive Procedure:
[**2169-1-10**] - AVR (21mm [**Company 1543**] Mosaic Porcine Valve); CABGx3 (Left
internal mammary->Left anterior descending artery, Vein->Obtuse
marginal artery, vein->right coronary artery)
History of Present Illness:
81 y/o female with known aortic stenosis which has been followed
by serial echocardiograms. Her most recent echocardiogram showed
severe aortic stenosis with dilation of her left atrium and left
ventricle. She underwent an elective cardiac catheterization
which revealed severe three vessel disease.
Past Medical History:
AS
CAD
Cataracts
Anemia
GI Bleed
AV malformation s/p Cauterization
Arthritis
TIA
Social History:
Retired book keeper. Kves with spouse. 30 pack year smoking
history quit 30 years ago. Drinks 1 glass of red wine daily.
Family History:
Father died of MI at age 63
Physical Exam:
60 sr 18 170/64 172/65 63" 125
GEN: NAD
SKIN: Unremarkable
HEENT: EOMI, PERRL, OP Benign
NECK: Supple, FROM, No LAD
LUNGS: CTA
HEART: RRR, 3/6 SEM
ABD: S/NT/ND/NABS
EXT: Warm, well perfused, no edema
NEURO: Grossly intact
Pertinent Results:
[**2169-1-9**] 02:45PM PT-12.7 PTT-26.7 INR(PT)-1.1
[**2169-1-9**] 02:45PM WBC-5.0 RBC-3.46* HGB-11.6* HCT-33.8* MCV-98
MCH-33.6* MCHC-34.4 RDW-13.8
[**2169-1-9**] 02:45PM ALT(SGPT)-25 AST(SGOT)-35 LD(LDH)-196 ALK
PHOS-80 AMYLASE-93 TOT BILI-0.3
[**2169-1-9**] 02:45PM GLUCOSE-104 UREA N-15 CREAT-0.8 SODIUM-144
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-33* ANION GAP-8
[**2169-1-10**] ECHO
PRE-CPB:1. The left atrium is moderately dilated. No thrombus is
seen in the left atrial appendage.
2. The right atrium is moderately dilated. No spontaneous echo
contrast is seen in the body of the right atrium. A prominent
eustacian valve is seen.
3. No atrial septal defect is seen by 2D or color Doppler.
4. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Transmitral Doppler and
tissue velocity imaging are consistent with Grade I (mild) LV
diastolic dysfunction.
5. Right ventricular chamber size and free wall motion are
normal.
6. The ascending aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta.
7. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened and show limited movement. No
masses or vegetations are seen on the aortic valve. There is
moderate to severe aortic valve stenosis (area 0.8-1.0cm2).
Moderate (2+) aortic regurgitation is seen.
8. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
9. There is a trivial/physiologic pericardial effusion.
POST-CPB: On infusion of
Brief Hospital Course:
Mrs. [**Known lastname 10019**] was admitted to the [**Hospital1 18**] on [**2169-1-9**] for elective
surgical management of her coronary artery and aortic valve
disease. On [**2169-1-10**] Mrs. [**Known lastname 10019**] was taken to the operating room
where she underwent coronary artery bypass grafting to three
vessels and an aortic valve replacement using a 21mm [**Company **]
mosaic porcine valve. Postoperatively she was taken to the
intensive care unit for monitoring. On postoperative day one,
Mrs. [**Known lastname 10019**] awoke neurologically intact and was extubated.
Aspirin, beta blockade and a statin were resumed. She was then
transferred to the step down unit for further recovery. She was
gently diuresed towards her preoperative weight. The physical
therapy service was consulted for assistance with her
postoperative strength and mobility.
Mrs. [**Known lastname 10019**] continued to make steady progress and was discharged
to home with VNA services. She will follow-up with Dr.
[**Last Name (STitle) 1290**], her cardiologist and her primary care physician as an
outpatient.
Medications on Admission:
Aspirin 81mg daily
Lipitor 10mg daily
Multivitamin
Caltrate 600mg daily
Fish oil
B-12
Ocuvite
Protonix 20mg daily
Ferosol 45mg daily
Colace 100mg daily
Calcium and vitamin D
Discharge Medications:
1. [**Last Name (un) 1724**]
[**Last Name (un) 1724**] ASA 81', lipitor 10', mvi', caltrate 600', fish oil 1200'
b12 1000', vit d 400', colace 100", feosol 45', protonix 20'
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 6 days.
Disp:*12 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. other Vitamins
Your other vitamins are ok to take / caltrate / fishoil etc
14. Feosol 45 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
CAD/AS s/p CABG/AVR [**2169-1-10**]
Hyperlipidemia
Anemia
Cataracts
GI bleed d/t AV Malformation
Arthritis
TIA
Hyperthyroid
Discharge Condition:
Stable
Discharge Instructions:
1) Please monitor wounds for signs of infection. These include
redness, drainage or increased pain. Please contact surgeon at
([**Telephone/Fax (1) 1504**] with any wound issues.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lifting greater then 10 pounds for 10 weeks.
5) No driving for 1 month.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 120**] in 2 weeks.
Follow-up with Dr. [**Last Name (STitle) 10020**] in 2 weeks. ([**Telephone/Fax (1) 10021**]
Completed by:[**2169-1-15**] | {
"clinical_findings": {
"I2510": [
{
"icd_10_cm_code": "I25.10",
"icd_10_cm_code_description": "Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Monitoring": [],
"Evaluation": [
{
"text": "severe three vessel disease",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "CAD",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "CABGx3 (Left\ninternal mammary->Left anterior descending artery, Vein->Obtuse\nmarginal artery, vein->right coronary artery)",
"page_numbers": [
1
]
},
{
"text": "s/p CABG/AVR",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "severe three vessel disease",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I25.10 is assigned for Atherosclerotic heart disease of native coronary artery. MEAT criteria are met with Evaluation evidence from the cardiac catheterization showing 'severe three vessel disease', Assessment evidence from the Discharge Diagnosis listing 'CAD', and Treatment evidence from the Major Surgical Procedure and Discharge Diagnosis indicating 'CABGx3' and 's/p CABG/AVR'."
}
],
"I422": [
{
"icd_10_cm_code": "I42.2",
"icd_10_cm_code_description": "Other hypertrophic cardiomyopathy",
"Monitoring": [],
"Evaluation": [
{
"text": "mild symmetric left ventricular hypertrophy",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild symmetric left ventricular hypertrophy",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I42.2 is assigned for Other hypertrophic cardiomyopathy, which includes symmetric left ventricular hypertrophy. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'mild symmetric left ventricular hypertrophy'."
}
],
"I5084": [
{
"icd_10_cm_code": "I50.84",
"icd_10_cm_code_description": "Diastolic heart failure",
"Monitoring": [],
"Evaluation": [
{
"text": "Grade I (mild) LV diastolic dysfunction",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "Grade I (mild) LV diastolic dysfunction",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I50.84 is assigned for Diastolic heart failure, as diastolic dysfunction is a component. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'Grade I (mild) LV diastolic dysfunction'. ICD-10-CM guidelines indicate to code also any associated underlying condition such as hypertrophic cardiomyopathy (I42.2), which is also coded and supported by MEAT."
}
],
"I7121": [
{
"icd_10_cm_code": "I71.21",
"icd_10_cm_code_description": "Aortic aneurysm of ascending aorta, without rupture",
"Monitoring": [],
"Evaluation": [
{
"text": "ascending aorta is mildly dilated",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ascending aorta is mildly dilated",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I71.21 is assigned for Aortic aneurysm of ascending aorta, without rupture, as dilation of the aorta is typically coded as an aneurysm or ectasia. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'ascending aorta is mildly dilated'."
}
],
"E785": [
{
"icd_10_cm_code": "E78.5",
"icd_10_cm_code_description": "Hyperlipidemia, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hyperlipidemia",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "Lipitor 10mg daily",
"page_numbers": [
1
]
},
{
"text": "Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "Hyperlipidemia",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code E78.5 is assigned for Hyperlipidemia, unspecified. MEAT criteria are met with Assessment evidence from the Discharge Diagnosis listing 'Hyperlipidemia' and Treatment evidence from the medication list showing 'Lipitor 10mg daily' and 'Atorvastatin 10 mg Tablet'."
}
]
}
} |
Extract only the clinical evaluation methods used for each condition, such as imaging, physical examination, or biopsy. | Admission Date: [**2169-1-9**] Discharge Date: [**2169-1-15**]
Date of Birth: [**2087-9-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Asymptomatic valve and coronary artery disease
Major Surgical or Invasive Procedure:
[**2169-1-10**] - AVR (21mm [**Company 1543**] Mosaic Porcine Valve); CABGx3 (Left
internal mammary->Left anterior descending artery, Vein->Obtuse
marginal artery, vein->right coronary artery)
History of Present Illness:
81 y/o female with known aortic stenosis which has been followed
by serial echocardiograms. Her most recent echocardiogram showed
severe aortic stenosis with dilation of her left atrium and left
ventricle. She underwent an elective cardiac catheterization
which revealed severe three vessel disease.
Past Medical History:
AS
CAD
Cataracts
Anemia
GI Bleed
AV malformation s/p Cauterization
Arthritis
TIA
Social History:
Retired book keeper. Kves with spouse. 30 pack year smoking
history quit 30 years ago. Drinks 1 glass of red wine daily.
Family History:
Father died of MI at age 63
Physical Exam:
60 sr 18 170/64 172/65 63" 125
GEN: NAD
SKIN: Unremarkable
HEENT: EOMI, PERRL, OP Benign
NECK: Supple, FROM, No LAD
LUNGS: CTA
HEART: RRR, 3/6 SEM
ABD: S/NT/ND/NABS
EXT: Warm, well perfused, no edema
NEURO: Grossly intact
Pertinent Results:
[**2169-1-9**] 02:45PM PT-12.7 PTT-26.7 INR(PT)-1.1
[**2169-1-9**] 02:45PM WBC-5.0 RBC-3.46* HGB-11.6* HCT-33.8* MCV-98
MCH-33.6* MCHC-34.4 RDW-13.8
[**2169-1-9**] 02:45PM ALT(SGPT)-25 AST(SGOT)-35 LD(LDH)-196 ALK
PHOS-80 AMYLASE-93 TOT BILI-0.3
[**2169-1-9**] 02:45PM GLUCOSE-104 UREA N-15 CREAT-0.8 SODIUM-144
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-33* ANION GAP-8
[**2169-1-10**] ECHO
PRE-CPB:1. The left atrium is moderately dilated. No thrombus is
seen in the left atrial appendage.
2. The right atrium is moderately dilated. No spontaneous echo
contrast is seen in the body of the right atrium. A prominent
eustacian valve is seen.
3. No atrial septal defect is seen by 2D or color Doppler.
4. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Transmitral Doppler and
tissue velocity imaging are consistent with Grade I (mild) LV
diastolic dysfunction.
5. Right ventricular chamber size and free wall motion are
normal.
6. The ascending aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta.
7. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened and show limited movement. No
masses or vegetations are seen on the aortic valve. There is
moderate to severe aortic valve stenosis (area 0.8-1.0cm2).
Moderate (2+) aortic regurgitation is seen.
8. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
9. There is a trivial/physiologic pericardial effusion.
POST-CPB: On infusion of
Brief Hospital Course:
Mrs. [**Known lastname 10019**] was admitted to the [**Hospital1 18**] on [**2169-1-9**] for elective
surgical management of her coronary artery and aortic valve
disease. On [**2169-1-10**] Mrs. [**Known lastname 10019**] was taken to the operating room
where she underwent coronary artery bypass grafting to three
vessels and an aortic valve replacement using a 21mm [**Company **]
mosaic porcine valve. Postoperatively she was taken to the
intensive care unit for monitoring. On postoperative day one,
Mrs. [**Known lastname 10019**] awoke neurologically intact and was extubated.
Aspirin, beta blockade and a statin were resumed. She was then
transferred to the step down unit for further recovery. She was
gently diuresed towards her preoperative weight. The physical
therapy service was consulted for assistance with her
postoperative strength and mobility.
Mrs. [**Known lastname 10019**] continued to make steady progress and was discharged
to home with VNA services. She will follow-up with Dr.
[**Last Name (STitle) 1290**], her cardiologist and her primary care physician as an
outpatient.
Medications on Admission:
Aspirin 81mg daily
Lipitor 10mg daily
Multivitamin
Caltrate 600mg daily
Fish oil
B-12
Ocuvite
Protonix 20mg daily
Ferosol 45mg daily
Colace 100mg daily
Calcium and vitamin D
Discharge Medications:
1. [**Last Name (un) 1724**]
[**Last Name (un) 1724**] ASA 81', lipitor 10', mvi', caltrate 600', fish oil 1200'
b12 1000', vit d 400', colace 100", feosol 45', protonix 20'
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 6 days.
Disp:*12 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. other Vitamins
Your other vitamins are ok to take / caltrate / fishoil etc
14. Feosol 45 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
CAD/AS s/p CABG/AVR [**2169-1-10**]
Hyperlipidemia
Anemia
Cataracts
GI bleed d/t AV Malformation
Arthritis
TIA
Hyperthyroid
Discharge Condition:
Stable
Discharge Instructions:
1) Please monitor wounds for signs of infection. These include
redness, drainage or increased pain. Please contact surgeon at
([**Telephone/Fax (1) 1504**] with any wound issues.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lifting greater then 10 pounds for 10 weeks.
5) No driving for 1 month.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 120**] in 2 weeks.
Follow-up with Dr. [**Last Name (STitle) 10020**] in 2 weeks. ([**Telephone/Fax (1) 10021**]
Completed by:[**2169-1-15**] | {
"clinical_findings": {
"I2510": [
{
"icd_10_cm_code": "I25.10",
"icd_10_cm_code_description": "Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Monitoring": [],
"Evaluation": [
{
"text": "severe three vessel disease",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "CAD",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "CABGx3 (Left\ninternal mammary->Left anterior descending artery, Vein->Obtuse\nmarginal artery, vein->right coronary artery)",
"page_numbers": [
1
]
},
{
"text": "s/p CABG/AVR",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "severe three vessel disease",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I25.10 is assigned for Atherosclerotic heart disease of native coronary artery. MEAT criteria are met with Evaluation evidence from the cardiac catheterization showing 'severe three vessel disease', Assessment evidence from the Discharge Diagnosis listing 'CAD', and Treatment evidence from the Major Surgical Procedure and Discharge Diagnosis indicating 'CABGx3' and 's/p CABG/AVR'."
}
],
"I422": [
{
"icd_10_cm_code": "I42.2",
"icd_10_cm_code_description": "Other hypertrophic cardiomyopathy",
"Monitoring": [],
"Evaluation": [
{
"text": "mild symmetric left ventricular hypertrophy",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild symmetric left ventricular hypertrophy",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I42.2 is assigned for Other hypertrophic cardiomyopathy, which includes symmetric left ventricular hypertrophy. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'mild symmetric left ventricular hypertrophy'."
}
],
"I5084": [
{
"icd_10_cm_code": "I50.84",
"icd_10_cm_code_description": "Diastolic heart failure",
"Monitoring": [],
"Evaluation": [
{
"text": "Grade I (mild) LV diastolic dysfunction",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "Grade I (mild) LV diastolic dysfunction",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I50.84 is assigned for Diastolic heart failure, as diastolic dysfunction is a component. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'Grade I (mild) LV diastolic dysfunction'. ICD-10-CM guidelines indicate to code also any associated underlying condition such as hypertrophic cardiomyopathy (I42.2), which is also coded and supported by MEAT."
}
],
"I7121": [
{
"icd_10_cm_code": "I71.21",
"icd_10_cm_code_description": "Aortic aneurysm of ascending aorta, without rupture",
"Monitoring": [],
"Evaluation": [
{
"text": "ascending aorta is mildly dilated",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ascending aorta is mildly dilated",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I71.21 is assigned for Aortic aneurysm of ascending aorta, without rupture, as dilation of the aorta is typically coded as an aneurysm or ectasia. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'ascending aorta is mildly dilated'."
}
],
"E785": [
{
"icd_10_cm_code": "E78.5",
"icd_10_cm_code_description": "Hyperlipidemia, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hyperlipidemia",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "Lipitor 10mg daily",
"page_numbers": [
1
]
},
{
"text": "Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "Hyperlipidemia",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code E78.5 is assigned for Hyperlipidemia, unspecified. MEAT criteria are met with Assessment evidence from the Discharge Diagnosis listing 'Hyperlipidemia' and Treatment evidence from the medication list showing 'Lipitor 10mg daily' and 'Atorvastatin 10 mg Tablet'."
}
]
}
} |
Extract only the clinical assessment findings for each condition, including diagnostic conclusions and staging. | Admission Date: [**2169-1-9**] Discharge Date: [**2169-1-15**]
Date of Birth: [**2087-9-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Asymptomatic valve and coronary artery disease
Major Surgical or Invasive Procedure:
[**2169-1-10**] - AVR (21mm [**Company 1543**] Mosaic Porcine Valve); CABGx3 (Left
internal mammary->Left anterior descending artery, Vein->Obtuse
marginal artery, vein->right coronary artery)
History of Present Illness:
81 y/o female with known aortic stenosis which has been followed
by serial echocardiograms. Her most recent echocardiogram showed
severe aortic stenosis with dilation of her left atrium and left
ventricle. She underwent an elective cardiac catheterization
which revealed severe three vessel disease.
Past Medical History:
AS
CAD
Cataracts
Anemia
GI Bleed
AV malformation s/p Cauterization
Arthritis
TIA
Social History:
Retired book keeper. Kves with spouse. 30 pack year smoking
history quit 30 years ago. Drinks 1 glass of red wine daily.
Family History:
Father died of MI at age 63
Physical Exam:
60 sr 18 170/64 172/65 63" 125
GEN: NAD
SKIN: Unremarkable
HEENT: EOMI, PERRL, OP Benign
NECK: Supple, FROM, No LAD
LUNGS: CTA
HEART: RRR, 3/6 SEM
ABD: S/NT/ND/NABS
EXT: Warm, well perfused, no edema
NEURO: Grossly intact
Pertinent Results:
[**2169-1-9**] 02:45PM PT-12.7 PTT-26.7 INR(PT)-1.1
[**2169-1-9**] 02:45PM WBC-5.0 RBC-3.46* HGB-11.6* HCT-33.8* MCV-98
MCH-33.6* MCHC-34.4 RDW-13.8
[**2169-1-9**] 02:45PM ALT(SGPT)-25 AST(SGOT)-35 LD(LDH)-196 ALK
PHOS-80 AMYLASE-93 TOT BILI-0.3
[**2169-1-9**] 02:45PM GLUCOSE-104 UREA N-15 CREAT-0.8 SODIUM-144
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-33* ANION GAP-8
[**2169-1-10**] ECHO
PRE-CPB:1. The left atrium is moderately dilated. No thrombus is
seen in the left atrial appendage.
2. The right atrium is moderately dilated. No spontaneous echo
contrast is seen in the body of the right atrium. A prominent
eustacian valve is seen.
3. No atrial septal defect is seen by 2D or color Doppler.
4. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Transmitral Doppler and
tissue velocity imaging are consistent with Grade I (mild) LV
diastolic dysfunction.
5. Right ventricular chamber size and free wall motion are
normal.
6. The ascending aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta.
7. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened and show limited movement. No
masses or vegetations are seen on the aortic valve. There is
moderate to severe aortic valve stenosis (area 0.8-1.0cm2).
Moderate (2+) aortic regurgitation is seen.
8. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
9. There is a trivial/physiologic pericardial effusion.
POST-CPB: On infusion of
Brief Hospital Course:
Mrs. [**Known lastname 10019**] was admitted to the [**Hospital1 18**] on [**2169-1-9**] for elective
surgical management of her coronary artery and aortic valve
disease. On [**2169-1-10**] Mrs. [**Known lastname 10019**] was taken to the operating room
where she underwent coronary artery bypass grafting to three
vessels and an aortic valve replacement using a 21mm [**Company **]
mosaic porcine valve. Postoperatively she was taken to the
intensive care unit for monitoring. On postoperative day one,
Mrs. [**Known lastname 10019**] awoke neurologically intact and was extubated.
Aspirin, beta blockade and a statin were resumed. She was then
transferred to the step down unit for further recovery. She was
gently diuresed towards her preoperative weight. The physical
therapy service was consulted for assistance with her
postoperative strength and mobility.
Mrs. [**Known lastname 10019**] continued to make steady progress and was discharged
to home with VNA services. She will follow-up with Dr.
[**Last Name (STitle) 1290**], her cardiologist and her primary care physician as an
outpatient.
Medications on Admission:
Aspirin 81mg daily
Lipitor 10mg daily
Multivitamin
Caltrate 600mg daily
Fish oil
B-12
Ocuvite
Protonix 20mg daily
Ferosol 45mg daily
Colace 100mg daily
Calcium and vitamin D
Discharge Medications:
1. [**Last Name (un) 1724**]
[**Last Name (un) 1724**] ASA 81', lipitor 10', mvi', caltrate 600', fish oil 1200'
b12 1000', vit d 400', colace 100", feosol 45', protonix 20'
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 6 days.
Disp:*12 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. other Vitamins
Your other vitamins are ok to take / caltrate / fishoil etc
14. Feosol 45 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
CAD/AS s/p CABG/AVR [**2169-1-10**]
Hyperlipidemia
Anemia
Cataracts
GI bleed d/t AV Malformation
Arthritis
TIA
Hyperthyroid
Discharge Condition:
Stable
Discharge Instructions:
1) Please monitor wounds for signs of infection. These include
redness, drainage or increased pain. Please contact surgeon at
([**Telephone/Fax (1) 1504**] with any wound issues.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lifting greater then 10 pounds for 10 weeks.
5) No driving for 1 month.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 120**] in 2 weeks.
Follow-up with Dr. [**Last Name (STitle) 10020**] in 2 weeks. ([**Telephone/Fax (1) 10021**]
Completed by:[**2169-1-15**] | {
"clinical_findings": {
"I2510": [
{
"icd_10_cm_code": "I25.10",
"icd_10_cm_code_description": "Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Monitoring": [],
"Evaluation": [
{
"text": "severe three vessel disease",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "CAD",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "CABGx3 (Left\ninternal mammary->Left anterior descending artery, Vein->Obtuse\nmarginal artery, vein->right coronary artery)",
"page_numbers": [
1
]
},
{
"text": "s/p CABG/AVR",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "severe three vessel disease",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I25.10 is assigned for Atherosclerotic heart disease of native coronary artery. MEAT criteria are met with Evaluation evidence from the cardiac catheterization showing 'severe three vessel disease', Assessment evidence from the Discharge Diagnosis listing 'CAD', and Treatment evidence from the Major Surgical Procedure and Discharge Diagnosis indicating 'CABGx3' and 's/p CABG/AVR'."
}
],
"I422": [
{
"icd_10_cm_code": "I42.2",
"icd_10_cm_code_description": "Other hypertrophic cardiomyopathy",
"Monitoring": [],
"Evaluation": [
{
"text": "mild symmetric left ventricular hypertrophy",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild symmetric left ventricular hypertrophy",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I42.2 is assigned for Other hypertrophic cardiomyopathy, which includes symmetric left ventricular hypertrophy. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'mild symmetric left ventricular hypertrophy'."
}
],
"I5084": [
{
"icd_10_cm_code": "I50.84",
"icd_10_cm_code_description": "Diastolic heart failure",
"Monitoring": [],
"Evaluation": [
{
"text": "Grade I (mild) LV diastolic dysfunction",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "Grade I (mild) LV diastolic dysfunction",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I50.84 is assigned for Diastolic heart failure, as diastolic dysfunction is a component. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'Grade I (mild) LV diastolic dysfunction'. ICD-10-CM guidelines indicate to code also any associated underlying condition such as hypertrophic cardiomyopathy (I42.2), which is also coded and supported by MEAT."
}
],
"I7121": [
{
"icd_10_cm_code": "I71.21",
"icd_10_cm_code_description": "Aortic aneurysm of ascending aorta, without rupture",
"Monitoring": [],
"Evaluation": [
{
"text": "ascending aorta is mildly dilated",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ascending aorta is mildly dilated",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I71.21 is assigned for Aortic aneurysm of ascending aorta, without rupture, as dilation of the aorta is typically coded as an aneurysm or ectasia. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'ascending aorta is mildly dilated'."
}
],
"E785": [
{
"icd_10_cm_code": "E78.5",
"icd_10_cm_code_description": "Hyperlipidemia, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hyperlipidemia",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "Lipitor 10mg daily",
"page_numbers": [
1
]
},
{
"text": "Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "Hyperlipidemia",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code E78.5 is assigned for Hyperlipidemia, unspecified. MEAT criteria are met with Assessment evidence from the Discharge Diagnosis listing 'Hyperlipidemia' and Treatment evidence from the medication list showing 'Lipitor 10mg daily' and 'Atorvastatin 10 mg Tablet'."
}
]
}
} |
Extract only the treatment or intervention given for each condition, including surgeries, procedures, and medications. | Admission Date: [**2169-1-9**] Discharge Date: [**2169-1-15**]
Date of Birth: [**2087-9-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Asymptomatic valve and coronary artery disease
Major Surgical or Invasive Procedure:
[**2169-1-10**] - AVR (21mm [**Company 1543**] Mosaic Porcine Valve); CABGx3 (Left
internal mammary->Left anterior descending artery, Vein->Obtuse
marginal artery, vein->right coronary artery)
History of Present Illness:
81 y/o female with known aortic stenosis which has been followed
by serial echocardiograms. Her most recent echocardiogram showed
severe aortic stenosis with dilation of her left atrium and left
ventricle. She underwent an elective cardiac catheterization
which revealed severe three vessel disease.
Past Medical History:
AS
CAD
Cataracts
Anemia
GI Bleed
AV malformation s/p Cauterization
Arthritis
TIA
Social History:
Retired book keeper. Kves with spouse. 30 pack year smoking
history quit 30 years ago. Drinks 1 glass of red wine daily.
Family History:
Father died of MI at age 63
Physical Exam:
60 sr 18 170/64 172/65 63" 125
GEN: NAD
SKIN: Unremarkable
HEENT: EOMI, PERRL, OP Benign
NECK: Supple, FROM, No LAD
LUNGS: CTA
HEART: RRR, 3/6 SEM
ABD: S/NT/ND/NABS
EXT: Warm, well perfused, no edema
NEURO: Grossly intact
Pertinent Results:
[**2169-1-9**] 02:45PM PT-12.7 PTT-26.7 INR(PT)-1.1
[**2169-1-9**] 02:45PM WBC-5.0 RBC-3.46* HGB-11.6* HCT-33.8* MCV-98
MCH-33.6* MCHC-34.4 RDW-13.8
[**2169-1-9**] 02:45PM ALT(SGPT)-25 AST(SGOT)-35 LD(LDH)-196 ALK
PHOS-80 AMYLASE-93 TOT BILI-0.3
[**2169-1-9**] 02:45PM GLUCOSE-104 UREA N-15 CREAT-0.8 SODIUM-144
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-33* ANION GAP-8
[**2169-1-10**] ECHO
PRE-CPB:1. The left atrium is moderately dilated. No thrombus is
seen in the left atrial appendage.
2. The right atrium is moderately dilated. No spontaneous echo
contrast is seen in the body of the right atrium. A prominent
eustacian valve is seen.
3. No atrial septal defect is seen by 2D or color Doppler.
4. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Transmitral Doppler and
tissue velocity imaging are consistent with Grade I (mild) LV
diastolic dysfunction.
5. Right ventricular chamber size and free wall motion are
normal.
6. The ascending aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta.
7. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened and show limited movement. No
masses or vegetations are seen on the aortic valve. There is
moderate to severe aortic valve stenosis (area 0.8-1.0cm2).
Moderate (2+) aortic regurgitation is seen.
8. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
9. There is a trivial/physiologic pericardial effusion.
POST-CPB: On infusion of
Brief Hospital Course:
Mrs. [**Known lastname 10019**] was admitted to the [**Hospital1 18**] on [**2169-1-9**] for elective
surgical management of her coronary artery and aortic valve
disease. On [**2169-1-10**] Mrs. [**Known lastname 10019**] was taken to the operating room
where she underwent coronary artery bypass grafting to three
vessels and an aortic valve replacement using a 21mm [**Company **]
mosaic porcine valve. Postoperatively she was taken to the
intensive care unit for monitoring. On postoperative day one,
Mrs. [**Known lastname 10019**] awoke neurologically intact and was extubated.
Aspirin, beta blockade and a statin were resumed. She was then
transferred to the step down unit for further recovery. She was
gently diuresed towards her preoperative weight. The physical
therapy service was consulted for assistance with her
postoperative strength and mobility.
Mrs. [**Known lastname 10019**] continued to make steady progress and was discharged
to home with VNA services. She will follow-up with Dr.
[**Last Name (STitle) 1290**], her cardiologist and her primary care physician as an
outpatient.
Medications on Admission:
Aspirin 81mg daily
Lipitor 10mg daily
Multivitamin
Caltrate 600mg daily
Fish oil
B-12
Ocuvite
Protonix 20mg daily
Ferosol 45mg daily
Colace 100mg daily
Calcium and vitamin D
Discharge Medications:
1. [**Last Name (un) 1724**]
[**Last Name (un) 1724**] ASA 81', lipitor 10', mvi', caltrate 600', fish oil 1200'
b12 1000', vit d 400', colace 100", feosol 45', protonix 20'
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 6 days.
Disp:*12 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. other Vitamins
Your other vitamins are ok to take / caltrate / fishoil etc
14. Feosol 45 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
CAD/AS s/p CABG/AVR [**2169-1-10**]
Hyperlipidemia
Anemia
Cataracts
GI bleed d/t AV Malformation
Arthritis
TIA
Hyperthyroid
Discharge Condition:
Stable
Discharge Instructions:
1) Please monitor wounds for signs of infection. These include
redness, drainage or increased pain. Please contact surgeon at
([**Telephone/Fax (1) 1504**] with any wound issues.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lifting greater then 10 pounds for 10 weeks.
5) No driving for 1 month.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 120**] in 2 weeks.
Follow-up with Dr. [**Last Name (STitle) 10020**] in 2 weeks. ([**Telephone/Fax (1) 10021**]
Completed by:[**2169-1-15**] | {
"clinical_findings": {
"I2510": [
{
"icd_10_cm_code": "I25.10",
"icd_10_cm_code_description": "Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Monitoring": [],
"Evaluation": [
{
"text": "severe three vessel disease",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "CAD",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "CABGx3 (Left\ninternal mammary->Left anterior descending artery, Vein->Obtuse\nmarginal artery, vein->right coronary artery)",
"page_numbers": [
1
]
},
{
"text": "s/p CABG/AVR",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "severe three vessel disease",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I25.10 is assigned for Atherosclerotic heart disease of native coronary artery. MEAT criteria are met with Evaluation evidence from the cardiac catheterization showing 'severe three vessel disease', Assessment evidence from the Discharge Diagnosis listing 'CAD', and Treatment evidence from the Major Surgical Procedure and Discharge Diagnosis indicating 'CABGx3' and 's/p CABG/AVR'."
}
],
"I422": [
{
"icd_10_cm_code": "I42.2",
"icd_10_cm_code_description": "Other hypertrophic cardiomyopathy",
"Monitoring": [],
"Evaluation": [
{
"text": "mild symmetric left ventricular hypertrophy",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild symmetric left ventricular hypertrophy",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I42.2 is assigned for Other hypertrophic cardiomyopathy, which includes symmetric left ventricular hypertrophy. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'mild symmetric left ventricular hypertrophy'."
}
],
"I5084": [
{
"icd_10_cm_code": "I50.84",
"icd_10_cm_code_description": "Diastolic heart failure",
"Monitoring": [],
"Evaluation": [
{
"text": "Grade I (mild) LV diastolic dysfunction",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "Grade I (mild) LV diastolic dysfunction",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I50.84 is assigned for Diastolic heart failure, as diastolic dysfunction is a component. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'Grade I (mild) LV diastolic dysfunction'. ICD-10-CM guidelines indicate to code also any associated underlying condition such as hypertrophic cardiomyopathy (I42.2), which is also coded and supported by MEAT."
}
],
"I7121": [
{
"icd_10_cm_code": "I71.21",
"icd_10_cm_code_description": "Aortic aneurysm of ascending aorta, without rupture",
"Monitoring": [],
"Evaluation": [
{
"text": "ascending aorta is mildly dilated",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ascending aorta is mildly dilated",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I71.21 is assigned for Aortic aneurysm of ascending aorta, without rupture, as dilation of the aorta is typically coded as an aneurysm or ectasia. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'ascending aorta is mildly dilated'."
}
],
"E785": [
{
"icd_10_cm_code": "E78.5",
"icd_10_cm_code_description": "Hyperlipidemia, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hyperlipidemia",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "Lipitor 10mg daily",
"page_numbers": [
1
]
},
{
"text": "Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "Hyperlipidemia",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code E78.5 is assigned for Hyperlipidemia, unspecified. MEAT criteria are met with Assessment evidence from the Discharge Diagnosis listing 'Hyperlipidemia' and Treatment evidence from the medication list showing 'Lipitor 10mg daily' and 'Atorvastatin 10 mg Tablet'."
}
]
}
} |
Extract only the evidence from the discharge summary that supports the existence of each condition. | Admission Date: [**2169-1-9**] Discharge Date: [**2169-1-15**]
Date of Birth: [**2087-9-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Asymptomatic valve and coronary artery disease
Major Surgical or Invasive Procedure:
[**2169-1-10**] - AVR (21mm [**Company 1543**] Mosaic Porcine Valve); CABGx3 (Left
internal mammary->Left anterior descending artery, Vein->Obtuse
marginal artery, vein->right coronary artery)
History of Present Illness:
81 y/o female with known aortic stenosis which has been followed
by serial echocardiograms. Her most recent echocardiogram showed
severe aortic stenosis with dilation of her left atrium and left
ventricle. She underwent an elective cardiac catheterization
which revealed severe three vessel disease.
Past Medical History:
AS
CAD
Cataracts
Anemia
GI Bleed
AV malformation s/p Cauterization
Arthritis
TIA
Social History:
Retired book keeper. Kves with spouse. 30 pack year smoking
history quit 30 years ago. Drinks 1 glass of red wine daily.
Family History:
Father died of MI at age 63
Physical Exam:
60 sr 18 170/64 172/65 63" 125
GEN: NAD
SKIN: Unremarkable
HEENT: EOMI, PERRL, OP Benign
NECK: Supple, FROM, No LAD
LUNGS: CTA
HEART: RRR, 3/6 SEM
ABD: S/NT/ND/NABS
EXT: Warm, well perfused, no edema
NEURO: Grossly intact
Pertinent Results:
[**2169-1-9**] 02:45PM PT-12.7 PTT-26.7 INR(PT)-1.1
[**2169-1-9**] 02:45PM WBC-5.0 RBC-3.46* HGB-11.6* HCT-33.8* MCV-98
MCH-33.6* MCHC-34.4 RDW-13.8
[**2169-1-9**] 02:45PM ALT(SGPT)-25 AST(SGOT)-35 LD(LDH)-196 ALK
PHOS-80 AMYLASE-93 TOT BILI-0.3
[**2169-1-9**] 02:45PM GLUCOSE-104 UREA N-15 CREAT-0.8 SODIUM-144
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-33* ANION GAP-8
[**2169-1-10**] ECHO
PRE-CPB:1. The left atrium is moderately dilated. No thrombus is
seen in the left atrial appendage.
2. The right atrium is moderately dilated. No spontaneous echo
contrast is seen in the body of the right atrium. A prominent
eustacian valve is seen.
3. No atrial septal defect is seen by 2D or color Doppler.
4. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Transmitral Doppler and
tissue velocity imaging are consistent with Grade I (mild) LV
diastolic dysfunction.
5. Right ventricular chamber size and free wall motion are
normal.
6. The ascending aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta.
7. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened and show limited movement. No
masses or vegetations are seen on the aortic valve. There is
moderate to severe aortic valve stenosis (area 0.8-1.0cm2).
Moderate (2+) aortic regurgitation is seen.
8. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
9. There is a trivial/physiologic pericardial effusion.
POST-CPB: On infusion of
Brief Hospital Course:
Mrs. [**Known lastname 10019**] was admitted to the [**Hospital1 18**] on [**2169-1-9**] for elective
surgical management of her coronary artery and aortic valve
disease. On [**2169-1-10**] Mrs. [**Known lastname 10019**] was taken to the operating room
where she underwent coronary artery bypass grafting to three
vessels and an aortic valve replacement using a 21mm [**Company **]
mosaic porcine valve. Postoperatively she was taken to the
intensive care unit for monitoring. On postoperative day one,
Mrs. [**Known lastname 10019**] awoke neurologically intact and was extubated.
Aspirin, beta blockade and a statin were resumed. She was then
transferred to the step down unit for further recovery. She was
gently diuresed towards her preoperative weight. The physical
therapy service was consulted for assistance with her
postoperative strength and mobility.
Mrs. [**Known lastname 10019**] continued to make steady progress and was discharged
to home with VNA services. She will follow-up with Dr.
[**Last Name (STitle) 1290**], her cardiologist and her primary care physician as an
outpatient.
Medications on Admission:
Aspirin 81mg daily
Lipitor 10mg daily
Multivitamin
Caltrate 600mg daily
Fish oil
B-12
Ocuvite
Protonix 20mg daily
Ferosol 45mg daily
Colace 100mg daily
Calcium and vitamin D
Discharge Medications:
1. [**Last Name (un) 1724**]
[**Last Name (un) 1724**] ASA 81', lipitor 10', mvi', caltrate 600', fish oil 1200'
b12 1000', vit d 400', colace 100", feosol 45', protonix 20'
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 6 days.
Disp:*12 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. other Vitamins
Your other vitamins are ok to take / caltrate / fishoil etc
14. Feosol 45 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
CAD/AS s/p CABG/AVR [**2169-1-10**]
Hyperlipidemia
Anemia
Cataracts
GI bleed d/t AV Malformation
Arthritis
TIA
Hyperthyroid
Discharge Condition:
Stable
Discharge Instructions:
1) Please monitor wounds for signs of infection. These include
redness, drainage or increased pain. Please contact surgeon at
([**Telephone/Fax (1) 1504**] with any wound issues.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lifting greater then 10 pounds for 10 weeks.
5) No driving for 1 month.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 120**] in 2 weeks.
Follow-up with Dr. [**Last Name (STitle) 10020**] in 2 weeks. ([**Telephone/Fax (1) 10021**]
Completed by:[**2169-1-15**] | {
"clinical_findings": {
"I2510": [
{
"icd_10_cm_code": "I25.10",
"icd_10_cm_code_description": "Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Monitoring": [],
"Evaluation": [
{
"text": "severe three vessel disease",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "CAD",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "CABGx3 (Left\ninternal mammary->Left anterior descending artery, Vein->Obtuse\nmarginal artery, vein->right coronary artery)",
"page_numbers": [
1
]
},
{
"text": "s/p CABG/AVR",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "severe three vessel disease",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I25.10 is assigned for Atherosclerotic heart disease of native coronary artery. MEAT criteria are met with Evaluation evidence from the cardiac catheterization showing 'severe three vessel disease', Assessment evidence from the Discharge Diagnosis listing 'CAD', and Treatment evidence from the Major Surgical Procedure and Discharge Diagnosis indicating 'CABGx3' and 's/p CABG/AVR'."
}
],
"I422": [
{
"icd_10_cm_code": "I42.2",
"icd_10_cm_code_description": "Other hypertrophic cardiomyopathy",
"Monitoring": [],
"Evaluation": [
{
"text": "mild symmetric left ventricular hypertrophy",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild symmetric left ventricular hypertrophy",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I42.2 is assigned for Other hypertrophic cardiomyopathy, which includes symmetric left ventricular hypertrophy. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'mild symmetric left ventricular hypertrophy'."
}
],
"I5084": [
{
"icd_10_cm_code": "I50.84",
"icd_10_cm_code_description": "Diastolic heart failure",
"Monitoring": [],
"Evaluation": [
{
"text": "Grade I (mild) LV diastolic dysfunction",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "Grade I (mild) LV diastolic dysfunction",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I50.84 is assigned for Diastolic heart failure, as diastolic dysfunction is a component. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'Grade I (mild) LV diastolic dysfunction'. ICD-10-CM guidelines indicate to code also any associated underlying condition such as hypertrophic cardiomyopathy (I42.2), which is also coded and supported by MEAT."
}
],
"I7121": [
{
"icd_10_cm_code": "I71.21",
"icd_10_cm_code_description": "Aortic aneurysm of ascending aorta, without rupture",
"Monitoring": [],
"Evaluation": [
{
"text": "ascending aorta is mildly dilated",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ascending aorta is mildly dilated",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I71.21 is assigned for Aortic aneurysm of ascending aorta, without rupture, as dilation of the aorta is typically coded as an aneurysm or ectasia. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'ascending aorta is mildly dilated'."
}
],
"E785": [
{
"icd_10_cm_code": "E78.5",
"icd_10_cm_code_description": "Hyperlipidemia, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hyperlipidemia",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "Lipitor 10mg daily",
"page_numbers": [
1
]
},
{
"text": "Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "Hyperlipidemia",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code E78.5 is assigned for Hyperlipidemia, unspecified. MEAT criteria are met with Assessment evidence from the Discharge Diagnosis listing 'Hyperlipidemia' and Treatment evidence from the medication list showing 'Lipitor 10mg daily' and 'Atorvastatin 10 mg Tablet'."
}
]
}
} |
Extract only the text-based justification for assigning the ICD-10-CM code to each condition. | Admission Date: [**2169-1-9**] Discharge Date: [**2169-1-15**]
Date of Birth: [**2087-9-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Asymptomatic valve and coronary artery disease
Major Surgical or Invasive Procedure:
[**2169-1-10**] - AVR (21mm [**Company 1543**] Mosaic Porcine Valve); CABGx3 (Left
internal mammary->Left anterior descending artery, Vein->Obtuse
marginal artery, vein->right coronary artery)
History of Present Illness:
81 y/o female with known aortic stenosis which has been followed
by serial echocardiograms. Her most recent echocardiogram showed
severe aortic stenosis with dilation of her left atrium and left
ventricle. She underwent an elective cardiac catheterization
which revealed severe three vessel disease.
Past Medical History:
AS
CAD
Cataracts
Anemia
GI Bleed
AV malformation s/p Cauterization
Arthritis
TIA
Social History:
Retired book keeper. Kves with spouse. 30 pack year smoking
history quit 30 years ago. Drinks 1 glass of red wine daily.
Family History:
Father died of MI at age 63
Physical Exam:
60 sr 18 170/64 172/65 63" 125
GEN: NAD
SKIN: Unremarkable
HEENT: EOMI, PERRL, OP Benign
NECK: Supple, FROM, No LAD
LUNGS: CTA
HEART: RRR, 3/6 SEM
ABD: S/NT/ND/NABS
EXT: Warm, well perfused, no edema
NEURO: Grossly intact
Pertinent Results:
[**2169-1-9**] 02:45PM PT-12.7 PTT-26.7 INR(PT)-1.1
[**2169-1-9**] 02:45PM WBC-5.0 RBC-3.46* HGB-11.6* HCT-33.8* MCV-98
MCH-33.6* MCHC-34.4 RDW-13.8
[**2169-1-9**] 02:45PM ALT(SGPT)-25 AST(SGOT)-35 LD(LDH)-196 ALK
PHOS-80 AMYLASE-93 TOT BILI-0.3
[**2169-1-9**] 02:45PM GLUCOSE-104 UREA N-15 CREAT-0.8 SODIUM-144
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-33* ANION GAP-8
[**2169-1-10**] ECHO
PRE-CPB:1. The left atrium is moderately dilated. No thrombus is
seen in the left atrial appendage.
2. The right atrium is moderately dilated. No spontaneous echo
contrast is seen in the body of the right atrium. A prominent
eustacian valve is seen.
3. No atrial septal defect is seen by 2D or color Doppler.
4. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Transmitral Doppler and
tissue velocity imaging are consistent with Grade I (mild) LV
diastolic dysfunction.
5. Right ventricular chamber size and free wall motion are
normal.
6. The ascending aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta.
7. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened and show limited movement. No
masses or vegetations are seen on the aortic valve. There is
moderate to severe aortic valve stenosis (area 0.8-1.0cm2).
Moderate (2+) aortic regurgitation is seen.
8. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
9. There is a trivial/physiologic pericardial effusion.
POST-CPB: On infusion of
Brief Hospital Course:
Mrs. [**Known lastname 10019**] was admitted to the [**Hospital1 18**] on [**2169-1-9**] for elective
surgical management of her coronary artery and aortic valve
disease. On [**2169-1-10**] Mrs. [**Known lastname 10019**] was taken to the operating room
where she underwent coronary artery bypass grafting to three
vessels and an aortic valve replacement using a 21mm [**Company **]
mosaic porcine valve. Postoperatively she was taken to the
intensive care unit for monitoring. On postoperative day one,
Mrs. [**Known lastname 10019**] awoke neurologically intact and was extubated.
Aspirin, beta blockade and a statin were resumed. She was then
transferred to the step down unit for further recovery. She was
gently diuresed towards her preoperative weight. The physical
therapy service was consulted for assistance with her
postoperative strength and mobility.
Mrs. [**Known lastname 10019**] continued to make steady progress and was discharged
to home with VNA services. She will follow-up with Dr.
[**Last Name (STitle) 1290**], her cardiologist and her primary care physician as an
outpatient.
Medications on Admission:
Aspirin 81mg daily
Lipitor 10mg daily
Multivitamin
Caltrate 600mg daily
Fish oil
B-12
Ocuvite
Protonix 20mg daily
Ferosol 45mg daily
Colace 100mg daily
Calcium and vitamin D
Discharge Medications:
1. [**Last Name (un) 1724**]
[**Last Name (un) 1724**] ASA 81', lipitor 10', mvi', caltrate 600', fish oil 1200'
b12 1000', vit d 400', colace 100", feosol 45', protonix 20'
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 6 days.
Disp:*12 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. other Vitamins
Your other vitamins are ok to take / caltrate / fishoil etc
14. Feosol 45 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
CAD/AS s/p CABG/AVR [**2169-1-10**]
Hyperlipidemia
Anemia
Cataracts
GI bleed d/t AV Malformation
Arthritis
TIA
Hyperthyroid
Discharge Condition:
Stable
Discharge Instructions:
1) Please monitor wounds for signs of infection. These include
redness, drainage or increased pain. Please contact surgeon at
([**Telephone/Fax (1) 1504**] with any wound issues.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lifting greater then 10 pounds for 10 weeks.
5) No driving for 1 month.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 120**] in 2 weeks.
Follow-up with Dr. [**Last Name (STitle) 10020**] in 2 weeks. ([**Telephone/Fax (1) 10021**]
Completed by:[**2169-1-15**] | {
"clinical_findings": {
"I2510": [
{
"icd_10_cm_code": "I25.10",
"icd_10_cm_code_description": "Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Monitoring": [],
"Evaluation": [
{
"text": "severe three vessel disease",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "CAD",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "CABGx3 (Left\ninternal mammary->Left anterior descending artery, Vein->Obtuse\nmarginal artery, vein->right coronary artery)",
"page_numbers": [
1
]
},
{
"text": "s/p CABG/AVR",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "severe three vessel disease",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I25.10 is assigned for Atherosclerotic heart disease of native coronary artery. MEAT criteria are met with Evaluation evidence from the cardiac catheterization showing 'severe three vessel disease', Assessment evidence from the Discharge Diagnosis listing 'CAD', and Treatment evidence from the Major Surgical Procedure and Discharge Diagnosis indicating 'CABGx3' and 's/p CABG/AVR'."
}
],
"I422": [
{
"icd_10_cm_code": "I42.2",
"icd_10_cm_code_description": "Other hypertrophic cardiomyopathy",
"Monitoring": [],
"Evaluation": [
{
"text": "mild symmetric left ventricular hypertrophy",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild symmetric left ventricular hypertrophy",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I42.2 is assigned for Other hypertrophic cardiomyopathy, which includes symmetric left ventricular hypertrophy. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'mild symmetric left ventricular hypertrophy'."
}
],
"I5084": [
{
"icd_10_cm_code": "I50.84",
"icd_10_cm_code_description": "Diastolic heart failure",
"Monitoring": [],
"Evaluation": [
{
"text": "Grade I (mild) LV diastolic dysfunction",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "Grade I (mild) LV diastolic dysfunction",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I50.84 is assigned for Diastolic heart failure, as diastolic dysfunction is a component. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'Grade I (mild) LV diastolic dysfunction'. ICD-10-CM guidelines indicate to code also any associated underlying condition such as hypertrophic cardiomyopathy (I42.2), which is also coded and supported by MEAT."
}
],
"I7121": [
{
"icd_10_cm_code": "I71.21",
"icd_10_cm_code_description": "Aortic aneurysm of ascending aorta, without rupture",
"Monitoring": [],
"Evaluation": [
{
"text": "ascending aorta is mildly dilated",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ascending aorta is mildly dilated",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I71.21 is assigned for Aortic aneurysm of ascending aorta, without rupture, as dilation of the aorta is typically coded as an aneurysm or ectasia. MEAT criteria are met with Evaluation evidence from the echocardiogram showing 'ascending aorta is mildly dilated'."
}
],
"E785": [
{
"icd_10_cm_code": "E78.5",
"icd_10_cm_code_description": "Hyperlipidemia, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hyperlipidemia",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "Lipitor 10mg daily",
"page_numbers": [
1
]
},
{
"text": "Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "Hyperlipidemia",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code E78.5 is assigned for Hyperlipidemia, unspecified. MEAT criteria are met with Assessment evidence from the Discharge Diagnosis listing 'Hyperlipidemia' and Treatment evidence from the medication list showing 'Lipitor 10mg daily' and 'Atorvastatin 10 mg Tablet'."
}
]
}
} |
Extract the ICD-10-CM code assigned to each clinical condition mentioned in the discharge summary. | Admission Date: [**2126-3-2**] Discharge Date: [**2126-3-6**]
Date of Birth: [**2061-11-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 9824**]
Chief Complaint:
N/V, Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt. is a 64 y/o F with a PMH of ESRD on HD, DM, and HTN
presenting after dialysis with hypotension, nausea, vomiting and
abdominal pain. The patient reports six episodes of emesis since
HD with mild epigastric pain. Per report temp to 100.5 at HD
with complaint of aches and chills. 4L fluid taken off at HD,
pre-treatment BP 96/58, post-treatment 169/92. T 97.8.
.
In the ED, initial vs were: T 102.9 BP 146/65, HR 110, RR 20 O2
92% RA. FS 215. Blood Cx sent. Emesis X1. Patient was given
Vancomycin 1gm IV, Levofloxacin 500mg IV, Flagyl 500mg IV,
Morphine 2mg IV. Her BP fell to 94/43 and she was given 1 L NS.
WBC 11.2, lactate 3.2. CXR demonstrated no evidence of
infiltrate. CT Abd/Pelvis showed no evidence of colitis. Per ED
report, beside US showed limited views but a normal caliber
aorta.
.
On arrival to the ICU, the patient was resting comfortably. She
denies lightheadedness. C/o b/l knee pain and low back pain
unchanged from her baseline. The pt. reports increased fatigue X
1 week, she has had decreased mobility since her knee surgery in
[**12-31**]. She reports that typically post-HD she has increased
enerygy, however she noted no improvement this week. Denies
fever, had chills last evening but temp was 97.8 at home. She
c/o abd pain, similar to her chronic symptoms, mostly epigastric
but burning symptoms occur in various locations with no clear
pattern or relation to meals. Denies cough, rhinorrhea. +Frontal
and occipital HA last pm. + chronic constipation, no diarrhea.
Her appetite is normal.
Past Medical History:
End stage renal disease on hemodialysis (TuThSa) - LSC HD
catheter changed [**2125-3-8**]
Hx of Back Abscess - [**2123**] treated with I&D, Vanc X 14 days
Diabetes mellitus type II
Hypertension
Hypercholesterolemia
Coronary artery disease (nonobstructive on cath in [**2119**], normal
stress in [**2124-6-23**])
Constipation
Status post total abdominal hysterectomy
Status post C-section
H. Pylori s/p treatment in [**2124-3-23**]
Gastritis
Right knee subtotal medial meniscectomy and subtotal lateral
meniscectomy with medial femoral chondroplasty [**2126-1-8**]
Social History:
Married and lives with husband, 2 children who live nearby,
former home health aid. Smokes <[**1-25**] ppd x 40 years, quit in [**3-3**]
after being hospitalized for influenza. no ETOH, no
drugs. Received the influenza and pneumococcal vaccines
Family History:
+ Premature CAD in brothers and mother. Daughter with kidney
disease. Siblings with DM, CAD, HTN, CVA, no cancer.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild TTP epigastrium, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no edema
Skin: multiple scars from prev fistula attempts on both
forearms, scar, scar - midback from prev. incision site, L SC
site no erythema surrounding catheter + skin breakdown around
adhesive dressing, no fluctuance, no drainage
Pertinent Results:
[**2126-3-2**] 01:15PM WBC-11.2*# RBC-3.97* HGB-12.7 HCT-37.9 MCV-95
MCH-32.0 MCHC-33.5 RDW-15.1
[**2126-3-2**] 01:15PM NEUTS-90.2* LYMPHS-4.6* MONOS-4.1 EOS-0.8
BASOS-0.2
[**2126-3-2**] 01:15PM PLT COUNT-203
[**2126-3-2**] 01:15PM GLUCOSE-197* UREA N-9 CREAT-2.9*# SODIUM-144
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-29 ANION GAP-22*
[**2126-3-2**] 01:15PM ALT(SGPT)-34 AST(SGOT)-31 CK(CPK)-69 ALK
PHOS-193* TOT BILI-0.5
[**2126-3-2**] 01:21PM LACTATE-3.1*
[**2126-3-2**] 04:16PM LACTATE-2.3*
[**2126-3-6**] 04:35AM BLOOD WBC-6.5 RBC-3.03* Hgb-9.3* Hct-28.8*
MCV-95 MCH-30.7 MCHC-32.3 RDW-15.5 Plt Ct-207
[**2126-3-6**] 04:35AM BLOOD Glucose-98 UreaN-16 Creat-4.6*# Na-137
K-4.2 Cl-98 HCO3-28 AnGap-15
[**2126-3-4**] 05:30AM BLOOD ALT-20 AST-15 LD(LDH)-151 AlkPhos-143*
TotBili-0.3
[**2126-3-3**] 01:35AM BLOOD Lipase-36
[**2126-3-2**] 01:15PM BLOOD CK-MB-3 cTropnT-0.05*
[**2126-3-6**] 04:35AM BLOOD Calcium-10.3* Phos-4.7*# Mg-1.8
[**2126-3-6**] 04:35AM BLOOD PTH-1368*
[**2126-3-5**] 06:35AM BLOOD Vanco-9.8*
[**2126-3-3**] 06:04PM BLOOD Vanco-12.4
[**2126-3-4**] 05:55AM BLOOD Lactate-1.2
[**2126-3-2**] 1:00 pm BLOOD CULTURE
**FINAL REPORT [**2126-3-9**]**
Blood Culture, Routine (Final [**2126-3-8**]):
PRESUMPTIVE PEPTOSTREPTOCOCCUS SPECIES.
ISOLATED FROM ONE SET ONLY.
BACILLUS SPECIES; NOT ANTHRACIS.
Sensitivity testing performed by Sensititre.
GENTAMICIN = SENSITIVE ( <=2 MCG/ML ).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BACILLUS SPECIES; NOT ANTHRACIS
|
CLINDAMYCIN----------- 0.5 S
GENTAMICIN------------ S
LEVOFLOXACIN----------<=0.25 S
VANCOMYCIN------------ <=1 S
[**2126-3-2**] 1:15 pm BLOOD CULTURE
**FINAL REPORT [**2126-3-8**]**
Blood Culture, Routine (Final [**2126-3-8**]):
BACILLUS SPECIES; NOT ANTHRACIS.
SENSITIVITIES PERFORMED ON CULTURE # 266-9949D [**2126-3-2**].
Anaerobic Bottle Gram Stain (Final [**2126-3-5**]):
GRAM POSITIVE ROD(S).
REPORTED BY PHONE TO [**Doctor First Name **] [**Doctor Last Name **]-[**Doctor Last Name **] #[**Numeric Identifier 11629**] [**2126-3-4**]
2:30PM.
CONSISTENT WITH CLOSTRIDIUM AND
BACILLUS SPECIES.
Blood Cx: [**3-2**], [**3-4**], [**3-4**], [**3-5**]: No growth
Cardiology Report ECG Study Date of [**2126-3-2**] 2:04:54 PM
Sinus rhythm. Modest inferolateral T wave changes which are
non-specific.
Compared to the previous tracing of [**2125-12-26**] there is no
significant diagnostic
change.
CXR: [**3-2**]
IMPRESSION: No significant change when compared to prior exam.
CT- abd/pelvis: [**3-2**]
IMPRESSION:
1. No evidence of colitis.
2. Unchanged angiomylipoma of right kidney. Multiple tiny
hypodensities in
the kidneys too small to accurately characterize.
3. Several small nodules in the left adrenal gland likely not
changed from
[**2122**] but incompletely characterized on the current study.
4. Atherosclerotic disease.
RUQ U/S [**3-3**]
IMPRESSION:
Unchanged cholelithiasis with no secondary findings to suggest
acute
cholecystitis.
TTE [**3-6**]
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with probable mild hypokinesis of the basal to mid
inferolateral and lateral segments (suboptimal image quality
limits interpretation). Right ventricular chamber size and free
wall motion are normal. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are moderately
thickened. No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. There is mild aortic valve stenosis (area 1.2-1.9cm2).
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No masses or vegetations are seen
on the mitral valve, but cannot be fully excluded due to
suboptimal image quality. Trivial mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] No masses or vegetations
are seen on the tricuspid valve, but cannot be fully excluded
due to suboptimal image quality. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality limits interpretation.
There is no evidence of endocarditis or abscess. Calcification
of the aortic valve and mitral annulus. Mild aortic stenosis and
trace aortic regurgitation. Probable inferolateral and lateral
hypokinesis.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
Compared with the prior study (images reviewed) of [**2122-11-6**],
the aortic valve is more calcified and there is now aortic
stenosis and trace aortic regurgitation. The degree of tricuspid
regurgitation has increased. The lateral/inferolateral
hypokinesis was similar in appearance on the prior echo.
Brief Hospital Course:
Assessment and Plan: The pt. is a 64 y/o F with a PMH of ESRD on
HD, DM, and HTN presenting after dialysis with hypotension,
nausea, vomiting and abdominal pain.
.
#. Bacteremia - The patient presented with associated symptoms
of N/V, but patient has hadh chronic abd pain and was not
clearly changed from prior. A CT A/P showed no acute process.
Her LFTs were wnl, with her alk ph mildly elevated.
Additionally, RUQ U/S did was unremarkable. Her CXR showed no
clear infiltrate. The patient was initially treated with
Vancomycin 1gm IV, Levofloxacin 500mg IV, Flagyl 500mg IV and
transferred to the ICU. The patient symptomatically improved
and her antibiotics were tailored to Vancomycin and Cipro and
transferred to the floor. The patient's blood cultures did grow
peptostreptococcus from one set and bacillus (non-anthracis)
from another set. The patient did not have evidence of dental
abcsess on exam. The patient remained afebrile and clinically
stable. She underwent TTE that did not show evidence of
endocarditis. She will continue a 2 week course of Vancomycin at
HD. The patient remained stable and no further blood cultures
were positive.
.
#. Hypotension - The pt briefly dropped BP to 90s systolic in
the ED. On review of HD flow sheets, the pt commonly has BP in
this range post-HD. She had 4L taken off at dialysis the day of
admission. The patient was given IVF and her pressures
responded. Her BP med were intially held. After transfer to the
floor she was restarted on clonidine, lisinopril, while her
diltiazem was held. She will follow-up with her PCP regarding
restarting her diltiazem.
.
#. Abd pain: The patient has a history of gastritis on EGD,
treated previously for H.pylori with f/u negative breath
testing. She was continued on her PPI [**Hospital1 **]. She continued to
have chronic abdominal pain, but it was not changed from her
baseline. CT A/P showed no acute process.
.
#. End stage renal disease on hemodialysis - The patient with
LSC HD catheter [**2125-3-8**]. She was continued on HD as scheduled
T/Th/Sa.
.
#. Diabetes mellitus type II - She was initially continued on
her home lantus 8U Qam, 26U Qpm. The patient's glucose were low
during her hospitalization and her PM lantus dose was titrated
down. This is likely due to adhereing to a diabetic diet while
in the hospital. She was discharged on 8U qAm and 24U qPM with
follow-up with her PCP.
.
#. Hypercholesterolemia - continue statin
.
#. Constipation - continue bowel regimen
.
#. Gastritis - continue PPI
.
#. FEN: diabetic diet
.
# Prophylaxis: Subcutaneous heparin
.
# Access: L SC HD, peripheral X2
.
# Code: Full
Medications on Admission:
Active Medication list as of [**2126-2-7**]:
CITALOPRAM [CELEXA] - 20 mg Tablet - 1 Tablet(s) by mouth once a
day; take half a tablet daily for the first week
CLONAZEPAM [KLONOPIN] - 0.5 mg Tablet - half Tablet(s) by mouth
twice a day as needed for anxiety
CLONIDINE - 0.2 mg Tablet - 1 Tablet(s) by mouth twice a day
DILTIAZEM HCL [DILACOR XR] - 240 mg Capsule,Degradable Cnt
Release - 1 (One) Capsule,Degradable Cnt Release(s) by mouth
every day in the afternoon
FLONASE - 50MCG Spray, Suspension - 2 SPRAYS IN EACH NOSTRIL
EVERY DAY
KETOCONAZOLE [NIZORAL] - 2 % Shampoo - appy daily
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
NORVASC - 10MG Tablet - ONE BY MOUTH EVERY DAY
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 (One)
Capsule(s) by mouth twice a day
OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - [**1-25**]
Tablet(s) by mouth every 4 hours as needed for pain. Do not
drink, drive or operate heavy machinery while taking this
medication.
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth once a day
Medications - OTC
ACETAMINOPHEN [TYLENOL 8 HOUR] - 650 mg Tablet Sustained Release
- 2 Tablet(s) by mouth three times a day
CLOTRIMAZOLE [CLOTRIMAZOLE-7] - 1 % Cream - 1 applicator full
applied at bedtime
INSULIN NPH HUMAN RECOMB [HUMULIN N] - 100 unit/mL Suspension -
8
units subcutaneous every morning and 26 units subcutaneous every
evening
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Klonopin 0.25 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO twice a day as needed.
3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
5. Ketoconazole 2 % Shampoo Sig: One (1) Topical once a day.
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tylenol 325 mg Tablet Sig: 1300 (1300) mg PO three times a
day.
12. Clotrimazole 1 % Cream Sig: One (1) Topical at bedtime.
13. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: as
directed Subcutaneous twice a day: 8U qAM/ 26U qPM.
14. Vancomycin 1,000 mg Recon Soln Sig: at HD Intravenous at HD
for 2 weeks: 2 week course
Last day: [**2126-3-15**].
15. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for pain.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Bacteremia
ESRD on HD
Secondary:
Diabetes mellitus type II
Hypertension
Hypercholesterolemia v
Coronary artery disease
Constipation
Gastritis
Discharge Condition:
stable, afebrile, normotensive, ambulating
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of an infection in
his blood. You were treated with antibiotics and improved. You
also had an ultrasound of your heart that did not show any
infection. You will continue Vancomycin at dialysis for 2 weeks.
Please follow the medications prescribed below.
1) Please stop taking your diltiazem for now given your low
blood pressure
2) Your night-time insulin was decreased to 24U. Please continue
your AM dose as usual.
3) Please take percocet prior to your PT sessions
Please follow up with the appointments below.
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2126-3-20**] 9:40
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2126-3-25**] 2:20
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2126-3-25**]
3:30
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2126-4-23**] 2:30
Completed by:[**2126-3-11**] | {
"clinical_findings": {
"N186": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
}
],
"Z992": [
{
"icd_10_cm_code": "Z99.2",
"icd_10_cm_code_description": "Dependence on renal dialysis",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code Z99.2 is assigned for Dependence on renal dialysis. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P in conjunction with ESRD), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code N18.6 is also assigned for End stage renal disease."
}
],
"Z794": [
{
"icd_10_cm_code": "Z79.4",
"icd_10_cm_code_description": "Long-term (current) use of insulin",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "initially continued on her home lantus 8U Qam, 26U Qpm.",
"page_numbers": [
2
]
},
{
"text": "discharged on 8U qAm and 24U qPM",
"page_numbers": [
2
]
},
{
"text": "Insulin NPH Human Recomb",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "INSULIN NPH HUMAN RECOMB [HUMULIN N]",
"page_numbers": [
2
]
},
{
"evidence_text": "Insulin NPH Human Recomb",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code Z79.4 is assigned for Long-term (current) use of insulin. MEAT criteria are met as evidenced by Treatment (ongoing insulin therapy documented in A/P and discharge medications). Code E11.9 is also assigned for Type 2 diabetes mellitus."
}
],
"E7800": [
{
"icd_10_cm_code": "E78.00",
"icd_10_cm_code_description": "Pure hypercholesterolemia, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hypercholesterolemia",
"page_numbers": [
1
]
},
{
"text": "Hypercholesterolemia",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "continue statin",
"page_numbers": [
2
]
},
{
"text": "SIMVASTATIN",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "Hypercholesterolemia",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypercholesterolemia",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E78.00 is assigned for Pure hypercholesterolemia, unspecified. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P) and Treatment (continued statin therapy)."
}
],
"I2720": [
{
"icd_10_cm_code": "I27.20",
"icd_10_cm_code_description": "Pulmonary hypertension, unspecified",
"Monitoring": [],
"Evaluation": [
{
"text": "mild pulmonary artery systolic\nhypertension.",
"page_numbers": [
2
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild pulmonary artery systolic\nhypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I27.20 is assigned for Pulmonary hypertension, unspecified. MEAT criteria are met as evidenced by Evaluation (finding on TTE)."
}
],
"E1122": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
},
{
"icd_10_cm_code": "E11.9",
"icd_10_cm_code_description": "Type 2 diabetes mellitus without complications",
"Monitoring": [
{
"text": "The patient's glucose were low during her hospitalization and her PM lantus dose was titrated down.",
"page_numbers": [
2
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "Diabetes mellitus type II",
"page_numbers": [
1
]
},
{
"text": "DM",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "initially continued on her home lantus 8U Qam, 26U Qpm.",
"page_numbers": [
2
]
},
{
"text": "discharged on 8U qAm and 24U qPM",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "DM",
"page_numbers": [
1
]
},
{
"evidence_text": "Diabetes mellitus type II",
"page_numbers": [
1
]
},
{
"evidence_text": "DM",
"page_numbers": [
2
]
},
{
"evidence_text": "Diabetes mellitus type II",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.9 is assigned for Type 2 diabetes mellitus without complications. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (glucose levels monitored and insulin adjusted), and Treatment (insulin therapy). Code Z79.4 is also assigned for long-term insulin use."
}
],
"I120": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
},
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hypertension",
"page_numbers": [
1
]
},
{
"text": "HTN",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "Her BP med were intially held. After transfer to the floor she was restarted on clonidine, lisinopril, while her diltiazem was held.",
"page_numbers": [
2
]
},
{
"text": "Clonidine",
"page_numbers": [
2
]
},
{
"text": "Lisinopril",
"page_numbers": [
2
]
},
{
"text": "Amlodipine",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "HTN",
"page_numbers": [
2
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P) and Treatment (medication adjustments and listed medications)."
}
]
}
} |
Extract the ICD-10-CM code description for each clinical condition mentioned in the discharge summary. | Admission Date: [**2126-3-2**] Discharge Date: [**2126-3-6**]
Date of Birth: [**2061-11-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 9824**]
Chief Complaint:
N/V, Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt. is a 64 y/o F with a PMH of ESRD on HD, DM, and HTN
presenting after dialysis with hypotension, nausea, vomiting and
abdominal pain. The patient reports six episodes of emesis since
HD with mild epigastric pain. Per report temp to 100.5 at HD
with complaint of aches and chills. 4L fluid taken off at HD,
pre-treatment BP 96/58, post-treatment 169/92. T 97.8.
.
In the ED, initial vs were: T 102.9 BP 146/65, HR 110, RR 20 O2
92% RA. FS 215. Blood Cx sent. Emesis X1. Patient was given
Vancomycin 1gm IV, Levofloxacin 500mg IV, Flagyl 500mg IV,
Morphine 2mg IV. Her BP fell to 94/43 and she was given 1 L NS.
WBC 11.2, lactate 3.2. CXR demonstrated no evidence of
infiltrate. CT Abd/Pelvis showed no evidence of colitis. Per ED
report, beside US showed limited views but a normal caliber
aorta.
.
On arrival to the ICU, the patient was resting comfortably. She
denies lightheadedness. C/o b/l knee pain and low back pain
unchanged from her baseline. The pt. reports increased fatigue X
1 week, she has had decreased mobility since her knee surgery in
[**12-31**]. She reports that typically post-HD she has increased
enerygy, however she noted no improvement this week. Denies
fever, had chills last evening but temp was 97.8 at home. She
c/o abd pain, similar to her chronic symptoms, mostly epigastric
but burning symptoms occur in various locations with no clear
pattern or relation to meals. Denies cough, rhinorrhea. +Frontal
and occipital HA last pm. + chronic constipation, no diarrhea.
Her appetite is normal.
Past Medical History:
End stage renal disease on hemodialysis (TuThSa) - LSC HD
catheter changed [**2125-3-8**]
Hx of Back Abscess - [**2123**] treated with I&D, Vanc X 14 days
Diabetes mellitus type II
Hypertension
Hypercholesterolemia
Coronary artery disease (nonobstructive on cath in [**2119**], normal
stress in [**2124-6-23**])
Constipation
Status post total abdominal hysterectomy
Status post C-section
H. Pylori s/p treatment in [**2124-3-23**]
Gastritis
Right knee subtotal medial meniscectomy and subtotal lateral
meniscectomy with medial femoral chondroplasty [**2126-1-8**]
Social History:
Married and lives with husband, 2 children who live nearby,
former home health aid. Smokes <[**1-25**] ppd x 40 years, quit in [**3-3**]
after being hospitalized for influenza. no ETOH, no
drugs. Received the influenza and pneumococcal vaccines
Family History:
+ Premature CAD in brothers and mother. Daughter with kidney
disease. Siblings with DM, CAD, HTN, CVA, no cancer.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild TTP epigastrium, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no edema
Skin: multiple scars from prev fistula attempts on both
forearms, scar, scar - midback from prev. incision site, L SC
site no erythema surrounding catheter + skin breakdown around
adhesive dressing, no fluctuance, no drainage
Pertinent Results:
[**2126-3-2**] 01:15PM WBC-11.2*# RBC-3.97* HGB-12.7 HCT-37.9 MCV-95
MCH-32.0 MCHC-33.5 RDW-15.1
[**2126-3-2**] 01:15PM NEUTS-90.2* LYMPHS-4.6* MONOS-4.1 EOS-0.8
BASOS-0.2
[**2126-3-2**] 01:15PM PLT COUNT-203
[**2126-3-2**] 01:15PM GLUCOSE-197* UREA N-9 CREAT-2.9*# SODIUM-144
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-29 ANION GAP-22*
[**2126-3-2**] 01:15PM ALT(SGPT)-34 AST(SGOT)-31 CK(CPK)-69 ALK
PHOS-193* TOT BILI-0.5
[**2126-3-2**] 01:21PM LACTATE-3.1*
[**2126-3-2**] 04:16PM LACTATE-2.3*
[**2126-3-6**] 04:35AM BLOOD WBC-6.5 RBC-3.03* Hgb-9.3* Hct-28.8*
MCV-95 MCH-30.7 MCHC-32.3 RDW-15.5 Plt Ct-207
[**2126-3-6**] 04:35AM BLOOD Glucose-98 UreaN-16 Creat-4.6*# Na-137
K-4.2 Cl-98 HCO3-28 AnGap-15
[**2126-3-4**] 05:30AM BLOOD ALT-20 AST-15 LD(LDH)-151 AlkPhos-143*
TotBili-0.3
[**2126-3-3**] 01:35AM BLOOD Lipase-36
[**2126-3-2**] 01:15PM BLOOD CK-MB-3 cTropnT-0.05*
[**2126-3-6**] 04:35AM BLOOD Calcium-10.3* Phos-4.7*# Mg-1.8
[**2126-3-6**] 04:35AM BLOOD PTH-1368*
[**2126-3-5**] 06:35AM BLOOD Vanco-9.8*
[**2126-3-3**] 06:04PM BLOOD Vanco-12.4
[**2126-3-4**] 05:55AM BLOOD Lactate-1.2
[**2126-3-2**] 1:00 pm BLOOD CULTURE
**FINAL REPORT [**2126-3-9**]**
Blood Culture, Routine (Final [**2126-3-8**]):
PRESUMPTIVE PEPTOSTREPTOCOCCUS SPECIES.
ISOLATED FROM ONE SET ONLY.
BACILLUS SPECIES; NOT ANTHRACIS.
Sensitivity testing performed by Sensititre.
GENTAMICIN = SENSITIVE ( <=2 MCG/ML ).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BACILLUS SPECIES; NOT ANTHRACIS
|
CLINDAMYCIN----------- 0.5 S
GENTAMICIN------------ S
LEVOFLOXACIN----------<=0.25 S
VANCOMYCIN------------ <=1 S
[**2126-3-2**] 1:15 pm BLOOD CULTURE
**FINAL REPORT [**2126-3-8**]**
Blood Culture, Routine (Final [**2126-3-8**]):
BACILLUS SPECIES; NOT ANTHRACIS.
SENSITIVITIES PERFORMED ON CULTURE # 266-9949D [**2126-3-2**].
Anaerobic Bottle Gram Stain (Final [**2126-3-5**]):
GRAM POSITIVE ROD(S).
REPORTED BY PHONE TO [**Doctor First Name **] [**Doctor Last Name **]-[**Doctor Last Name **] #[**Numeric Identifier 11629**] [**2126-3-4**]
2:30PM.
CONSISTENT WITH CLOSTRIDIUM AND
BACILLUS SPECIES.
Blood Cx: [**3-2**], [**3-4**], [**3-4**], [**3-5**]: No growth
Cardiology Report ECG Study Date of [**2126-3-2**] 2:04:54 PM
Sinus rhythm. Modest inferolateral T wave changes which are
non-specific.
Compared to the previous tracing of [**2125-12-26**] there is no
significant diagnostic
change.
CXR: [**3-2**]
IMPRESSION: No significant change when compared to prior exam.
CT- abd/pelvis: [**3-2**]
IMPRESSION:
1. No evidence of colitis.
2. Unchanged angiomylipoma of right kidney. Multiple tiny
hypodensities in
the kidneys too small to accurately characterize.
3. Several small nodules in the left adrenal gland likely not
changed from
[**2122**] but incompletely characterized on the current study.
4. Atherosclerotic disease.
RUQ U/S [**3-3**]
IMPRESSION:
Unchanged cholelithiasis with no secondary findings to suggest
acute
cholecystitis.
TTE [**3-6**]
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with probable mild hypokinesis of the basal to mid
inferolateral and lateral segments (suboptimal image quality
limits interpretation). Right ventricular chamber size and free
wall motion are normal. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are moderately
thickened. No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. There is mild aortic valve stenosis (area 1.2-1.9cm2).
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No masses or vegetations are seen
on the mitral valve, but cannot be fully excluded due to
suboptimal image quality. Trivial mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] No masses or vegetations
are seen on the tricuspid valve, but cannot be fully excluded
due to suboptimal image quality. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality limits interpretation.
There is no evidence of endocarditis or abscess. Calcification
of the aortic valve and mitral annulus. Mild aortic stenosis and
trace aortic regurgitation. Probable inferolateral and lateral
hypokinesis.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
Compared with the prior study (images reviewed) of [**2122-11-6**],
the aortic valve is more calcified and there is now aortic
stenosis and trace aortic regurgitation. The degree of tricuspid
regurgitation has increased. The lateral/inferolateral
hypokinesis was similar in appearance on the prior echo.
Brief Hospital Course:
Assessment and Plan: The pt. is a 64 y/o F with a PMH of ESRD on
HD, DM, and HTN presenting after dialysis with hypotension,
nausea, vomiting and abdominal pain.
.
#. Bacteremia - The patient presented with associated symptoms
of N/V, but patient has hadh chronic abd pain and was not
clearly changed from prior. A CT A/P showed no acute process.
Her LFTs were wnl, with her alk ph mildly elevated.
Additionally, RUQ U/S did was unremarkable. Her CXR showed no
clear infiltrate. The patient was initially treated with
Vancomycin 1gm IV, Levofloxacin 500mg IV, Flagyl 500mg IV and
transferred to the ICU. The patient symptomatically improved
and her antibiotics were tailored to Vancomycin and Cipro and
transferred to the floor. The patient's blood cultures did grow
peptostreptococcus from one set and bacillus (non-anthracis)
from another set. The patient did not have evidence of dental
abcsess on exam. The patient remained afebrile and clinically
stable. She underwent TTE that did not show evidence of
endocarditis. She will continue a 2 week course of Vancomycin at
HD. The patient remained stable and no further blood cultures
were positive.
.
#. Hypotension - The pt briefly dropped BP to 90s systolic in
the ED. On review of HD flow sheets, the pt commonly has BP in
this range post-HD. She had 4L taken off at dialysis the day of
admission. The patient was given IVF and her pressures
responded. Her BP med were intially held. After transfer to the
floor she was restarted on clonidine, lisinopril, while her
diltiazem was held. She will follow-up with her PCP regarding
restarting her diltiazem.
.
#. Abd pain: The patient has a history of gastritis on EGD,
treated previously for H.pylori with f/u negative breath
testing. She was continued on her PPI [**Hospital1 **]. She continued to
have chronic abdominal pain, but it was not changed from her
baseline. CT A/P showed no acute process.
.
#. End stage renal disease on hemodialysis - The patient with
LSC HD catheter [**2125-3-8**]. She was continued on HD as scheduled
T/Th/Sa.
.
#. Diabetes mellitus type II - She was initially continued on
her home lantus 8U Qam, 26U Qpm. The patient's glucose were low
during her hospitalization and her PM lantus dose was titrated
down. This is likely due to adhereing to a diabetic diet while
in the hospital. She was discharged on 8U qAm and 24U qPM with
follow-up with her PCP.
.
#. Hypercholesterolemia - continue statin
.
#. Constipation - continue bowel regimen
.
#. Gastritis - continue PPI
.
#. FEN: diabetic diet
.
# Prophylaxis: Subcutaneous heparin
.
# Access: L SC HD, peripheral X2
.
# Code: Full
Medications on Admission:
Active Medication list as of [**2126-2-7**]:
CITALOPRAM [CELEXA] - 20 mg Tablet - 1 Tablet(s) by mouth once a
day; take half a tablet daily for the first week
CLONAZEPAM [KLONOPIN] - 0.5 mg Tablet - half Tablet(s) by mouth
twice a day as needed for anxiety
CLONIDINE - 0.2 mg Tablet - 1 Tablet(s) by mouth twice a day
DILTIAZEM HCL [DILACOR XR] - 240 mg Capsule,Degradable Cnt
Release - 1 (One) Capsule,Degradable Cnt Release(s) by mouth
every day in the afternoon
FLONASE - 50MCG Spray, Suspension - 2 SPRAYS IN EACH NOSTRIL
EVERY DAY
KETOCONAZOLE [NIZORAL] - 2 % Shampoo - appy daily
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
NORVASC - 10MG Tablet - ONE BY MOUTH EVERY DAY
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 (One)
Capsule(s) by mouth twice a day
OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - [**1-25**]
Tablet(s) by mouth every 4 hours as needed for pain. Do not
drink, drive or operate heavy machinery while taking this
medication.
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth once a day
Medications - OTC
ACETAMINOPHEN [TYLENOL 8 HOUR] - 650 mg Tablet Sustained Release
- 2 Tablet(s) by mouth three times a day
CLOTRIMAZOLE [CLOTRIMAZOLE-7] - 1 % Cream - 1 applicator full
applied at bedtime
INSULIN NPH HUMAN RECOMB [HUMULIN N] - 100 unit/mL Suspension -
8
units subcutaneous every morning and 26 units subcutaneous every
evening
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Klonopin 0.25 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO twice a day as needed.
3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
5. Ketoconazole 2 % Shampoo Sig: One (1) Topical once a day.
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tylenol 325 mg Tablet Sig: 1300 (1300) mg PO three times a
day.
12. Clotrimazole 1 % Cream Sig: One (1) Topical at bedtime.
13. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: as
directed Subcutaneous twice a day: 8U qAM/ 26U qPM.
14. Vancomycin 1,000 mg Recon Soln Sig: at HD Intravenous at HD
for 2 weeks: 2 week course
Last day: [**2126-3-15**].
15. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for pain.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Bacteremia
ESRD on HD
Secondary:
Diabetes mellitus type II
Hypertension
Hypercholesterolemia v
Coronary artery disease
Constipation
Gastritis
Discharge Condition:
stable, afebrile, normotensive, ambulating
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of an infection in
his blood. You were treated with antibiotics and improved. You
also had an ultrasound of your heart that did not show any
infection. You will continue Vancomycin at dialysis for 2 weeks.
Please follow the medications prescribed below.
1) Please stop taking your diltiazem for now given your low
blood pressure
2) Your night-time insulin was decreased to 24U. Please continue
your AM dose as usual.
3) Please take percocet prior to your PT sessions
Please follow up with the appointments below.
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2126-3-20**] 9:40
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2126-3-25**] 2:20
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2126-3-25**]
3:30
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2126-4-23**] 2:30
Completed by:[**2126-3-11**] | {
"clinical_findings": {
"N186": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
}
],
"Z992": [
{
"icd_10_cm_code": "Z99.2",
"icd_10_cm_code_description": "Dependence on renal dialysis",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code Z99.2 is assigned for Dependence on renal dialysis. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P in conjunction with ESRD), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code N18.6 is also assigned for End stage renal disease."
}
],
"Z794": [
{
"icd_10_cm_code": "Z79.4",
"icd_10_cm_code_description": "Long-term (current) use of insulin",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "initially continued on her home lantus 8U Qam, 26U Qpm.",
"page_numbers": [
2
]
},
{
"text": "discharged on 8U qAm and 24U qPM",
"page_numbers": [
2
]
},
{
"text": "Insulin NPH Human Recomb",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "INSULIN NPH HUMAN RECOMB [HUMULIN N]",
"page_numbers": [
2
]
},
{
"evidence_text": "Insulin NPH Human Recomb",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code Z79.4 is assigned for Long-term (current) use of insulin. MEAT criteria are met as evidenced by Treatment (ongoing insulin therapy documented in A/P and discharge medications). Code E11.9 is also assigned for Type 2 diabetes mellitus."
}
],
"E7800": [
{
"icd_10_cm_code": "E78.00",
"icd_10_cm_code_description": "Pure hypercholesterolemia, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hypercholesterolemia",
"page_numbers": [
1
]
},
{
"text": "Hypercholesterolemia",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "continue statin",
"page_numbers": [
2
]
},
{
"text": "SIMVASTATIN",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "Hypercholesterolemia",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypercholesterolemia",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E78.00 is assigned for Pure hypercholesterolemia, unspecified. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P) and Treatment (continued statin therapy)."
}
],
"I2720": [
{
"icd_10_cm_code": "I27.20",
"icd_10_cm_code_description": "Pulmonary hypertension, unspecified",
"Monitoring": [],
"Evaluation": [
{
"text": "mild pulmonary artery systolic\nhypertension.",
"page_numbers": [
2
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild pulmonary artery systolic\nhypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I27.20 is assigned for Pulmonary hypertension, unspecified. MEAT criteria are met as evidenced by Evaluation (finding on TTE)."
}
],
"E1122": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
},
{
"icd_10_cm_code": "E11.9",
"icd_10_cm_code_description": "Type 2 diabetes mellitus without complications",
"Monitoring": [
{
"text": "The patient's glucose were low during her hospitalization and her PM lantus dose was titrated down.",
"page_numbers": [
2
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "Diabetes mellitus type II",
"page_numbers": [
1
]
},
{
"text": "DM",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "initially continued on her home lantus 8U Qam, 26U Qpm.",
"page_numbers": [
2
]
},
{
"text": "discharged on 8U qAm and 24U qPM",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "DM",
"page_numbers": [
1
]
},
{
"evidence_text": "Diabetes mellitus type II",
"page_numbers": [
1
]
},
{
"evidence_text": "DM",
"page_numbers": [
2
]
},
{
"evidence_text": "Diabetes mellitus type II",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.9 is assigned for Type 2 diabetes mellitus without complications. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (glucose levels monitored and insulin adjusted), and Treatment (insulin therapy). Code Z79.4 is also assigned for long-term insulin use."
}
],
"I120": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
},
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hypertension",
"page_numbers": [
1
]
},
{
"text": "HTN",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "Her BP med were intially held. After transfer to the floor she was restarted on clonidine, lisinopril, while her diltiazem was held.",
"page_numbers": [
2
]
},
{
"text": "Clonidine",
"page_numbers": [
2
]
},
{
"text": "Lisinopril",
"page_numbers": [
2
]
},
{
"text": "Amlodipine",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "HTN",
"page_numbers": [
2
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P) and Treatment (medication adjustments and listed medications)."
}
]
}
} |
Extract only the monitoring information related to each clinical condition, such as vital signs, labs, or telemetry data. | Admission Date: [**2126-3-2**] Discharge Date: [**2126-3-6**]
Date of Birth: [**2061-11-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 9824**]
Chief Complaint:
N/V, Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt. is a 64 y/o F with a PMH of ESRD on HD, DM, and HTN
presenting after dialysis with hypotension, nausea, vomiting and
abdominal pain. The patient reports six episodes of emesis since
HD with mild epigastric pain. Per report temp to 100.5 at HD
with complaint of aches and chills. 4L fluid taken off at HD,
pre-treatment BP 96/58, post-treatment 169/92. T 97.8.
.
In the ED, initial vs were: T 102.9 BP 146/65, HR 110, RR 20 O2
92% RA. FS 215. Blood Cx sent. Emesis X1. Patient was given
Vancomycin 1gm IV, Levofloxacin 500mg IV, Flagyl 500mg IV,
Morphine 2mg IV. Her BP fell to 94/43 and she was given 1 L NS.
WBC 11.2, lactate 3.2. CXR demonstrated no evidence of
infiltrate. CT Abd/Pelvis showed no evidence of colitis. Per ED
report, beside US showed limited views but a normal caliber
aorta.
.
On arrival to the ICU, the patient was resting comfortably. She
denies lightheadedness. C/o b/l knee pain and low back pain
unchanged from her baseline. The pt. reports increased fatigue X
1 week, she has had decreased mobility since her knee surgery in
[**12-31**]. She reports that typically post-HD she has increased
enerygy, however she noted no improvement this week. Denies
fever, had chills last evening but temp was 97.8 at home. She
c/o abd pain, similar to her chronic symptoms, mostly epigastric
but burning symptoms occur in various locations with no clear
pattern or relation to meals. Denies cough, rhinorrhea. +Frontal
and occipital HA last pm. + chronic constipation, no diarrhea.
Her appetite is normal.
Past Medical History:
End stage renal disease on hemodialysis (TuThSa) - LSC HD
catheter changed [**2125-3-8**]
Hx of Back Abscess - [**2123**] treated with I&D, Vanc X 14 days
Diabetes mellitus type II
Hypertension
Hypercholesterolemia
Coronary artery disease (nonobstructive on cath in [**2119**], normal
stress in [**2124-6-23**])
Constipation
Status post total abdominal hysterectomy
Status post C-section
H. Pylori s/p treatment in [**2124-3-23**]
Gastritis
Right knee subtotal medial meniscectomy and subtotal lateral
meniscectomy with medial femoral chondroplasty [**2126-1-8**]
Social History:
Married and lives with husband, 2 children who live nearby,
former home health aid. Smokes <[**1-25**] ppd x 40 years, quit in [**3-3**]
after being hospitalized for influenza. no ETOH, no
drugs. Received the influenza and pneumococcal vaccines
Family History:
+ Premature CAD in brothers and mother. Daughter with kidney
disease. Siblings with DM, CAD, HTN, CVA, no cancer.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild TTP epigastrium, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no edema
Skin: multiple scars from prev fistula attempts on both
forearms, scar, scar - midback from prev. incision site, L SC
site no erythema surrounding catheter + skin breakdown around
adhesive dressing, no fluctuance, no drainage
Pertinent Results:
[**2126-3-2**] 01:15PM WBC-11.2*# RBC-3.97* HGB-12.7 HCT-37.9 MCV-95
MCH-32.0 MCHC-33.5 RDW-15.1
[**2126-3-2**] 01:15PM NEUTS-90.2* LYMPHS-4.6* MONOS-4.1 EOS-0.8
BASOS-0.2
[**2126-3-2**] 01:15PM PLT COUNT-203
[**2126-3-2**] 01:15PM GLUCOSE-197* UREA N-9 CREAT-2.9*# SODIUM-144
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-29 ANION GAP-22*
[**2126-3-2**] 01:15PM ALT(SGPT)-34 AST(SGOT)-31 CK(CPK)-69 ALK
PHOS-193* TOT BILI-0.5
[**2126-3-2**] 01:21PM LACTATE-3.1*
[**2126-3-2**] 04:16PM LACTATE-2.3*
[**2126-3-6**] 04:35AM BLOOD WBC-6.5 RBC-3.03* Hgb-9.3* Hct-28.8*
MCV-95 MCH-30.7 MCHC-32.3 RDW-15.5 Plt Ct-207
[**2126-3-6**] 04:35AM BLOOD Glucose-98 UreaN-16 Creat-4.6*# Na-137
K-4.2 Cl-98 HCO3-28 AnGap-15
[**2126-3-4**] 05:30AM BLOOD ALT-20 AST-15 LD(LDH)-151 AlkPhos-143*
TotBili-0.3
[**2126-3-3**] 01:35AM BLOOD Lipase-36
[**2126-3-2**] 01:15PM BLOOD CK-MB-3 cTropnT-0.05*
[**2126-3-6**] 04:35AM BLOOD Calcium-10.3* Phos-4.7*# Mg-1.8
[**2126-3-6**] 04:35AM BLOOD PTH-1368*
[**2126-3-5**] 06:35AM BLOOD Vanco-9.8*
[**2126-3-3**] 06:04PM BLOOD Vanco-12.4
[**2126-3-4**] 05:55AM BLOOD Lactate-1.2
[**2126-3-2**] 1:00 pm BLOOD CULTURE
**FINAL REPORT [**2126-3-9**]**
Blood Culture, Routine (Final [**2126-3-8**]):
PRESUMPTIVE PEPTOSTREPTOCOCCUS SPECIES.
ISOLATED FROM ONE SET ONLY.
BACILLUS SPECIES; NOT ANTHRACIS.
Sensitivity testing performed by Sensititre.
GENTAMICIN = SENSITIVE ( <=2 MCG/ML ).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BACILLUS SPECIES; NOT ANTHRACIS
|
CLINDAMYCIN----------- 0.5 S
GENTAMICIN------------ S
LEVOFLOXACIN----------<=0.25 S
VANCOMYCIN------------ <=1 S
[**2126-3-2**] 1:15 pm BLOOD CULTURE
**FINAL REPORT [**2126-3-8**]**
Blood Culture, Routine (Final [**2126-3-8**]):
BACILLUS SPECIES; NOT ANTHRACIS.
SENSITIVITIES PERFORMED ON CULTURE # 266-9949D [**2126-3-2**].
Anaerobic Bottle Gram Stain (Final [**2126-3-5**]):
GRAM POSITIVE ROD(S).
REPORTED BY PHONE TO [**Doctor First Name **] [**Doctor Last Name **]-[**Doctor Last Name **] #[**Numeric Identifier 11629**] [**2126-3-4**]
2:30PM.
CONSISTENT WITH CLOSTRIDIUM AND
BACILLUS SPECIES.
Blood Cx: [**3-2**], [**3-4**], [**3-4**], [**3-5**]: No growth
Cardiology Report ECG Study Date of [**2126-3-2**] 2:04:54 PM
Sinus rhythm. Modest inferolateral T wave changes which are
non-specific.
Compared to the previous tracing of [**2125-12-26**] there is no
significant diagnostic
change.
CXR: [**3-2**]
IMPRESSION: No significant change when compared to prior exam.
CT- abd/pelvis: [**3-2**]
IMPRESSION:
1. No evidence of colitis.
2. Unchanged angiomylipoma of right kidney. Multiple tiny
hypodensities in
the kidneys too small to accurately characterize.
3. Several small nodules in the left adrenal gland likely not
changed from
[**2122**] but incompletely characterized on the current study.
4. Atherosclerotic disease.
RUQ U/S [**3-3**]
IMPRESSION:
Unchanged cholelithiasis with no secondary findings to suggest
acute
cholecystitis.
TTE [**3-6**]
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with probable mild hypokinesis of the basal to mid
inferolateral and lateral segments (suboptimal image quality
limits interpretation). Right ventricular chamber size and free
wall motion are normal. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are moderately
thickened. No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. There is mild aortic valve stenosis (area 1.2-1.9cm2).
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No masses or vegetations are seen
on the mitral valve, but cannot be fully excluded due to
suboptimal image quality. Trivial mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] No masses or vegetations
are seen on the tricuspid valve, but cannot be fully excluded
due to suboptimal image quality. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality limits interpretation.
There is no evidence of endocarditis or abscess. Calcification
of the aortic valve and mitral annulus. Mild aortic stenosis and
trace aortic regurgitation. Probable inferolateral and lateral
hypokinesis.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
Compared with the prior study (images reviewed) of [**2122-11-6**],
the aortic valve is more calcified and there is now aortic
stenosis and trace aortic regurgitation. The degree of tricuspid
regurgitation has increased. The lateral/inferolateral
hypokinesis was similar in appearance on the prior echo.
Brief Hospital Course:
Assessment and Plan: The pt. is a 64 y/o F with a PMH of ESRD on
HD, DM, and HTN presenting after dialysis with hypotension,
nausea, vomiting and abdominal pain.
.
#. Bacteremia - The patient presented with associated symptoms
of N/V, but patient has hadh chronic abd pain and was not
clearly changed from prior. A CT A/P showed no acute process.
Her LFTs were wnl, with her alk ph mildly elevated.
Additionally, RUQ U/S did was unremarkable. Her CXR showed no
clear infiltrate. The patient was initially treated with
Vancomycin 1gm IV, Levofloxacin 500mg IV, Flagyl 500mg IV and
transferred to the ICU. The patient symptomatically improved
and her antibiotics were tailored to Vancomycin and Cipro and
transferred to the floor. The patient's blood cultures did grow
peptostreptococcus from one set and bacillus (non-anthracis)
from another set. The patient did not have evidence of dental
abcsess on exam. The patient remained afebrile and clinically
stable. She underwent TTE that did not show evidence of
endocarditis. She will continue a 2 week course of Vancomycin at
HD. The patient remained stable and no further blood cultures
were positive.
.
#. Hypotension - The pt briefly dropped BP to 90s systolic in
the ED. On review of HD flow sheets, the pt commonly has BP in
this range post-HD. She had 4L taken off at dialysis the day of
admission. The patient was given IVF and her pressures
responded. Her BP med were intially held. After transfer to the
floor she was restarted on clonidine, lisinopril, while her
diltiazem was held. She will follow-up with her PCP regarding
restarting her diltiazem.
.
#. Abd pain: The patient has a history of gastritis on EGD,
treated previously for H.pylori with f/u negative breath
testing. She was continued on her PPI [**Hospital1 **]. She continued to
have chronic abdominal pain, but it was not changed from her
baseline. CT A/P showed no acute process.
.
#. End stage renal disease on hemodialysis - The patient with
LSC HD catheter [**2125-3-8**]. She was continued on HD as scheduled
T/Th/Sa.
.
#. Diabetes mellitus type II - She was initially continued on
her home lantus 8U Qam, 26U Qpm. The patient's glucose were low
during her hospitalization and her PM lantus dose was titrated
down. This is likely due to adhereing to a diabetic diet while
in the hospital. She was discharged on 8U qAm and 24U qPM with
follow-up with her PCP.
.
#. Hypercholesterolemia - continue statin
.
#. Constipation - continue bowel regimen
.
#. Gastritis - continue PPI
.
#. FEN: diabetic diet
.
# Prophylaxis: Subcutaneous heparin
.
# Access: L SC HD, peripheral X2
.
# Code: Full
Medications on Admission:
Active Medication list as of [**2126-2-7**]:
CITALOPRAM [CELEXA] - 20 mg Tablet - 1 Tablet(s) by mouth once a
day; take half a tablet daily for the first week
CLONAZEPAM [KLONOPIN] - 0.5 mg Tablet - half Tablet(s) by mouth
twice a day as needed for anxiety
CLONIDINE - 0.2 mg Tablet - 1 Tablet(s) by mouth twice a day
DILTIAZEM HCL [DILACOR XR] - 240 mg Capsule,Degradable Cnt
Release - 1 (One) Capsule,Degradable Cnt Release(s) by mouth
every day in the afternoon
FLONASE - 50MCG Spray, Suspension - 2 SPRAYS IN EACH NOSTRIL
EVERY DAY
KETOCONAZOLE [NIZORAL] - 2 % Shampoo - appy daily
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
NORVASC - 10MG Tablet - ONE BY MOUTH EVERY DAY
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 (One)
Capsule(s) by mouth twice a day
OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - [**1-25**]
Tablet(s) by mouth every 4 hours as needed for pain. Do not
drink, drive or operate heavy machinery while taking this
medication.
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth once a day
Medications - OTC
ACETAMINOPHEN [TYLENOL 8 HOUR] - 650 mg Tablet Sustained Release
- 2 Tablet(s) by mouth three times a day
CLOTRIMAZOLE [CLOTRIMAZOLE-7] - 1 % Cream - 1 applicator full
applied at bedtime
INSULIN NPH HUMAN RECOMB [HUMULIN N] - 100 unit/mL Suspension -
8
units subcutaneous every morning and 26 units subcutaneous every
evening
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Klonopin 0.25 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO twice a day as needed.
3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
5. Ketoconazole 2 % Shampoo Sig: One (1) Topical once a day.
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tylenol 325 mg Tablet Sig: 1300 (1300) mg PO three times a
day.
12. Clotrimazole 1 % Cream Sig: One (1) Topical at bedtime.
13. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: as
directed Subcutaneous twice a day: 8U qAM/ 26U qPM.
14. Vancomycin 1,000 mg Recon Soln Sig: at HD Intravenous at HD
for 2 weeks: 2 week course
Last day: [**2126-3-15**].
15. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for pain.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Bacteremia
ESRD on HD
Secondary:
Diabetes mellitus type II
Hypertension
Hypercholesterolemia v
Coronary artery disease
Constipation
Gastritis
Discharge Condition:
stable, afebrile, normotensive, ambulating
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of an infection in
his blood. You were treated with antibiotics and improved. You
also had an ultrasound of your heart that did not show any
infection. You will continue Vancomycin at dialysis for 2 weeks.
Please follow the medications prescribed below.
1) Please stop taking your diltiazem for now given your low
blood pressure
2) Your night-time insulin was decreased to 24U. Please continue
your AM dose as usual.
3) Please take percocet prior to your PT sessions
Please follow up with the appointments below.
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2126-3-20**] 9:40
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2126-3-25**] 2:20
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2126-3-25**]
3:30
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2126-4-23**] 2:30
Completed by:[**2126-3-11**] | {
"clinical_findings": {
"N186": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
}
],
"Z992": [
{
"icd_10_cm_code": "Z99.2",
"icd_10_cm_code_description": "Dependence on renal dialysis",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code Z99.2 is assigned for Dependence on renal dialysis. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P in conjunction with ESRD), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code N18.6 is also assigned for End stage renal disease."
}
],
"Z794": [
{
"icd_10_cm_code": "Z79.4",
"icd_10_cm_code_description": "Long-term (current) use of insulin",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "initially continued on her home lantus 8U Qam, 26U Qpm.",
"page_numbers": [
2
]
},
{
"text": "discharged on 8U qAm and 24U qPM",
"page_numbers": [
2
]
},
{
"text": "Insulin NPH Human Recomb",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "INSULIN NPH HUMAN RECOMB [HUMULIN N]",
"page_numbers": [
2
]
},
{
"evidence_text": "Insulin NPH Human Recomb",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code Z79.4 is assigned for Long-term (current) use of insulin. MEAT criteria are met as evidenced by Treatment (ongoing insulin therapy documented in A/P and discharge medications). Code E11.9 is also assigned for Type 2 diabetes mellitus."
}
],
"E7800": [
{
"icd_10_cm_code": "E78.00",
"icd_10_cm_code_description": "Pure hypercholesterolemia, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hypercholesterolemia",
"page_numbers": [
1
]
},
{
"text": "Hypercholesterolemia",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "continue statin",
"page_numbers": [
2
]
},
{
"text": "SIMVASTATIN",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "Hypercholesterolemia",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypercholesterolemia",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E78.00 is assigned for Pure hypercholesterolemia, unspecified. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P) and Treatment (continued statin therapy)."
}
],
"I2720": [
{
"icd_10_cm_code": "I27.20",
"icd_10_cm_code_description": "Pulmonary hypertension, unspecified",
"Monitoring": [],
"Evaluation": [
{
"text": "mild pulmonary artery systolic\nhypertension.",
"page_numbers": [
2
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild pulmonary artery systolic\nhypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I27.20 is assigned for Pulmonary hypertension, unspecified. MEAT criteria are met as evidenced by Evaluation (finding on TTE)."
}
],
"E1122": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
},
{
"icd_10_cm_code": "E11.9",
"icd_10_cm_code_description": "Type 2 diabetes mellitus without complications",
"Monitoring": [
{
"text": "The patient's glucose were low during her hospitalization and her PM lantus dose was titrated down.",
"page_numbers": [
2
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "Diabetes mellitus type II",
"page_numbers": [
1
]
},
{
"text": "DM",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "initially continued on her home lantus 8U Qam, 26U Qpm.",
"page_numbers": [
2
]
},
{
"text": "discharged on 8U qAm and 24U qPM",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "DM",
"page_numbers": [
1
]
},
{
"evidence_text": "Diabetes mellitus type II",
"page_numbers": [
1
]
},
{
"evidence_text": "DM",
"page_numbers": [
2
]
},
{
"evidence_text": "Diabetes mellitus type II",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.9 is assigned for Type 2 diabetes mellitus without complications. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (glucose levels monitored and insulin adjusted), and Treatment (insulin therapy). Code Z79.4 is also assigned for long-term insulin use."
}
],
"I120": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
},
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hypertension",
"page_numbers": [
1
]
},
{
"text": "HTN",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "Her BP med were intially held. After transfer to the floor she was restarted on clonidine, lisinopril, while her diltiazem was held.",
"page_numbers": [
2
]
},
{
"text": "Clonidine",
"page_numbers": [
2
]
},
{
"text": "Lisinopril",
"page_numbers": [
2
]
},
{
"text": "Amlodipine",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "HTN",
"page_numbers": [
2
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P) and Treatment (medication adjustments and listed medications)."
}
]
}
} |
Extract only the clinical evaluation methods used for each condition, such as imaging, physical examination, or biopsy. | Admission Date: [**2126-3-2**] Discharge Date: [**2126-3-6**]
Date of Birth: [**2061-11-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 9824**]
Chief Complaint:
N/V, Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt. is a 64 y/o F with a PMH of ESRD on HD, DM, and HTN
presenting after dialysis with hypotension, nausea, vomiting and
abdominal pain. The patient reports six episodes of emesis since
HD with mild epigastric pain. Per report temp to 100.5 at HD
with complaint of aches and chills. 4L fluid taken off at HD,
pre-treatment BP 96/58, post-treatment 169/92. T 97.8.
.
In the ED, initial vs were: T 102.9 BP 146/65, HR 110, RR 20 O2
92% RA. FS 215. Blood Cx sent. Emesis X1. Patient was given
Vancomycin 1gm IV, Levofloxacin 500mg IV, Flagyl 500mg IV,
Morphine 2mg IV. Her BP fell to 94/43 and she was given 1 L NS.
WBC 11.2, lactate 3.2. CXR demonstrated no evidence of
infiltrate. CT Abd/Pelvis showed no evidence of colitis. Per ED
report, beside US showed limited views but a normal caliber
aorta.
.
On arrival to the ICU, the patient was resting comfortably. She
denies lightheadedness. C/o b/l knee pain and low back pain
unchanged from her baseline. The pt. reports increased fatigue X
1 week, she has had decreased mobility since her knee surgery in
[**12-31**]. She reports that typically post-HD she has increased
enerygy, however she noted no improvement this week. Denies
fever, had chills last evening but temp was 97.8 at home. She
c/o abd pain, similar to her chronic symptoms, mostly epigastric
but burning symptoms occur in various locations with no clear
pattern or relation to meals. Denies cough, rhinorrhea. +Frontal
and occipital HA last pm. + chronic constipation, no diarrhea.
Her appetite is normal.
Past Medical History:
End stage renal disease on hemodialysis (TuThSa) - LSC HD
catheter changed [**2125-3-8**]
Hx of Back Abscess - [**2123**] treated with I&D, Vanc X 14 days
Diabetes mellitus type II
Hypertension
Hypercholesterolemia
Coronary artery disease (nonobstructive on cath in [**2119**], normal
stress in [**2124-6-23**])
Constipation
Status post total abdominal hysterectomy
Status post C-section
H. Pylori s/p treatment in [**2124-3-23**]
Gastritis
Right knee subtotal medial meniscectomy and subtotal lateral
meniscectomy with medial femoral chondroplasty [**2126-1-8**]
Social History:
Married and lives with husband, 2 children who live nearby,
former home health aid. Smokes <[**1-25**] ppd x 40 years, quit in [**3-3**]
after being hospitalized for influenza. no ETOH, no
drugs. Received the influenza and pneumococcal vaccines
Family History:
+ Premature CAD in brothers and mother. Daughter with kidney
disease. Siblings with DM, CAD, HTN, CVA, no cancer.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild TTP epigastrium, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no edema
Skin: multiple scars from prev fistula attempts on both
forearms, scar, scar - midback from prev. incision site, L SC
site no erythema surrounding catheter + skin breakdown around
adhesive dressing, no fluctuance, no drainage
Pertinent Results:
[**2126-3-2**] 01:15PM WBC-11.2*# RBC-3.97* HGB-12.7 HCT-37.9 MCV-95
MCH-32.0 MCHC-33.5 RDW-15.1
[**2126-3-2**] 01:15PM NEUTS-90.2* LYMPHS-4.6* MONOS-4.1 EOS-0.8
BASOS-0.2
[**2126-3-2**] 01:15PM PLT COUNT-203
[**2126-3-2**] 01:15PM GLUCOSE-197* UREA N-9 CREAT-2.9*# SODIUM-144
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-29 ANION GAP-22*
[**2126-3-2**] 01:15PM ALT(SGPT)-34 AST(SGOT)-31 CK(CPK)-69 ALK
PHOS-193* TOT BILI-0.5
[**2126-3-2**] 01:21PM LACTATE-3.1*
[**2126-3-2**] 04:16PM LACTATE-2.3*
[**2126-3-6**] 04:35AM BLOOD WBC-6.5 RBC-3.03* Hgb-9.3* Hct-28.8*
MCV-95 MCH-30.7 MCHC-32.3 RDW-15.5 Plt Ct-207
[**2126-3-6**] 04:35AM BLOOD Glucose-98 UreaN-16 Creat-4.6*# Na-137
K-4.2 Cl-98 HCO3-28 AnGap-15
[**2126-3-4**] 05:30AM BLOOD ALT-20 AST-15 LD(LDH)-151 AlkPhos-143*
TotBili-0.3
[**2126-3-3**] 01:35AM BLOOD Lipase-36
[**2126-3-2**] 01:15PM BLOOD CK-MB-3 cTropnT-0.05*
[**2126-3-6**] 04:35AM BLOOD Calcium-10.3* Phos-4.7*# Mg-1.8
[**2126-3-6**] 04:35AM BLOOD PTH-1368*
[**2126-3-5**] 06:35AM BLOOD Vanco-9.8*
[**2126-3-3**] 06:04PM BLOOD Vanco-12.4
[**2126-3-4**] 05:55AM BLOOD Lactate-1.2
[**2126-3-2**] 1:00 pm BLOOD CULTURE
**FINAL REPORT [**2126-3-9**]**
Blood Culture, Routine (Final [**2126-3-8**]):
PRESUMPTIVE PEPTOSTREPTOCOCCUS SPECIES.
ISOLATED FROM ONE SET ONLY.
BACILLUS SPECIES; NOT ANTHRACIS.
Sensitivity testing performed by Sensititre.
GENTAMICIN = SENSITIVE ( <=2 MCG/ML ).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BACILLUS SPECIES; NOT ANTHRACIS
|
CLINDAMYCIN----------- 0.5 S
GENTAMICIN------------ S
LEVOFLOXACIN----------<=0.25 S
VANCOMYCIN------------ <=1 S
[**2126-3-2**] 1:15 pm BLOOD CULTURE
**FINAL REPORT [**2126-3-8**]**
Blood Culture, Routine (Final [**2126-3-8**]):
BACILLUS SPECIES; NOT ANTHRACIS.
SENSITIVITIES PERFORMED ON CULTURE # 266-9949D [**2126-3-2**].
Anaerobic Bottle Gram Stain (Final [**2126-3-5**]):
GRAM POSITIVE ROD(S).
REPORTED BY PHONE TO [**Doctor First Name **] [**Doctor Last Name **]-[**Doctor Last Name **] #[**Numeric Identifier 11629**] [**2126-3-4**]
2:30PM.
CONSISTENT WITH CLOSTRIDIUM AND
BACILLUS SPECIES.
Blood Cx: [**3-2**], [**3-4**], [**3-4**], [**3-5**]: No growth
Cardiology Report ECG Study Date of [**2126-3-2**] 2:04:54 PM
Sinus rhythm. Modest inferolateral T wave changes which are
non-specific.
Compared to the previous tracing of [**2125-12-26**] there is no
significant diagnostic
change.
CXR: [**3-2**]
IMPRESSION: No significant change when compared to prior exam.
CT- abd/pelvis: [**3-2**]
IMPRESSION:
1. No evidence of colitis.
2. Unchanged angiomylipoma of right kidney. Multiple tiny
hypodensities in
the kidneys too small to accurately characterize.
3. Several small nodules in the left adrenal gland likely not
changed from
[**2122**] but incompletely characterized on the current study.
4. Atherosclerotic disease.
RUQ U/S [**3-3**]
IMPRESSION:
Unchanged cholelithiasis with no secondary findings to suggest
acute
cholecystitis.
TTE [**3-6**]
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with probable mild hypokinesis of the basal to mid
inferolateral and lateral segments (suboptimal image quality
limits interpretation). Right ventricular chamber size and free
wall motion are normal. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are moderately
thickened. No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. There is mild aortic valve stenosis (area 1.2-1.9cm2).
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No masses or vegetations are seen
on the mitral valve, but cannot be fully excluded due to
suboptimal image quality. Trivial mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] No masses or vegetations
are seen on the tricuspid valve, but cannot be fully excluded
due to suboptimal image quality. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality limits interpretation.
There is no evidence of endocarditis or abscess. Calcification
of the aortic valve and mitral annulus. Mild aortic stenosis and
trace aortic regurgitation. Probable inferolateral and lateral
hypokinesis.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
Compared with the prior study (images reviewed) of [**2122-11-6**],
the aortic valve is more calcified and there is now aortic
stenosis and trace aortic regurgitation. The degree of tricuspid
regurgitation has increased. The lateral/inferolateral
hypokinesis was similar in appearance on the prior echo.
Brief Hospital Course:
Assessment and Plan: The pt. is a 64 y/o F with a PMH of ESRD on
HD, DM, and HTN presenting after dialysis with hypotension,
nausea, vomiting and abdominal pain.
.
#. Bacteremia - The patient presented with associated symptoms
of N/V, but patient has hadh chronic abd pain and was not
clearly changed from prior. A CT A/P showed no acute process.
Her LFTs were wnl, with her alk ph mildly elevated.
Additionally, RUQ U/S did was unremarkable. Her CXR showed no
clear infiltrate. The patient was initially treated with
Vancomycin 1gm IV, Levofloxacin 500mg IV, Flagyl 500mg IV and
transferred to the ICU. The patient symptomatically improved
and her antibiotics were tailored to Vancomycin and Cipro and
transferred to the floor. The patient's blood cultures did grow
peptostreptococcus from one set and bacillus (non-anthracis)
from another set. The patient did not have evidence of dental
abcsess on exam. The patient remained afebrile and clinically
stable. She underwent TTE that did not show evidence of
endocarditis. She will continue a 2 week course of Vancomycin at
HD. The patient remained stable and no further blood cultures
were positive.
.
#. Hypotension - The pt briefly dropped BP to 90s systolic in
the ED. On review of HD flow sheets, the pt commonly has BP in
this range post-HD. She had 4L taken off at dialysis the day of
admission. The patient was given IVF and her pressures
responded. Her BP med were intially held. After transfer to the
floor she was restarted on clonidine, lisinopril, while her
diltiazem was held. She will follow-up with her PCP regarding
restarting her diltiazem.
.
#. Abd pain: The patient has a history of gastritis on EGD,
treated previously for H.pylori with f/u negative breath
testing. She was continued on her PPI [**Hospital1 **]. She continued to
have chronic abdominal pain, but it was not changed from her
baseline. CT A/P showed no acute process.
.
#. End stage renal disease on hemodialysis - The patient with
LSC HD catheter [**2125-3-8**]. She was continued on HD as scheduled
T/Th/Sa.
.
#. Diabetes mellitus type II - She was initially continued on
her home lantus 8U Qam, 26U Qpm. The patient's glucose were low
during her hospitalization and her PM lantus dose was titrated
down. This is likely due to adhereing to a diabetic diet while
in the hospital. She was discharged on 8U qAm and 24U qPM with
follow-up with her PCP.
.
#. Hypercholesterolemia - continue statin
.
#. Constipation - continue bowel regimen
.
#. Gastritis - continue PPI
.
#. FEN: diabetic diet
.
# Prophylaxis: Subcutaneous heparin
.
# Access: L SC HD, peripheral X2
.
# Code: Full
Medications on Admission:
Active Medication list as of [**2126-2-7**]:
CITALOPRAM [CELEXA] - 20 mg Tablet - 1 Tablet(s) by mouth once a
day; take half a tablet daily for the first week
CLONAZEPAM [KLONOPIN] - 0.5 mg Tablet - half Tablet(s) by mouth
twice a day as needed for anxiety
CLONIDINE - 0.2 mg Tablet - 1 Tablet(s) by mouth twice a day
DILTIAZEM HCL [DILACOR XR] - 240 mg Capsule,Degradable Cnt
Release - 1 (One) Capsule,Degradable Cnt Release(s) by mouth
every day in the afternoon
FLONASE - 50MCG Spray, Suspension - 2 SPRAYS IN EACH NOSTRIL
EVERY DAY
KETOCONAZOLE [NIZORAL] - 2 % Shampoo - appy daily
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
NORVASC - 10MG Tablet - ONE BY MOUTH EVERY DAY
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 (One)
Capsule(s) by mouth twice a day
OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - [**1-25**]
Tablet(s) by mouth every 4 hours as needed for pain. Do not
drink, drive or operate heavy machinery while taking this
medication.
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth once a day
Medications - OTC
ACETAMINOPHEN [TYLENOL 8 HOUR] - 650 mg Tablet Sustained Release
- 2 Tablet(s) by mouth three times a day
CLOTRIMAZOLE [CLOTRIMAZOLE-7] - 1 % Cream - 1 applicator full
applied at bedtime
INSULIN NPH HUMAN RECOMB [HUMULIN N] - 100 unit/mL Suspension -
8
units subcutaneous every morning and 26 units subcutaneous every
evening
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Klonopin 0.25 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO twice a day as needed.
3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
5. Ketoconazole 2 % Shampoo Sig: One (1) Topical once a day.
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tylenol 325 mg Tablet Sig: 1300 (1300) mg PO three times a
day.
12. Clotrimazole 1 % Cream Sig: One (1) Topical at bedtime.
13. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: as
directed Subcutaneous twice a day: 8U qAM/ 26U qPM.
14. Vancomycin 1,000 mg Recon Soln Sig: at HD Intravenous at HD
for 2 weeks: 2 week course
Last day: [**2126-3-15**].
15. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for pain.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Bacteremia
ESRD on HD
Secondary:
Diabetes mellitus type II
Hypertension
Hypercholesterolemia v
Coronary artery disease
Constipation
Gastritis
Discharge Condition:
stable, afebrile, normotensive, ambulating
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of an infection in
his blood. You were treated with antibiotics and improved. You
also had an ultrasound of your heart that did not show any
infection. You will continue Vancomycin at dialysis for 2 weeks.
Please follow the medications prescribed below.
1) Please stop taking your diltiazem for now given your low
blood pressure
2) Your night-time insulin was decreased to 24U. Please continue
your AM dose as usual.
3) Please take percocet prior to your PT sessions
Please follow up with the appointments below.
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2126-3-20**] 9:40
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2126-3-25**] 2:20
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2126-3-25**]
3:30
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2126-4-23**] 2:30
Completed by:[**2126-3-11**] | {
"clinical_findings": {
"N186": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
}
],
"Z992": [
{
"icd_10_cm_code": "Z99.2",
"icd_10_cm_code_description": "Dependence on renal dialysis",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code Z99.2 is assigned for Dependence on renal dialysis. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P in conjunction with ESRD), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code N18.6 is also assigned for End stage renal disease."
}
],
"Z794": [
{
"icd_10_cm_code": "Z79.4",
"icd_10_cm_code_description": "Long-term (current) use of insulin",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "initially continued on her home lantus 8U Qam, 26U Qpm.",
"page_numbers": [
2
]
},
{
"text": "discharged on 8U qAm and 24U qPM",
"page_numbers": [
2
]
},
{
"text": "Insulin NPH Human Recomb",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "INSULIN NPH HUMAN RECOMB [HUMULIN N]",
"page_numbers": [
2
]
},
{
"evidence_text": "Insulin NPH Human Recomb",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code Z79.4 is assigned for Long-term (current) use of insulin. MEAT criteria are met as evidenced by Treatment (ongoing insulin therapy documented in A/P and discharge medications). Code E11.9 is also assigned for Type 2 diabetes mellitus."
}
],
"E7800": [
{
"icd_10_cm_code": "E78.00",
"icd_10_cm_code_description": "Pure hypercholesterolemia, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hypercholesterolemia",
"page_numbers": [
1
]
},
{
"text": "Hypercholesterolemia",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "continue statin",
"page_numbers": [
2
]
},
{
"text": "SIMVASTATIN",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "Hypercholesterolemia",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypercholesterolemia",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E78.00 is assigned for Pure hypercholesterolemia, unspecified. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P) and Treatment (continued statin therapy)."
}
],
"I2720": [
{
"icd_10_cm_code": "I27.20",
"icd_10_cm_code_description": "Pulmonary hypertension, unspecified",
"Monitoring": [],
"Evaluation": [
{
"text": "mild pulmonary artery systolic\nhypertension.",
"page_numbers": [
2
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild pulmonary artery systolic\nhypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I27.20 is assigned for Pulmonary hypertension, unspecified. MEAT criteria are met as evidenced by Evaluation (finding on TTE)."
}
],
"E1122": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
},
{
"icd_10_cm_code": "E11.9",
"icd_10_cm_code_description": "Type 2 diabetes mellitus without complications",
"Monitoring": [
{
"text": "The patient's glucose were low during her hospitalization and her PM lantus dose was titrated down.",
"page_numbers": [
2
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "Diabetes mellitus type II",
"page_numbers": [
1
]
},
{
"text": "DM",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "initially continued on her home lantus 8U Qam, 26U Qpm.",
"page_numbers": [
2
]
},
{
"text": "discharged on 8U qAm and 24U qPM",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "DM",
"page_numbers": [
1
]
},
{
"evidence_text": "Diabetes mellitus type II",
"page_numbers": [
1
]
},
{
"evidence_text": "DM",
"page_numbers": [
2
]
},
{
"evidence_text": "Diabetes mellitus type II",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.9 is assigned for Type 2 diabetes mellitus without complications. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (glucose levels monitored and insulin adjusted), and Treatment (insulin therapy). Code Z79.4 is also assigned for long-term insulin use."
}
],
"I120": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
},
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hypertension",
"page_numbers": [
1
]
},
{
"text": "HTN",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "Her BP med were intially held. After transfer to the floor she was restarted on clonidine, lisinopril, while her diltiazem was held.",
"page_numbers": [
2
]
},
{
"text": "Clonidine",
"page_numbers": [
2
]
},
{
"text": "Lisinopril",
"page_numbers": [
2
]
},
{
"text": "Amlodipine",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "HTN",
"page_numbers": [
2
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P) and Treatment (medication adjustments and listed medications)."
}
]
}
} |
Extract only the clinical assessment findings for each condition, including diagnostic conclusions and staging. | Admission Date: [**2126-3-2**] Discharge Date: [**2126-3-6**]
Date of Birth: [**2061-11-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 9824**]
Chief Complaint:
N/V, Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt. is a 64 y/o F with a PMH of ESRD on HD, DM, and HTN
presenting after dialysis with hypotension, nausea, vomiting and
abdominal pain. The patient reports six episodes of emesis since
HD with mild epigastric pain. Per report temp to 100.5 at HD
with complaint of aches and chills. 4L fluid taken off at HD,
pre-treatment BP 96/58, post-treatment 169/92. T 97.8.
.
In the ED, initial vs were: T 102.9 BP 146/65, HR 110, RR 20 O2
92% RA. FS 215. Blood Cx sent. Emesis X1. Patient was given
Vancomycin 1gm IV, Levofloxacin 500mg IV, Flagyl 500mg IV,
Morphine 2mg IV. Her BP fell to 94/43 and she was given 1 L NS.
WBC 11.2, lactate 3.2. CXR demonstrated no evidence of
infiltrate. CT Abd/Pelvis showed no evidence of colitis. Per ED
report, beside US showed limited views but a normal caliber
aorta.
.
On arrival to the ICU, the patient was resting comfortably. She
denies lightheadedness. C/o b/l knee pain and low back pain
unchanged from her baseline. The pt. reports increased fatigue X
1 week, she has had decreased mobility since her knee surgery in
[**12-31**]. She reports that typically post-HD she has increased
enerygy, however she noted no improvement this week. Denies
fever, had chills last evening but temp was 97.8 at home. She
c/o abd pain, similar to her chronic symptoms, mostly epigastric
but burning symptoms occur in various locations with no clear
pattern or relation to meals. Denies cough, rhinorrhea. +Frontal
and occipital HA last pm. + chronic constipation, no diarrhea.
Her appetite is normal.
Past Medical History:
End stage renal disease on hemodialysis (TuThSa) - LSC HD
catheter changed [**2125-3-8**]
Hx of Back Abscess - [**2123**] treated with I&D, Vanc X 14 days
Diabetes mellitus type II
Hypertension
Hypercholesterolemia
Coronary artery disease (nonobstructive on cath in [**2119**], normal
stress in [**2124-6-23**])
Constipation
Status post total abdominal hysterectomy
Status post C-section
H. Pylori s/p treatment in [**2124-3-23**]
Gastritis
Right knee subtotal medial meniscectomy and subtotal lateral
meniscectomy with medial femoral chondroplasty [**2126-1-8**]
Social History:
Married and lives with husband, 2 children who live nearby,
former home health aid. Smokes <[**1-25**] ppd x 40 years, quit in [**3-3**]
after being hospitalized for influenza. no ETOH, no
drugs. Received the influenza and pneumococcal vaccines
Family History:
+ Premature CAD in brothers and mother. Daughter with kidney
disease. Siblings with DM, CAD, HTN, CVA, no cancer.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild TTP epigastrium, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no edema
Skin: multiple scars from prev fistula attempts on both
forearms, scar, scar - midback from prev. incision site, L SC
site no erythema surrounding catheter + skin breakdown around
adhesive dressing, no fluctuance, no drainage
Pertinent Results:
[**2126-3-2**] 01:15PM WBC-11.2*# RBC-3.97* HGB-12.7 HCT-37.9 MCV-95
MCH-32.0 MCHC-33.5 RDW-15.1
[**2126-3-2**] 01:15PM NEUTS-90.2* LYMPHS-4.6* MONOS-4.1 EOS-0.8
BASOS-0.2
[**2126-3-2**] 01:15PM PLT COUNT-203
[**2126-3-2**] 01:15PM GLUCOSE-197* UREA N-9 CREAT-2.9*# SODIUM-144
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-29 ANION GAP-22*
[**2126-3-2**] 01:15PM ALT(SGPT)-34 AST(SGOT)-31 CK(CPK)-69 ALK
PHOS-193* TOT BILI-0.5
[**2126-3-2**] 01:21PM LACTATE-3.1*
[**2126-3-2**] 04:16PM LACTATE-2.3*
[**2126-3-6**] 04:35AM BLOOD WBC-6.5 RBC-3.03* Hgb-9.3* Hct-28.8*
MCV-95 MCH-30.7 MCHC-32.3 RDW-15.5 Plt Ct-207
[**2126-3-6**] 04:35AM BLOOD Glucose-98 UreaN-16 Creat-4.6*# Na-137
K-4.2 Cl-98 HCO3-28 AnGap-15
[**2126-3-4**] 05:30AM BLOOD ALT-20 AST-15 LD(LDH)-151 AlkPhos-143*
TotBili-0.3
[**2126-3-3**] 01:35AM BLOOD Lipase-36
[**2126-3-2**] 01:15PM BLOOD CK-MB-3 cTropnT-0.05*
[**2126-3-6**] 04:35AM BLOOD Calcium-10.3* Phos-4.7*# Mg-1.8
[**2126-3-6**] 04:35AM BLOOD PTH-1368*
[**2126-3-5**] 06:35AM BLOOD Vanco-9.8*
[**2126-3-3**] 06:04PM BLOOD Vanco-12.4
[**2126-3-4**] 05:55AM BLOOD Lactate-1.2
[**2126-3-2**] 1:00 pm BLOOD CULTURE
**FINAL REPORT [**2126-3-9**]**
Blood Culture, Routine (Final [**2126-3-8**]):
PRESUMPTIVE PEPTOSTREPTOCOCCUS SPECIES.
ISOLATED FROM ONE SET ONLY.
BACILLUS SPECIES; NOT ANTHRACIS.
Sensitivity testing performed by Sensititre.
GENTAMICIN = SENSITIVE ( <=2 MCG/ML ).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BACILLUS SPECIES; NOT ANTHRACIS
|
CLINDAMYCIN----------- 0.5 S
GENTAMICIN------------ S
LEVOFLOXACIN----------<=0.25 S
VANCOMYCIN------------ <=1 S
[**2126-3-2**] 1:15 pm BLOOD CULTURE
**FINAL REPORT [**2126-3-8**]**
Blood Culture, Routine (Final [**2126-3-8**]):
BACILLUS SPECIES; NOT ANTHRACIS.
SENSITIVITIES PERFORMED ON CULTURE # 266-9949D [**2126-3-2**].
Anaerobic Bottle Gram Stain (Final [**2126-3-5**]):
GRAM POSITIVE ROD(S).
REPORTED BY PHONE TO [**Doctor First Name **] [**Doctor Last Name **]-[**Doctor Last Name **] #[**Numeric Identifier 11629**] [**2126-3-4**]
2:30PM.
CONSISTENT WITH CLOSTRIDIUM AND
BACILLUS SPECIES.
Blood Cx: [**3-2**], [**3-4**], [**3-4**], [**3-5**]: No growth
Cardiology Report ECG Study Date of [**2126-3-2**] 2:04:54 PM
Sinus rhythm. Modest inferolateral T wave changes which are
non-specific.
Compared to the previous tracing of [**2125-12-26**] there is no
significant diagnostic
change.
CXR: [**3-2**]
IMPRESSION: No significant change when compared to prior exam.
CT- abd/pelvis: [**3-2**]
IMPRESSION:
1. No evidence of colitis.
2. Unchanged angiomylipoma of right kidney. Multiple tiny
hypodensities in
the kidneys too small to accurately characterize.
3. Several small nodules in the left adrenal gland likely not
changed from
[**2122**] but incompletely characterized on the current study.
4. Atherosclerotic disease.
RUQ U/S [**3-3**]
IMPRESSION:
Unchanged cholelithiasis with no secondary findings to suggest
acute
cholecystitis.
TTE [**3-6**]
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with probable mild hypokinesis of the basal to mid
inferolateral and lateral segments (suboptimal image quality
limits interpretation). Right ventricular chamber size and free
wall motion are normal. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are moderately
thickened. No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. There is mild aortic valve stenosis (area 1.2-1.9cm2).
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No masses or vegetations are seen
on the mitral valve, but cannot be fully excluded due to
suboptimal image quality. Trivial mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] No masses or vegetations
are seen on the tricuspid valve, but cannot be fully excluded
due to suboptimal image quality. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality limits interpretation.
There is no evidence of endocarditis or abscess. Calcification
of the aortic valve and mitral annulus. Mild aortic stenosis and
trace aortic regurgitation. Probable inferolateral and lateral
hypokinesis.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
Compared with the prior study (images reviewed) of [**2122-11-6**],
the aortic valve is more calcified and there is now aortic
stenosis and trace aortic regurgitation. The degree of tricuspid
regurgitation has increased. The lateral/inferolateral
hypokinesis was similar in appearance on the prior echo.
Brief Hospital Course:
Assessment and Plan: The pt. is a 64 y/o F with a PMH of ESRD on
HD, DM, and HTN presenting after dialysis with hypotension,
nausea, vomiting and abdominal pain.
.
#. Bacteremia - The patient presented with associated symptoms
of N/V, but patient has hadh chronic abd pain and was not
clearly changed from prior. A CT A/P showed no acute process.
Her LFTs were wnl, with her alk ph mildly elevated.
Additionally, RUQ U/S did was unremarkable. Her CXR showed no
clear infiltrate. The patient was initially treated with
Vancomycin 1gm IV, Levofloxacin 500mg IV, Flagyl 500mg IV and
transferred to the ICU. The patient symptomatically improved
and her antibiotics were tailored to Vancomycin and Cipro and
transferred to the floor. The patient's blood cultures did grow
peptostreptococcus from one set and bacillus (non-anthracis)
from another set. The patient did not have evidence of dental
abcsess on exam. The patient remained afebrile and clinically
stable. She underwent TTE that did not show evidence of
endocarditis. She will continue a 2 week course of Vancomycin at
HD. The patient remained stable and no further blood cultures
were positive.
.
#. Hypotension - The pt briefly dropped BP to 90s systolic in
the ED. On review of HD flow sheets, the pt commonly has BP in
this range post-HD. She had 4L taken off at dialysis the day of
admission. The patient was given IVF and her pressures
responded. Her BP med were intially held. After transfer to the
floor she was restarted on clonidine, lisinopril, while her
diltiazem was held. She will follow-up with her PCP regarding
restarting her diltiazem.
.
#. Abd pain: The patient has a history of gastritis on EGD,
treated previously for H.pylori with f/u negative breath
testing. She was continued on her PPI [**Hospital1 **]. She continued to
have chronic abdominal pain, but it was not changed from her
baseline. CT A/P showed no acute process.
.
#. End stage renal disease on hemodialysis - The patient with
LSC HD catheter [**2125-3-8**]. She was continued on HD as scheduled
T/Th/Sa.
.
#. Diabetes mellitus type II - She was initially continued on
her home lantus 8U Qam, 26U Qpm. The patient's glucose were low
during her hospitalization and her PM lantus dose was titrated
down. This is likely due to adhereing to a diabetic diet while
in the hospital. She was discharged on 8U qAm and 24U qPM with
follow-up with her PCP.
.
#. Hypercholesterolemia - continue statin
.
#. Constipation - continue bowel regimen
.
#. Gastritis - continue PPI
.
#. FEN: diabetic diet
.
# Prophylaxis: Subcutaneous heparin
.
# Access: L SC HD, peripheral X2
.
# Code: Full
Medications on Admission:
Active Medication list as of [**2126-2-7**]:
CITALOPRAM [CELEXA] - 20 mg Tablet - 1 Tablet(s) by mouth once a
day; take half a tablet daily for the first week
CLONAZEPAM [KLONOPIN] - 0.5 mg Tablet - half Tablet(s) by mouth
twice a day as needed for anxiety
CLONIDINE - 0.2 mg Tablet - 1 Tablet(s) by mouth twice a day
DILTIAZEM HCL [DILACOR XR] - 240 mg Capsule,Degradable Cnt
Release - 1 (One) Capsule,Degradable Cnt Release(s) by mouth
every day in the afternoon
FLONASE - 50MCG Spray, Suspension - 2 SPRAYS IN EACH NOSTRIL
EVERY DAY
KETOCONAZOLE [NIZORAL] - 2 % Shampoo - appy daily
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
NORVASC - 10MG Tablet - ONE BY MOUTH EVERY DAY
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 (One)
Capsule(s) by mouth twice a day
OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - [**1-25**]
Tablet(s) by mouth every 4 hours as needed for pain. Do not
drink, drive or operate heavy machinery while taking this
medication.
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth once a day
Medications - OTC
ACETAMINOPHEN [TYLENOL 8 HOUR] - 650 mg Tablet Sustained Release
- 2 Tablet(s) by mouth three times a day
CLOTRIMAZOLE [CLOTRIMAZOLE-7] - 1 % Cream - 1 applicator full
applied at bedtime
INSULIN NPH HUMAN RECOMB [HUMULIN N] - 100 unit/mL Suspension -
8
units subcutaneous every morning and 26 units subcutaneous every
evening
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Klonopin 0.25 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO twice a day as needed.
3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
5. Ketoconazole 2 % Shampoo Sig: One (1) Topical once a day.
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tylenol 325 mg Tablet Sig: 1300 (1300) mg PO three times a
day.
12. Clotrimazole 1 % Cream Sig: One (1) Topical at bedtime.
13. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: as
directed Subcutaneous twice a day: 8U qAM/ 26U qPM.
14. Vancomycin 1,000 mg Recon Soln Sig: at HD Intravenous at HD
for 2 weeks: 2 week course
Last day: [**2126-3-15**].
15. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for pain.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Bacteremia
ESRD on HD
Secondary:
Diabetes mellitus type II
Hypertension
Hypercholesterolemia v
Coronary artery disease
Constipation
Gastritis
Discharge Condition:
stable, afebrile, normotensive, ambulating
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of an infection in
his blood. You were treated with antibiotics and improved. You
also had an ultrasound of your heart that did not show any
infection. You will continue Vancomycin at dialysis for 2 weeks.
Please follow the medications prescribed below.
1) Please stop taking your diltiazem for now given your low
blood pressure
2) Your night-time insulin was decreased to 24U. Please continue
your AM dose as usual.
3) Please take percocet prior to your PT sessions
Please follow up with the appointments below.
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2126-3-20**] 9:40
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2126-3-25**] 2:20
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2126-3-25**]
3:30
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2126-4-23**] 2:30
Completed by:[**2126-3-11**] | {
"clinical_findings": {
"N186": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
}
],
"Z992": [
{
"icd_10_cm_code": "Z99.2",
"icd_10_cm_code_description": "Dependence on renal dialysis",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code Z99.2 is assigned for Dependence on renal dialysis. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P in conjunction with ESRD), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code N18.6 is also assigned for End stage renal disease."
}
],
"Z794": [
{
"icd_10_cm_code": "Z79.4",
"icd_10_cm_code_description": "Long-term (current) use of insulin",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "initially continued on her home lantus 8U Qam, 26U Qpm.",
"page_numbers": [
2
]
},
{
"text": "discharged on 8U qAm and 24U qPM",
"page_numbers": [
2
]
},
{
"text": "Insulin NPH Human Recomb",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "INSULIN NPH HUMAN RECOMB [HUMULIN N]",
"page_numbers": [
2
]
},
{
"evidence_text": "Insulin NPH Human Recomb",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code Z79.4 is assigned for Long-term (current) use of insulin. MEAT criteria are met as evidenced by Treatment (ongoing insulin therapy documented in A/P and discharge medications). Code E11.9 is also assigned for Type 2 diabetes mellitus."
}
],
"E7800": [
{
"icd_10_cm_code": "E78.00",
"icd_10_cm_code_description": "Pure hypercholesterolemia, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hypercholesterolemia",
"page_numbers": [
1
]
},
{
"text": "Hypercholesterolemia",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "continue statin",
"page_numbers": [
2
]
},
{
"text": "SIMVASTATIN",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "Hypercholesterolemia",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypercholesterolemia",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E78.00 is assigned for Pure hypercholesterolemia, unspecified. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P) and Treatment (continued statin therapy)."
}
],
"I2720": [
{
"icd_10_cm_code": "I27.20",
"icd_10_cm_code_description": "Pulmonary hypertension, unspecified",
"Monitoring": [],
"Evaluation": [
{
"text": "mild pulmonary artery systolic\nhypertension.",
"page_numbers": [
2
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild pulmonary artery systolic\nhypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I27.20 is assigned for Pulmonary hypertension, unspecified. MEAT criteria are met as evidenced by Evaluation (finding on TTE)."
}
],
"E1122": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
},
{
"icd_10_cm_code": "E11.9",
"icd_10_cm_code_description": "Type 2 diabetes mellitus without complications",
"Monitoring": [
{
"text": "The patient's glucose were low during her hospitalization and her PM lantus dose was titrated down.",
"page_numbers": [
2
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "Diabetes mellitus type II",
"page_numbers": [
1
]
},
{
"text": "DM",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "initially continued on her home lantus 8U Qam, 26U Qpm.",
"page_numbers": [
2
]
},
{
"text": "discharged on 8U qAm and 24U qPM",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "DM",
"page_numbers": [
1
]
},
{
"evidence_text": "Diabetes mellitus type II",
"page_numbers": [
1
]
},
{
"evidence_text": "DM",
"page_numbers": [
2
]
},
{
"evidence_text": "Diabetes mellitus type II",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.9 is assigned for Type 2 diabetes mellitus without complications. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (glucose levels monitored and insulin adjusted), and Treatment (insulin therapy). Code Z79.4 is also assigned for long-term insulin use."
}
],
"I120": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
},
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hypertension",
"page_numbers": [
1
]
},
{
"text": "HTN",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "Her BP med were intially held. After transfer to the floor she was restarted on clonidine, lisinopril, while her diltiazem was held.",
"page_numbers": [
2
]
},
{
"text": "Clonidine",
"page_numbers": [
2
]
},
{
"text": "Lisinopril",
"page_numbers": [
2
]
},
{
"text": "Amlodipine",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "HTN",
"page_numbers": [
2
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P) and Treatment (medication adjustments and listed medications)."
}
]
}
} |
Extract only the treatment or intervention given for each condition, including surgeries, procedures, and medications. | Admission Date: [**2126-3-2**] Discharge Date: [**2126-3-6**]
Date of Birth: [**2061-11-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 9824**]
Chief Complaint:
N/V, Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt. is a 64 y/o F with a PMH of ESRD on HD, DM, and HTN
presenting after dialysis with hypotension, nausea, vomiting and
abdominal pain. The patient reports six episodes of emesis since
HD with mild epigastric pain. Per report temp to 100.5 at HD
with complaint of aches and chills. 4L fluid taken off at HD,
pre-treatment BP 96/58, post-treatment 169/92. T 97.8.
.
In the ED, initial vs were: T 102.9 BP 146/65, HR 110, RR 20 O2
92% RA. FS 215. Blood Cx sent. Emesis X1. Patient was given
Vancomycin 1gm IV, Levofloxacin 500mg IV, Flagyl 500mg IV,
Morphine 2mg IV. Her BP fell to 94/43 and she was given 1 L NS.
WBC 11.2, lactate 3.2. CXR demonstrated no evidence of
infiltrate. CT Abd/Pelvis showed no evidence of colitis. Per ED
report, beside US showed limited views but a normal caliber
aorta.
.
On arrival to the ICU, the patient was resting comfortably. She
denies lightheadedness. C/o b/l knee pain and low back pain
unchanged from her baseline. The pt. reports increased fatigue X
1 week, she has had decreased mobility since her knee surgery in
[**12-31**]. She reports that typically post-HD she has increased
enerygy, however she noted no improvement this week. Denies
fever, had chills last evening but temp was 97.8 at home. She
c/o abd pain, similar to her chronic symptoms, mostly epigastric
but burning symptoms occur in various locations with no clear
pattern or relation to meals. Denies cough, rhinorrhea. +Frontal
and occipital HA last pm. + chronic constipation, no diarrhea.
Her appetite is normal.
Past Medical History:
End stage renal disease on hemodialysis (TuThSa) - LSC HD
catheter changed [**2125-3-8**]
Hx of Back Abscess - [**2123**] treated with I&D, Vanc X 14 days
Diabetes mellitus type II
Hypertension
Hypercholesterolemia
Coronary artery disease (nonobstructive on cath in [**2119**], normal
stress in [**2124-6-23**])
Constipation
Status post total abdominal hysterectomy
Status post C-section
H. Pylori s/p treatment in [**2124-3-23**]
Gastritis
Right knee subtotal medial meniscectomy and subtotal lateral
meniscectomy with medial femoral chondroplasty [**2126-1-8**]
Social History:
Married and lives with husband, 2 children who live nearby,
former home health aid. Smokes <[**1-25**] ppd x 40 years, quit in [**3-3**]
after being hospitalized for influenza. no ETOH, no
drugs. Received the influenza and pneumococcal vaccines
Family History:
+ Premature CAD in brothers and mother. Daughter with kidney
disease. Siblings with DM, CAD, HTN, CVA, no cancer.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild TTP epigastrium, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no edema
Skin: multiple scars from prev fistula attempts on both
forearms, scar, scar - midback from prev. incision site, L SC
site no erythema surrounding catheter + skin breakdown around
adhesive dressing, no fluctuance, no drainage
Pertinent Results:
[**2126-3-2**] 01:15PM WBC-11.2*# RBC-3.97* HGB-12.7 HCT-37.9 MCV-95
MCH-32.0 MCHC-33.5 RDW-15.1
[**2126-3-2**] 01:15PM NEUTS-90.2* LYMPHS-4.6* MONOS-4.1 EOS-0.8
BASOS-0.2
[**2126-3-2**] 01:15PM PLT COUNT-203
[**2126-3-2**] 01:15PM GLUCOSE-197* UREA N-9 CREAT-2.9*# SODIUM-144
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-29 ANION GAP-22*
[**2126-3-2**] 01:15PM ALT(SGPT)-34 AST(SGOT)-31 CK(CPK)-69 ALK
PHOS-193* TOT BILI-0.5
[**2126-3-2**] 01:21PM LACTATE-3.1*
[**2126-3-2**] 04:16PM LACTATE-2.3*
[**2126-3-6**] 04:35AM BLOOD WBC-6.5 RBC-3.03* Hgb-9.3* Hct-28.8*
MCV-95 MCH-30.7 MCHC-32.3 RDW-15.5 Plt Ct-207
[**2126-3-6**] 04:35AM BLOOD Glucose-98 UreaN-16 Creat-4.6*# Na-137
K-4.2 Cl-98 HCO3-28 AnGap-15
[**2126-3-4**] 05:30AM BLOOD ALT-20 AST-15 LD(LDH)-151 AlkPhos-143*
TotBili-0.3
[**2126-3-3**] 01:35AM BLOOD Lipase-36
[**2126-3-2**] 01:15PM BLOOD CK-MB-3 cTropnT-0.05*
[**2126-3-6**] 04:35AM BLOOD Calcium-10.3* Phos-4.7*# Mg-1.8
[**2126-3-6**] 04:35AM BLOOD PTH-1368*
[**2126-3-5**] 06:35AM BLOOD Vanco-9.8*
[**2126-3-3**] 06:04PM BLOOD Vanco-12.4
[**2126-3-4**] 05:55AM BLOOD Lactate-1.2
[**2126-3-2**] 1:00 pm BLOOD CULTURE
**FINAL REPORT [**2126-3-9**]**
Blood Culture, Routine (Final [**2126-3-8**]):
PRESUMPTIVE PEPTOSTREPTOCOCCUS SPECIES.
ISOLATED FROM ONE SET ONLY.
BACILLUS SPECIES; NOT ANTHRACIS.
Sensitivity testing performed by Sensititre.
GENTAMICIN = SENSITIVE ( <=2 MCG/ML ).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BACILLUS SPECIES; NOT ANTHRACIS
|
CLINDAMYCIN----------- 0.5 S
GENTAMICIN------------ S
LEVOFLOXACIN----------<=0.25 S
VANCOMYCIN------------ <=1 S
[**2126-3-2**] 1:15 pm BLOOD CULTURE
**FINAL REPORT [**2126-3-8**]**
Blood Culture, Routine (Final [**2126-3-8**]):
BACILLUS SPECIES; NOT ANTHRACIS.
SENSITIVITIES PERFORMED ON CULTURE # 266-9949D [**2126-3-2**].
Anaerobic Bottle Gram Stain (Final [**2126-3-5**]):
GRAM POSITIVE ROD(S).
REPORTED BY PHONE TO [**Doctor First Name **] [**Doctor Last Name **]-[**Doctor Last Name **] #[**Numeric Identifier 11629**] [**2126-3-4**]
2:30PM.
CONSISTENT WITH CLOSTRIDIUM AND
BACILLUS SPECIES.
Blood Cx: [**3-2**], [**3-4**], [**3-4**], [**3-5**]: No growth
Cardiology Report ECG Study Date of [**2126-3-2**] 2:04:54 PM
Sinus rhythm. Modest inferolateral T wave changes which are
non-specific.
Compared to the previous tracing of [**2125-12-26**] there is no
significant diagnostic
change.
CXR: [**3-2**]
IMPRESSION: No significant change when compared to prior exam.
CT- abd/pelvis: [**3-2**]
IMPRESSION:
1. No evidence of colitis.
2. Unchanged angiomylipoma of right kidney. Multiple tiny
hypodensities in
the kidneys too small to accurately characterize.
3. Several small nodules in the left adrenal gland likely not
changed from
[**2122**] but incompletely characterized on the current study.
4. Atherosclerotic disease.
RUQ U/S [**3-3**]
IMPRESSION:
Unchanged cholelithiasis with no secondary findings to suggest
acute
cholecystitis.
TTE [**3-6**]
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with probable mild hypokinesis of the basal to mid
inferolateral and lateral segments (suboptimal image quality
limits interpretation). Right ventricular chamber size and free
wall motion are normal. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are moderately
thickened. No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. There is mild aortic valve stenosis (area 1.2-1.9cm2).
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No masses or vegetations are seen
on the mitral valve, but cannot be fully excluded due to
suboptimal image quality. Trivial mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] No masses or vegetations
are seen on the tricuspid valve, but cannot be fully excluded
due to suboptimal image quality. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality limits interpretation.
There is no evidence of endocarditis or abscess. Calcification
of the aortic valve and mitral annulus. Mild aortic stenosis and
trace aortic regurgitation. Probable inferolateral and lateral
hypokinesis.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
Compared with the prior study (images reviewed) of [**2122-11-6**],
the aortic valve is more calcified and there is now aortic
stenosis and trace aortic regurgitation. The degree of tricuspid
regurgitation has increased. The lateral/inferolateral
hypokinesis was similar in appearance on the prior echo.
Brief Hospital Course:
Assessment and Plan: The pt. is a 64 y/o F with a PMH of ESRD on
HD, DM, and HTN presenting after dialysis with hypotension,
nausea, vomiting and abdominal pain.
.
#. Bacteremia - The patient presented with associated symptoms
of N/V, but patient has hadh chronic abd pain and was not
clearly changed from prior. A CT A/P showed no acute process.
Her LFTs were wnl, with her alk ph mildly elevated.
Additionally, RUQ U/S did was unremarkable. Her CXR showed no
clear infiltrate. The patient was initially treated with
Vancomycin 1gm IV, Levofloxacin 500mg IV, Flagyl 500mg IV and
transferred to the ICU. The patient symptomatically improved
and her antibiotics were tailored to Vancomycin and Cipro and
transferred to the floor. The patient's blood cultures did grow
peptostreptococcus from one set and bacillus (non-anthracis)
from another set. The patient did not have evidence of dental
abcsess on exam. The patient remained afebrile and clinically
stable. She underwent TTE that did not show evidence of
endocarditis. She will continue a 2 week course of Vancomycin at
HD. The patient remained stable and no further blood cultures
were positive.
.
#. Hypotension - The pt briefly dropped BP to 90s systolic in
the ED. On review of HD flow sheets, the pt commonly has BP in
this range post-HD. She had 4L taken off at dialysis the day of
admission. The patient was given IVF and her pressures
responded. Her BP med were intially held. After transfer to the
floor she was restarted on clonidine, lisinopril, while her
diltiazem was held. She will follow-up with her PCP regarding
restarting her diltiazem.
.
#. Abd pain: The patient has a history of gastritis on EGD,
treated previously for H.pylori with f/u negative breath
testing. She was continued on her PPI [**Hospital1 **]. She continued to
have chronic abdominal pain, but it was not changed from her
baseline. CT A/P showed no acute process.
.
#. End stage renal disease on hemodialysis - The patient with
LSC HD catheter [**2125-3-8**]. She was continued on HD as scheduled
T/Th/Sa.
.
#. Diabetes mellitus type II - She was initially continued on
her home lantus 8U Qam, 26U Qpm. The patient's glucose were low
during her hospitalization and her PM lantus dose was titrated
down. This is likely due to adhereing to a diabetic diet while
in the hospital. She was discharged on 8U qAm and 24U qPM with
follow-up with her PCP.
.
#. Hypercholesterolemia - continue statin
.
#. Constipation - continue bowel regimen
.
#. Gastritis - continue PPI
.
#. FEN: diabetic diet
.
# Prophylaxis: Subcutaneous heparin
.
# Access: L SC HD, peripheral X2
.
# Code: Full
Medications on Admission:
Active Medication list as of [**2126-2-7**]:
CITALOPRAM [CELEXA] - 20 mg Tablet - 1 Tablet(s) by mouth once a
day; take half a tablet daily for the first week
CLONAZEPAM [KLONOPIN] - 0.5 mg Tablet - half Tablet(s) by mouth
twice a day as needed for anxiety
CLONIDINE - 0.2 mg Tablet - 1 Tablet(s) by mouth twice a day
DILTIAZEM HCL [DILACOR XR] - 240 mg Capsule,Degradable Cnt
Release - 1 (One) Capsule,Degradable Cnt Release(s) by mouth
every day in the afternoon
FLONASE - 50MCG Spray, Suspension - 2 SPRAYS IN EACH NOSTRIL
EVERY DAY
KETOCONAZOLE [NIZORAL] - 2 % Shampoo - appy daily
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
NORVASC - 10MG Tablet - ONE BY MOUTH EVERY DAY
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 (One)
Capsule(s) by mouth twice a day
OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - [**1-25**]
Tablet(s) by mouth every 4 hours as needed for pain. Do not
drink, drive or operate heavy machinery while taking this
medication.
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth once a day
Medications - OTC
ACETAMINOPHEN [TYLENOL 8 HOUR] - 650 mg Tablet Sustained Release
- 2 Tablet(s) by mouth three times a day
CLOTRIMAZOLE [CLOTRIMAZOLE-7] - 1 % Cream - 1 applicator full
applied at bedtime
INSULIN NPH HUMAN RECOMB [HUMULIN N] - 100 unit/mL Suspension -
8
units subcutaneous every morning and 26 units subcutaneous every
evening
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Klonopin 0.25 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO twice a day as needed.
3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
5. Ketoconazole 2 % Shampoo Sig: One (1) Topical once a day.
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tylenol 325 mg Tablet Sig: 1300 (1300) mg PO three times a
day.
12. Clotrimazole 1 % Cream Sig: One (1) Topical at bedtime.
13. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: as
directed Subcutaneous twice a day: 8U qAM/ 26U qPM.
14. Vancomycin 1,000 mg Recon Soln Sig: at HD Intravenous at HD
for 2 weeks: 2 week course
Last day: [**2126-3-15**].
15. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for pain.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Bacteremia
ESRD on HD
Secondary:
Diabetes mellitus type II
Hypertension
Hypercholesterolemia v
Coronary artery disease
Constipation
Gastritis
Discharge Condition:
stable, afebrile, normotensive, ambulating
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of an infection in
his blood. You were treated with antibiotics and improved. You
also had an ultrasound of your heart that did not show any
infection. You will continue Vancomycin at dialysis for 2 weeks.
Please follow the medications prescribed below.
1) Please stop taking your diltiazem for now given your low
blood pressure
2) Your night-time insulin was decreased to 24U. Please continue
your AM dose as usual.
3) Please take percocet prior to your PT sessions
Please follow up with the appointments below.
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2126-3-20**] 9:40
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2126-3-25**] 2:20
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2126-3-25**]
3:30
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2126-4-23**] 2:30
Completed by:[**2126-3-11**] | {
"clinical_findings": {
"N186": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
}
],
"Z992": [
{
"icd_10_cm_code": "Z99.2",
"icd_10_cm_code_description": "Dependence on renal dialysis",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code Z99.2 is assigned for Dependence on renal dialysis. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P in conjunction with ESRD), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code N18.6 is also assigned for End stage renal disease."
}
],
"Z794": [
{
"icd_10_cm_code": "Z79.4",
"icd_10_cm_code_description": "Long-term (current) use of insulin",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "initially continued on her home lantus 8U Qam, 26U Qpm.",
"page_numbers": [
2
]
},
{
"text": "discharged on 8U qAm and 24U qPM",
"page_numbers": [
2
]
},
{
"text": "Insulin NPH Human Recomb",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "INSULIN NPH HUMAN RECOMB [HUMULIN N]",
"page_numbers": [
2
]
},
{
"evidence_text": "Insulin NPH Human Recomb",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code Z79.4 is assigned for Long-term (current) use of insulin. MEAT criteria are met as evidenced by Treatment (ongoing insulin therapy documented in A/P and discharge medications). Code E11.9 is also assigned for Type 2 diabetes mellitus."
}
],
"E7800": [
{
"icd_10_cm_code": "E78.00",
"icd_10_cm_code_description": "Pure hypercholesterolemia, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hypercholesterolemia",
"page_numbers": [
1
]
},
{
"text": "Hypercholesterolemia",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "continue statin",
"page_numbers": [
2
]
},
{
"text": "SIMVASTATIN",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "Hypercholesterolemia",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypercholesterolemia",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E78.00 is assigned for Pure hypercholesterolemia, unspecified. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P) and Treatment (continued statin therapy)."
}
],
"I2720": [
{
"icd_10_cm_code": "I27.20",
"icd_10_cm_code_description": "Pulmonary hypertension, unspecified",
"Monitoring": [],
"Evaluation": [
{
"text": "mild pulmonary artery systolic\nhypertension.",
"page_numbers": [
2
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild pulmonary artery systolic\nhypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I27.20 is assigned for Pulmonary hypertension, unspecified. MEAT criteria are met as evidenced by Evaluation (finding on TTE)."
}
],
"E1122": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
},
{
"icd_10_cm_code": "E11.9",
"icd_10_cm_code_description": "Type 2 diabetes mellitus without complications",
"Monitoring": [
{
"text": "The patient's glucose were low during her hospitalization and her PM lantus dose was titrated down.",
"page_numbers": [
2
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "Diabetes mellitus type II",
"page_numbers": [
1
]
},
{
"text": "DM",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "initially continued on her home lantus 8U Qam, 26U Qpm.",
"page_numbers": [
2
]
},
{
"text": "discharged on 8U qAm and 24U qPM",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "DM",
"page_numbers": [
1
]
},
{
"evidence_text": "Diabetes mellitus type II",
"page_numbers": [
1
]
},
{
"evidence_text": "DM",
"page_numbers": [
2
]
},
{
"evidence_text": "Diabetes mellitus type II",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.9 is assigned for Type 2 diabetes mellitus without complications. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (glucose levels monitored and insulin adjusted), and Treatment (insulin therapy). Code Z79.4 is also assigned for long-term insulin use."
}
],
"I120": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
},
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hypertension",
"page_numbers": [
1
]
},
{
"text": "HTN",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "Her BP med were intially held. After transfer to the floor she was restarted on clonidine, lisinopril, while her diltiazem was held.",
"page_numbers": [
2
]
},
{
"text": "Clonidine",
"page_numbers": [
2
]
},
{
"text": "Lisinopril",
"page_numbers": [
2
]
},
{
"text": "Amlodipine",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "HTN",
"page_numbers": [
2
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P) and Treatment (medication adjustments and listed medications)."
}
]
}
} |
Extract only the evidence from the discharge summary that supports the existence of each condition. | Admission Date: [**2126-3-2**] Discharge Date: [**2126-3-6**]
Date of Birth: [**2061-11-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 9824**]
Chief Complaint:
N/V, Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt. is a 64 y/o F with a PMH of ESRD on HD, DM, and HTN
presenting after dialysis with hypotension, nausea, vomiting and
abdominal pain. The patient reports six episodes of emesis since
HD with mild epigastric pain. Per report temp to 100.5 at HD
with complaint of aches and chills. 4L fluid taken off at HD,
pre-treatment BP 96/58, post-treatment 169/92. T 97.8.
.
In the ED, initial vs were: T 102.9 BP 146/65, HR 110, RR 20 O2
92% RA. FS 215. Blood Cx sent. Emesis X1. Patient was given
Vancomycin 1gm IV, Levofloxacin 500mg IV, Flagyl 500mg IV,
Morphine 2mg IV. Her BP fell to 94/43 and she was given 1 L NS.
WBC 11.2, lactate 3.2. CXR demonstrated no evidence of
infiltrate. CT Abd/Pelvis showed no evidence of colitis. Per ED
report, beside US showed limited views but a normal caliber
aorta.
.
On arrival to the ICU, the patient was resting comfortably. She
denies lightheadedness. C/o b/l knee pain and low back pain
unchanged from her baseline. The pt. reports increased fatigue X
1 week, she has had decreased mobility since her knee surgery in
[**12-31**]. She reports that typically post-HD she has increased
enerygy, however she noted no improvement this week. Denies
fever, had chills last evening but temp was 97.8 at home. She
c/o abd pain, similar to her chronic symptoms, mostly epigastric
but burning symptoms occur in various locations with no clear
pattern or relation to meals. Denies cough, rhinorrhea. +Frontal
and occipital HA last pm. + chronic constipation, no diarrhea.
Her appetite is normal.
Past Medical History:
End stage renal disease on hemodialysis (TuThSa) - LSC HD
catheter changed [**2125-3-8**]
Hx of Back Abscess - [**2123**] treated with I&D, Vanc X 14 days
Diabetes mellitus type II
Hypertension
Hypercholesterolemia
Coronary artery disease (nonobstructive on cath in [**2119**], normal
stress in [**2124-6-23**])
Constipation
Status post total abdominal hysterectomy
Status post C-section
H. Pylori s/p treatment in [**2124-3-23**]
Gastritis
Right knee subtotal medial meniscectomy and subtotal lateral
meniscectomy with medial femoral chondroplasty [**2126-1-8**]
Social History:
Married and lives with husband, 2 children who live nearby,
former home health aid. Smokes <[**1-25**] ppd x 40 years, quit in [**3-3**]
after being hospitalized for influenza. no ETOH, no
drugs. Received the influenza and pneumococcal vaccines
Family History:
+ Premature CAD in brothers and mother. Daughter with kidney
disease. Siblings with DM, CAD, HTN, CVA, no cancer.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild TTP epigastrium, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no edema
Skin: multiple scars from prev fistula attempts on both
forearms, scar, scar - midback from prev. incision site, L SC
site no erythema surrounding catheter + skin breakdown around
adhesive dressing, no fluctuance, no drainage
Pertinent Results:
[**2126-3-2**] 01:15PM WBC-11.2*# RBC-3.97* HGB-12.7 HCT-37.9 MCV-95
MCH-32.0 MCHC-33.5 RDW-15.1
[**2126-3-2**] 01:15PM NEUTS-90.2* LYMPHS-4.6* MONOS-4.1 EOS-0.8
BASOS-0.2
[**2126-3-2**] 01:15PM PLT COUNT-203
[**2126-3-2**] 01:15PM GLUCOSE-197* UREA N-9 CREAT-2.9*# SODIUM-144
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-29 ANION GAP-22*
[**2126-3-2**] 01:15PM ALT(SGPT)-34 AST(SGOT)-31 CK(CPK)-69 ALK
PHOS-193* TOT BILI-0.5
[**2126-3-2**] 01:21PM LACTATE-3.1*
[**2126-3-2**] 04:16PM LACTATE-2.3*
[**2126-3-6**] 04:35AM BLOOD WBC-6.5 RBC-3.03* Hgb-9.3* Hct-28.8*
MCV-95 MCH-30.7 MCHC-32.3 RDW-15.5 Plt Ct-207
[**2126-3-6**] 04:35AM BLOOD Glucose-98 UreaN-16 Creat-4.6*# Na-137
K-4.2 Cl-98 HCO3-28 AnGap-15
[**2126-3-4**] 05:30AM BLOOD ALT-20 AST-15 LD(LDH)-151 AlkPhos-143*
TotBili-0.3
[**2126-3-3**] 01:35AM BLOOD Lipase-36
[**2126-3-2**] 01:15PM BLOOD CK-MB-3 cTropnT-0.05*
[**2126-3-6**] 04:35AM BLOOD Calcium-10.3* Phos-4.7*# Mg-1.8
[**2126-3-6**] 04:35AM BLOOD PTH-1368*
[**2126-3-5**] 06:35AM BLOOD Vanco-9.8*
[**2126-3-3**] 06:04PM BLOOD Vanco-12.4
[**2126-3-4**] 05:55AM BLOOD Lactate-1.2
[**2126-3-2**] 1:00 pm BLOOD CULTURE
**FINAL REPORT [**2126-3-9**]**
Blood Culture, Routine (Final [**2126-3-8**]):
PRESUMPTIVE PEPTOSTREPTOCOCCUS SPECIES.
ISOLATED FROM ONE SET ONLY.
BACILLUS SPECIES; NOT ANTHRACIS.
Sensitivity testing performed by Sensititre.
GENTAMICIN = SENSITIVE ( <=2 MCG/ML ).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BACILLUS SPECIES; NOT ANTHRACIS
|
CLINDAMYCIN----------- 0.5 S
GENTAMICIN------------ S
LEVOFLOXACIN----------<=0.25 S
VANCOMYCIN------------ <=1 S
[**2126-3-2**] 1:15 pm BLOOD CULTURE
**FINAL REPORT [**2126-3-8**]**
Blood Culture, Routine (Final [**2126-3-8**]):
BACILLUS SPECIES; NOT ANTHRACIS.
SENSITIVITIES PERFORMED ON CULTURE # 266-9949D [**2126-3-2**].
Anaerobic Bottle Gram Stain (Final [**2126-3-5**]):
GRAM POSITIVE ROD(S).
REPORTED BY PHONE TO [**Doctor First Name **] [**Doctor Last Name **]-[**Doctor Last Name **] #[**Numeric Identifier 11629**] [**2126-3-4**]
2:30PM.
CONSISTENT WITH CLOSTRIDIUM AND
BACILLUS SPECIES.
Blood Cx: [**3-2**], [**3-4**], [**3-4**], [**3-5**]: No growth
Cardiology Report ECG Study Date of [**2126-3-2**] 2:04:54 PM
Sinus rhythm. Modest inferolateral T wave changes which are
non-specific.
Compared to the previous tracing of [**2125-12-26**] there is no
significant diagnostic
change.
CXR: [**3-2**]
IMPRESSION: No significant change when compared to prior exam.
CT- abd/pelvis: [**3-2**]
IMPRESSION:
1. No evidence of colitis.
2. Unchanged angiomylipoma of right kidney. Multiple tiny
hypodensities in
the kidneys too small to accurately characterize.
3. Several small nodules in the left adrenal gland likely not
changed from
[**2122**] but incompletely characterized on the current study.
4. Atherosclerotic disease.
RUQ U/S [**3-3**]
IMPRESSION:
Unchanged cholelithiasis with no secondary findings to suggest
acute
cholecystitis.
TTE [**3-6**]
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with probable mild hypokinesis of the basal to mid
inferolateral and lateral segments (suboptimal image quality
limits interpretation). Right ventricular chamber size and free
wall motion are normal. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are moderately
thickened. No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. There is mild aortic valve stenosis (area 1.2-1.9cm2).
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No masses or vegetations are seen
on the mitral valve, but cannot be fully excluded due to
suboptimal image quality. Trivial mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] No masses or vegetations
are seen on the tricuspid valve, but cannot be fully excluded
due to suboptimal image quality. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality limits interpretation.
There is no evidence of endocarditis or abscess. Calcification
of the aortic valve and mitral annulus. Mild aortic stenosis and
trace aortic regurgitation. Probable inferolateral and lateral
hypokinesis.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
Compared with the prior study (images reviewed) of [**2122-11-6**],
the aortic valve is more calcified and there is now aortic
stenosis and trace aortic regurgitation. The degree of tricuspid
regurgitation has increased. The lateral/inferolateral
hypokinesis was similar in appearance on the prior echo.
Brief Hospital Course:
Assessment and Plan: The pt. is a 64 y/o F with a PMH of ESRD on
HD, DM, and HTN presenting after dialysis with hypotension,
nausea, vomiting and abdominal pain.
.
#. Bacteremia - The patient presented with associated symptoms
of N/V, but patient has hadh chronic abd pain and was not
clearly changed from prior. A CT A/P showed no acute process.
Her LFTs were wnl, with her alk ph mildly elevated.
Additionally, RUQ U/S did was unremarkable. Her CXR showed no
clear infiltrate. The patient was initially treated with
Vancomycin 1gm IV, Levofloxacin 500mg IV, Flagyl 500mg IV and
transferred to the ICU. The patient symptomatically improved
and her antibiotics were tailored to Vancomycin and Cipro and
transferred to the floor. The patient's blood cultures did grow
peptostreptococcus from one set and bacillus (non-anthracis)
from another set. The patient did not have evidence of dental
abcsess on exam. The patient remained afebrile and clinically
stable. She underwent TTE that did not show evidence of
endocarditis. She will continue a 2 week course of Vancomycin at
HD. The patient remained stable and no further blood cultures
were positive.
.
#. Hypotension - The pt briefly dropped BP to 90s systolic in
the ED. On review of HD flow sheets, the pt commonly has BP in
this range post-HD. She had 4L taken off at dialysis the day of
admission. The patient was given IVF and her pressures
responded. Her BP med were intially held. After transfer to the
floor she was restarted on clonidine, lisinopril, while her
diltiazem was held. She will follow-up with her PCP regarding
restarting her diltiazem.
.
#. Abd pain: The patient has a history of gastritis on EGD,
treated previously for H.pylori with f/u negative breath
testing. She was continued on her PPI [**Hospital1 **]. She continued to
have chronic abdominal pain, but it was not changed from her
baseline. CT A/P showed no acute process.
.
#. End stage renal disease on hemodialysis - The patient with
LSC HD catheter [**2125-3-8**]. She was continued on HD as scheduled
T/Th/Sa.
.
#. Diabetes mellitus type II - She was initially continued on
her home lantus 8U Qam, 26U Qpm. The patient's glucose were low
during her hospitalization and her PM lantus dose was titrated
down. This is likely due to adhereing to a diabetic diet while
in the hospital. She was discharged on 8U qAm and 24U qPM with
follow-up with her PCP.
.
#. Hypercholesterolemia - continue statin
.
#. Constipation - continue bowel regimen
.
#. Gastritis - continue PPI
.
#. FEN: diabetic diet
.
# Prophylaxis: Subcutaneous heparin
.
# Access: L SC HD, peripheral X2
.
# Code: Full
Medications on Admission:
Active Medication list as of [**2126-2-7**]:
CITALOPRAM [CELEXA] - 20 mg Tablet - 1 Tablet(s) by mouth once a
day; take half a tablet daily for the first week
CLONAZEPAM [KLONOPIN] - 0.5 mg Tablet - half Tablet(s) by mouth
twice a day as needed for anxiety
CLONIDINE - 0.2 mg Tablet - 1 Tablet(s) by mouth twice a day
DILTIAZEM HCL [DILACOR XR] - 240 mg Capsule,Degradable Cnt
Release - 1 (One) Capsule,Degradable Cnt Release(s) by mouth
every day in the afternoon
FLONASE - 50MCG Spray, Suspension - 2 SPRAYS IN EACH NOSTRIL
EVERY DAY
KETOCONAZOLE [NIZORAL] - 2 % Shampoo - appy daily
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
NORVASC - 10MG Tablet - ONE BY MOUTH EVERY DAY
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 (One)
Capsule(s) by mouth twice a day
OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - [**1-25**]
Tablet(s) by mouth every 4 hours as needed for pain. Do not
drink, drive or operate heavy machinery while taking this
medication.
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth once a day
Medications - OTC
ACETAMINOPHEN [TYLENOL 8 HOUR] - 650 mg Tablet Sustained Release
- 2 Tablet(s) by mouth three times a day
CLOTRIMAZOLE [CLOTRIMAZOLE-7] - 1 % Cream - 1 applicator full
applied at bedtime
INSULIN NPH HUMAN RECOMB [HUMULIN N] - 100 unit/mL Suspension -
8
units subcutaneous every morning and 26 units subcutaneous every
evening
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Klonopin 0.25 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO twice a day as needed.
3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
5. Ketoconazole 2 % Shampoo Sig: One (1) Topical once a day.
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tylenol 325 mg Tablet Sig: 1300 (1300) mg PO three times a
day.
12. Clotrimazole 1 % Cream Sig: One (1) Topical at bedtime.
13. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: as
directed Subcutaneous twice a day: 8U qAM/ 26U qPM.
14. Vancomycin 1,000 mg Recon Soln Sig: at HD Intravenous at HD
for 2 weeks: 2 week course
Last day: [**2126-3-15**].
15. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for pain.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Bacteremia
ESRD on HD
Secondary:
Diabetes mellitus type II
Hypertension
Hypercholesterolemia v
Coronary artery disease
Constipation
Gastritis
Discharge Condition:
stable, afebrile, normotensive, ambulating
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of an infection in
his blood. You were treated with antibiotics and improved. You
also had an ultrasound of your heart that did not show any
infection. You will continue Vancomycin at dialysis for 2 weeks.
Please follow the medications prescribed below.
1) Please stop taking your diltiazem for now given your low
blood pressure
2) Your night-time insulin was decreased to 24U. Please continue
your AM dose as usual.
3) Please take percocet prior to your PT sessions
Please follow up with the appointments below.
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2126-3-20**] 9:40
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2126-3-25**] 2:20
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2126-3-25**]
3:30
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2126-4-23**] 2:30
Completed by:[**2126-3-11**] | {
"clinical_findings": {
"N186": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
}
],
"Z992": [
{
"icd_10_cm_code": "Z99.2",
"icd_10_cm_code_description": "Dependence on renal dialysis",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code Z99.2 is assigned for Dependence on renal dialysis. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P in conjunction with ESRD), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code N18.6 is also assigned for End stage renal disease."
}
],
"Z794": [
{
"icd_10_cm_code": "Z79.4",
"icd_10_cm_code_description": "Long-term (current) use of insulin",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "initially continued on her home lantus 8U Qam, 26U Qpm.",
"page_numbers": [
2
]
},
{
"text": "discharged on 8U qAm and 24U qPM",
"page_numbers": [
2
]
},
{
"text": "Insulin NPH Human Recomb",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "INSULIN NPH HUMAN RECOMB [HUMULIN N]",
"page_numbers": [
2
]
},
{
"evidence_text": "Insulin NPH Human Recomb",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code Z79.4 is assigned for Long-term (current) use of insulin. MEAT criteria are met as evidenced by Treatment (ongoing insulin therapy documented in A/P and discharge medications). Code E11.9 is also assigned for Type 2 diabetes mellitus."
}
],
"E7800": [
{
"icd_10_cm_code": "E78.00",
"icd_10_cm_code_description": "Pure hypercholesterolemia, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hypercholesterolemia",
"page_numbers": [
1
]
},
{
"text": "Hypercholesterolemia",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "continue statin",
"page_numbers": [
2
]
},
{
"text": "SIMVASTATIN",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "Hypercholesterolemia",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypercholesterolemia",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E78.00 is assigned for Pure hypercholesterolemia, unspecified. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P) and Treatment (continued statin therapy)."
}
],
"I2720": [
{
"icd_10_cm_code": "I27.20",
"icd_10_cm_code_description": "Pulmonary hypertension, unspecified",
"Monitoring": [],
"Evaluation": [
{
"text": "mild pulmonary artery systolic\nhypertension.",
"page_numbers": [
2
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild pulmonary artery systolic\nhypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I27.20 is assigned for Pulmonary hypertension, unspecified. MEAT criteria are met as evidenced by Evaluation (finding on TTE)."
}
],
"E1122": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
},
{
"icd_10_cm_code": "E11.9",
"icd_10_cm_code_description": "Type 2 diabetes mellitus without complications",
"Monitoring": [
{
"text": "The patient's glucose were low during her hospitalization and her PM lantus dose was titrated down.",
"page_numbers": [
2
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "Diabetes mellitus type II",
"page_numbers": [
1
]
},
{
"text": "DM",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "initially continued on her home lantus 8U Qam, 26U Qpm.",
"page_numbers": [
2
]
},
{
"text": "discharged on 8U qAm and 24U qPM",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "DM",
"page_numbers": [
1
]
},
{
"evidence_text": "Diabetes mellitus type II",
"page_numbers": [
1
]
},
{
"evidence_text": "DM",
"page_numbers": [
2
]
},
{
"evidence_text": "Diabetes mellitus type II",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.9 is assigned for Type 2 diabetes mellitus without complications. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (glucose levels monitored and insulin adjusted), and Treatment (insulin therapy). Code Z79.4 is also assigned for long-term insulin use."
}
],
"I120": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
},
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hypertension",
"page_numbers": [
1
]
},
{
"text": "HTN",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "Her BP med were intially held. After transfer to the floor she was restarted on clonidine, lisinopril, while her diltiazem was held.",
"page_numbers": [
2
]
},
{
"text": "Clonidine",
"page_numbers": [
2
]
},
{
"text": "Lisinopril",
"page_numbers": [
2
]
},
{
"text": "Amlodipine",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "HTN",
"page_numbers": [
2
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P) and Treatment (medication adjustments and listed medications)."
}
]
}
} |
Extract only the text-based justification for assigning the ICD-10-CM code to each condition. | Admission Date: [**2126-3-2**] Discharge Date: [**2126-3-6**]
Date of Birth: [**2061-11-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 9824**]
Chief Complaint:
N/V, Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt. is a 64 y/o F with a PMH of ESRD on HD, DM, and HTN
presenting after dialysis with hypotension, nausea, vomiting and
abdominal pain. The patient reports six episodes of emesis since
HD with mild epigastric pain. Per report temp to 100.5 at HD
with complaint of aches and chills. 4L fluid taken off at HD,
pre-treatment BP 96/58, post-treatment 169/92. T 97.8.
.
In the ED, initial vs were: T 102.9 BP 146/65, HR 110, RR 20 O2
92% RA. FS 215. Blood Cx sent. Emesis X1. Patient was given
Vancomycin 1gm IV, Levofloxacin 500mg IV, Flagyl 500mg IV,
Morphine 2mg IV. Her BP fell to 94/43 and she was given 1 L NS.
WBC 11.2, lactate 3.2. CXR demonstrated no evidence of
infiltrate. CT Abd/Pelvis showed no evidence of colitis. Per ED
report, beside US showed limited views but a normal caliber
aorta.
.
On arrival to the ICU, the patient was resting comfortably. She
denies lightheadedness. C/o b/l knee pain and low back pain
unchanged from her baseline. The pt. reports increased fatigue X
1 week, she has had decreased mobility since her knee surgery in
[**12-31**]. She reports that typically post-HD she has increased
enerygy, however she noted no improvement this week. Denies
fever, had chills last evening but temp was 97.8 at home. She
c/o abd pain, similar to her chronic symptoms, mostly epigastric
but burning symptoms occur in various locations with no clear
pattern or relation to meals. Denies cough, rhinorrhea. +Frontal
and occipital HA last pm. + chronic constipation, no diarrhea.
Her appetite is normal.
Past Medical History:
End stage renal disease on hemodialysis (TuThSa) - LSC HD
catheter changed [**2125-3-8**]
Hx of Back Abscess - [**2123**] treated with I&D, Vanc X 14 days
Diabetes mellitus type II
Hypertension
Hypercholesterolemia
Coronary artery disease (nonobstructive on cath in [**2119**], normal
stress in [**2124-6-23**])
Constipation
Status post total abdominal hysterectomy
Status post C-section
H. Pylori s/p treatment in [**2124-3-23**]
Gastritis
Right knee subtotal medial meniscectomy and subtotal lateral
meniscectomy with medial femoral chondroplasty [**2126-1-8**]
Social History:
Married and lives with husband, 2 children who live nearby,
former home health aid. Smokes <[**1-25**] ppd x 40 years, quit in [**3-3**]
after being hospitalized for influenza. no ETOH, no
drugs. Received the influenza and pneumococcal vaccines
Family History:
+ Premature CAD in brothers and mother. Daughter with kidney
disease. Siblings with DM, CAD, HTN, CVA, no cancer.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild TTP epigastrium, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no edema
Skin: multiple scars from prev fistula attempts on both
forearms, scar, scar - midback from prev. incision site, L SC
site no erythema surrounding catheter + skin breakdown around
adhesive dressing, no fluctuance, no drainage
Pertinent Results:
[**2126-3-2**] 01:15PM WBC-11.2*# RBC-3.97* HGB-12.7 HCT-37.9 MCV-95
MCH-32.0 MCHC-33.5 RDW-15.1
[**2126-3-2**] 01:15PM NEUTS-90.2* LYMPHS-4.6* MONOS-4.1 EOS-0.8
BASOS-0.2
[**2126-3-2**] 01:15PM PLT COUNT-203
[**2126-3-2**] 01:15PM GLUCOSE-197* UREA N-9 CREAT-2.9*# SODIUM-144
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-29 ANION GAP-22*
[**2126-3-2**] 01:15PM ALT(SGPT)-34 AST(SGOT)-31 CK(CPK)-69 ALK
PHOS-193* TOT BILI-0.5
[**2126-3-2**] 01:21PM LACTATE-3.1*
[**2126-3-2**] 04:16PM LACTATE-2.3*
[**2126-3-6**] 04:35AM BLOOD WBC-6.5 RBC-3.03* Hgb-9.3* Hct-28.8*
MCV-95 MCH-30.7 MCHC-32.3 RDW-15.5 Plt Ct-207
[**2126-3-6**] 04:35AM BLOOD Glucose-98 UreaN-16 Creat-4.6*# Na-137
K-4.2 Cl-98 HCO3-28 AnGap-15
[**2126-3-4**] 05:30AM BLOOD ALT-20 AST-15 LD(LDH)-151 AlkPhos-143*
TotBili-0.3
[**2126-3-3**] 01:35AM BLOOD Lipase-36
[**2126-3-2**] 01:15PM BLOOD CK-MB-3 cTropnT-0.05*
[**2126-3-6**] 04:35AM BLOOD Calcium-10.3* Phos-4.7*# Mg-1.8
[**2126-3-6**] 04:35AM BLOOD PTH-1368*
[**2126-3-5**] 06:35AM BLOOD Vanco-9.8*
[**2126-3-3**] 06:04PM BLOOD Vanco-12.4
[**2126-3-4**] 05:55AM BLOOD Lactate-1.2
[**2126-3-2**] 1:00 pm BLOOD CULTURE
**FINAL REPORT [**2126-3-9**]**
Blood Culture, Routine (Final [**2126-3-8**]):
PRESUMPTIVE PEPTOSTREPTOCOCCUS SPECIES.
ISOLATED FROM ONE SET ONLY.
BACILLUS SPECIES; NOT ANTHRACIS.
Sensitivity testing performed by Sensititre.
GENTAMICIN = SENSITIVE ( <=2 MCG/ML ).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BACILLUS SPECIES; NOT ANTHRACIS
|
CLINDAMYCIN----------- 0.5 S
GENTAMICIN------------ S
LEVOFLOXACIN----------<=0.25 S
VANCOMYCIN------------ <=1 S
[**2126-3-2**] 1:15 pm BLOOD CULTURE
**FINAL REPORT [**2126-3-8**]**
Blood Culture, Routine (Final [**2126-3-8**]):
BACILLUS SPECIES; NOT ANTHRACIS.
SENSITIVITIES PERFORMED ON CULTURE # 266-9949D [**2126-3-2**].
Anaerobic Bottle Gram Stain (Final [**2126-3-5**]):
GRAM POSITIVE ROD(S).
REPORTED BY PHONE TO [**Doctor First Name **] [**Doctor Last Name **]-[**Doctor Last Name **] #[**Numeric Identifier 11629**] [**2126-3-4**]
2:30PM.
CONSISTENT WITH CLOSTRIDIUM AND
BACILLUS SPECIES.
Blood Cx: [**3-2**], [**3-4**], [**3-4**], [**3-5**]: No growth
Cardiology Report ECG Study Date of [**2126-3-2**] 2:04:54 PM
Sinus rhythm. Modest inferolateral T wave changes which are
non-specific.
Compared to the previous tracing of [**2125-12-26**] there is no
significant diagnostic
change.
CXR: [**3-2**]
IMPRESSION: No significant change when compared to prior exam.
CT- abd/pelvis: [**3-2**]
IMPRESSION:
1. No evidence of colitis.
2. Unchanged angiomylipoma of right kidney. Multiple tiny
hypodensities in
the kidneys too small to accurately characterize.
3. Several small nodules in the left adrenal gland likely not
changed from
[**2122**] but incompletely characterized on the current study.
4. Atherosclerotic disease.
RUQ U/S [**3-3**]
IMPRESSION:
Unchanged cholelithiasis with no secondary findings to suggest
acute
cholecystitis.
TTE [**3-6**]
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with probable mild hypokinesis of the basal to mid
inferolateral and lateral segments (suboptimal image quality
limits interpretation). Right ventricular chamber size and free
wall motion are normal. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are moderately
thickened. No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. There is mild aortic valve stenosis (area 1.2-1.9cm2).
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No masses or vegetations are seen
on the mitral valve, but cannot be fully excluded due to
suboptimal image quality. Trivial mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] No masses or vegetations
are seen on the tricuspid valve, but cannot be fully excluded
due to suboptimal image quality. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality limits interpretation.
There is no evidence of endocarditis or abscess. Calcification
of the aortic valve and mitral annulus. Mild aortic stenosis and
trace aortic regurgitation. Probable inferolateral and lateral
hypokinesis.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
Compared with the prior study (images reviewed) of [**2122-11-6**],
the aortic valve is more calcified and there is now aortic
stenosis and trace aortic regurgitation. The degree of tricuspid
regurgitation has increased. The lateral/inferolateral
hypokinesis was similar in appearance on the prior echo.
Brief Hospital Course:
Assessment and Plan: The pt. is a 64 y/o F with a PMH of ESRD on
HD, DM, and HTN presenting after dialysis with hypotension,
nausea, vomiting and abdominal pain.
.
#. Bacteremia - The patient presented with associated symptoms
of N/V, but patient has hadh chronic abd pain and was not
clearly changed from prior. A CT A/P showed no acute process.
Her LFTs were wnl, with her alk ph mildly elevated.
Additionally, RUQ U/S did was unremarkable. Her CXR showed no
clear infiltrate. The patient was initially treated with
Vancomycin 1gm IV, Levofloxacin 500mg IV, Flagyl 500mg IV and
transferred to the ICU. The patient symptomatically improved
and her antibiotics were tailored to Vancomycin and Cipro and
transferred to the floor. The patient's blood cultures did grow
peptostreptococcus from one set and bacillus (non-anthracis)
from another set. The patient did not have evidence of dental
abcsess on exam. The patient remained afebrile and clinically
stable. She underwent TTE that did not show evidence of
endocarditis. She will continue a 2 week course of Vancomycin at
HD. The patient remained stable and no further blood cultures
were positive.
.
#. Hypotension - The pt briefly dropped BP to 90s systolic in
the ED. On review of HD flow sheets, the pt commonly has BP in
this range post-HD. She had 4L taken off at dialysis the day of
admission. The patient was given IVF and her pressures
responded. Her BP med were intially held. After transfer to the
floor she was restarted on clonidine, lisinopril, while her
diltiazem was held. She will follow-up with her PCP regarding
restarting her diltiazem.
.
#. Abd pain: The patient has a history of gastritis on EGD,
treated previously for H.pylori with f/u negative breath
testing. She was continued on her PPI [**Hospital1 **]. She continued to
have chronic abdominal pain, but it was not changed from her
baseline. CT A/P showed no acute process.
.
#. End stage renal disease on hemodialysis - The patient with
LSC HD catheter [**2125-3-8**]. She was continued on HD as scheduled
T/Th/Sa.
.
#. Diabetes mellitus type II - She was initially continued on
her home lantus 8U Qam, 26U Qpm. The patient's glucose were low
during her hospitalization and her PM lantus dose was titrated
down. This is likely due to adhereing to a diabetic diet while
in the hospital. She was discharged on 8U qAm and 24U qPM with
follow-up with her PCP.
.
#. Hypercholesterolemia - continue statin
.
#. Constipation - continue bowel regimen
.
#. Gastritis - continue PPI
.
#. FEN: diabetic diet
.
# Prophylaxis: Subcutaneous heparin
.
# Access: L SC HD, peripheral X2
.
# Code: Full
Medications on Admission:
Active Medication list as of [**2126-2-7**]:
CITALOPRAM [CELEXA] - 20 mg Tablet - 1 Tablet(s) by mouth once a
day; take half a tablet daily for the first week
CLONAZEPAM [KLONOPIN] - 0.5 mg Tablet - half Tablet(s) by mouth
twice a day as needed for anxiety
CLONIDINE - 0.2 mg Tablet - 1 Tablet(s) by mouth twice a day
DILTIAZEM HCL [DILACOR XR] - 240 mg Capsule,Degradable Cnt
Release - 1 (One) Capsule,Degradable Cnt Release(s) by mouth
every day in the afternoon
FLONASE - 50MCG Spray, Suspension - 2 SPRAYS IN EACH NOSTRIL
EVERY DAY
KETOCONAZOLE [NIZORAL] - 2 % Shampoo - appy daily
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
NORVASC - 10MG Tablet - ONE BY MOUTH EVERY DAY
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 (One)
Capsule(s) by mouth twice a day
OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - [**1-25**]
Tablet(s) by mouth every 4 hours as needed for pain. Do not
drink, drive or operate heavy machinery while taking this
medication.
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth once a day
Medications - OTC
ACETAMINOPHEN [TYLENOL 8 HOUR] - 650 mg Tablet Sustained Release
- 2 Tablet(s) by mouth three times a day
CLOTRIMAZOLE [CLOTRIMAZOLE-7] - 1 % Cream - 1 applicator full
applied at bedtime
INSULIN NPH HUMAN RECOMB [HUMULIN N] - 100 unit/mL Suspension -
8
units subcutaneous every morning and 26 units subcutaneous every
evening
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Klonopin 0.25 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO twice a day as needed.
3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
5. Ketoconazole 2 % Shampoo Sig: One (1) Topical once a day.
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tylenol 325 mg Tablet Sig: 1300 (1300) mg PO three times a
day.
12. Clotrimazole 1 % Cream Sig: One (1) Topical at bedtime.
13. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: as
directed Subcutaneous twice a day: 8U qAM/ 26U qPM.
14. Vancomycin 1,000 mg Recon Soln Sig: at HD Intravenous at HD
for 2 weeks: 2 week course
Last day: [**2126-3-15**].
15. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for pain.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Bacteremia
ESRD on HD
Secondary:
Diabetes mellitus type II
Hypertension
Hypercholesterolemia v
Coronary artery disease
Constipation
Gastritis
Discharge Condition:
stable, afebrile, normotensive, ambulating
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of an infection in
his blood. You were treated with antibiotics and improved. You
also had an ultrasound of your heart that did not show any
infection. You will continue Vancomycin at dialysis for 2 weeks.
Please follow the medications prescribed below.
1) Please stop taking your diltiazem for now given your low
blood pressure
2) Your night-time insulin was decreased to 24U. Please continue
your AM dose as usual.
3) Please take percocet prior to your PT sessions
Please follow up with the appointments below.
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2126-3-20**] 9:40
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2126-3-25**] 2:20
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2126-3-25**]
3:30
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2126-4-23**] 2:30
Completed by:[**2126-3-11**] | {
"clinical_findings": {
"N186": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
}
],
"Z992": [
{
"icd_10_cm_code": "Z99.2",
"icd_10_cm_code_description": "Dependence on renal dialysis",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code Z99.2 is assigned for Dependence on renal dialysis. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P in conjunction with ESRD), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code N18.6 is also assigned for End stage renal disease."
}
],
"Z794": [
{
"icd_10_cm_code": "Z79.4",
"icd_10_cm_code_description": "Long-term (current) use of insulin",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "initially continued on her home lantus 8U Qam, 26U Qpm.",
"page_numbers": [
2
]
},
{
"text": "discharged on 8U qAm and 24U qPM",
"page_numbers": [
2
]
},
{
"text": "Insulin NPH Human Recomb",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "INSULIN NPH HUMAN RECOMB [HUMULIN N]",
"page_numbers": [
2
]
},
{
"evidence_text": "Insulin NPH Human Recomb",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code Z79.4 is assigned for Long-term (current) use of insulin. MEAT criteria are met as evidenced by Treatment (ongoing insulin therapy documented in A/P and discharge medications). Code E11.9 is also assigned for Type 2 diabetes mellitus."
}
],
"E7800": [
{
"icd_10_cm_code": "E78.00",
"icd_10_cm_code_description": "Pure hypercholesterolemia, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hypercholesterolemia",
"page_numbers": [
1
]
},
{
"text": "Hypercholesterolemia",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "continue statin",
"page_numbers": [
2
]
},
{
"text": "SIMVASTATIN",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "Hypercholesterolemia",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypercholesterolemia",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E78.00 is assigned for Pure hypercholesterolemia, unspecified. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P) and Treatment (continued statin therapy)."
}
],
"I2720": [
{
"icd_10_cm_code": "I27.20",
"icd_10_cm_code_description": "Pulmonary hypertension, unspecified",
"Monitoring": [],
"Evaluation": [
{
"text": "mild pulmonary artery systolic\nhypertension.",
"page_numbers": [
2
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild pulmonary artery systolic\nhypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I27.20 is assigned for Pulmonary hypertension, unspecified. MEAT criteria are met as evidenced by Evaluation (finding on TTE)."
}
],
"E1122": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
},
{
"icd_10_cm_code": "E11.9",
"icd_10_cm_code_description": "Type 2 diabetes mellitus without complications",
"Monitoring": [
{
"text": "The patient's glucose were low during her hospitalization and her PM lantus dose was titrated down.",
"page_numbers": [
2
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "Diabetes mellitus type II",
"page_numbers": [
1
]
},
{
"text": "DM",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "initially continued on her home lantus 8U Qam, 26U Qpm.",
"page_numbers": [
2
]
},
{
"text": "discharged on 8U qAm and 24U qPM",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "DM",
"page_numbers": [
1
]
},
{
"evidence_text": "Diabetes mellitus type II",
"page_numbers": [
1
]
},
{
"evidence_text": "DM",
"page_numbers": [
2
]
},
{
"evidence_text": "Diabetes mellitus type II",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.9 is assigned for Type 2 diabetes mellitus without complications. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (glucose levels monitored and insulin adjusted), and Treatment (insulin therapy). Code Z79.4 is also assigned for long-term insulin use."
}
],
"I120": [
{
"icd_10_cm_code": "N18.6",
"icd_10_cm_code_description": "End stage renal disease",
"Monitoring": [
{
"text": "She was continued on HD as scheduled T/Th/Sa.",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "LSC HD\ncatheter changed [**2125-3-8**]",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"text": "ESRD on\nHD",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "ESRD on HD",
"page_numbers": [
1
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
1
]
},
{
"evidence_text": "ESRD on\nHD",
"page_numbers": [
2
]
},
{
"evidence_text": "End stage renal disease on hemodialysis",
"page_numbers": [
2
]
},
{
"evidence_text": "ESRD on HD",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code N18.6 is assigned for End stage renal disease. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P), Monitoring (continued HD schedule), and Evaluation (HD catheter status). Code Z99.2 is also assigned for dependence on renal dialysis."
},
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "Hypertension",
"page_numbers": [
1
]
},
{
"text": "HTN",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "Her BP med were intially held. After transfer to the floor she was restarted on clonidine, lisinopril, while her diltiazem was held.",
"page_numbers": [
2
]
},
{
"text": "Clonidine",
"page_numbers": [
2
]
},
{
"text": "Lisinopril",
"page_numbers": [
2
]
},
{
"text": "Amlodipine",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "HTN",
"page_numbers": [
2
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. MEAT criteria are met as evidenced by Assessment (listed in PMH and A/P) and Treatment (medication adjustments and listed medications)."
}
]
}
} |
Extract the ICD-10-CM code assigned to each clinical condition mentioned in the discharge summary. | Admission Date: [**2139-6-23**] Discharge Date: [**2139-6-24**]
Date of Birth: [**2086-1-10**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
L sided weakness and IPH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Name14 (STitle) 5229**] is a 53 yo Right-handed male patient with h/o HIV,
HCV, recent septic arthritis on Cefazoline IV and Lovenox
prophylaxis who was transferred from [**Hospital3 4107**] due to L
hemiparesis.
Last night, at 3AM, patient reports having L weakness when he
got up to use the bathroom( able to go to bathroom normally at
2AM). Patient states that he could not move his L arm and leg at
all and needed assistance from his father to go back to bed. He
was unable to sit or stand unsupported. He was aware of his
deficits, but did not want to go to the ED, because of a bad
experience recently at [**Hospital1 2025**]. Later in the morning, patient was
found to have L hemiplegia by visiting nurse and transferred to
[**Hospital3 4107**] and [**Hospital1 18**] due to intracranial hemorrhage on
CT-scan. At OSH, patient was normotensive, afebrile. He was
given
Ativan 2 mg per unclear reason, possibly anxiety, as patient
denies any convulsions. The patient was alert and oriented
during
ambulance ride, but became more drowsy, unclear about the timing
in relation to receiving Ativan.
Patient was evaluated by neurology team at 10AM. Appears to
be
drowsy but arousable and cooperative. Reports that he cannot
move
his L extremities at all, which is stable from onset at 3am.
ROS:
Positive for chills, sweats, chronic numbness of toes, R knee
pain
Negative fevers, headache, diplopia, vision loss, tingling, loss
bowel/bladder control, chest pain, SOB, N/V.
Past Medical History:
1. HIV on Abacavir, Truvada and Raltegravir. Diagnosed [**2125**], he
reports seeing PCP monthly and recent CD4 count 600s.
2. HCV on Ribavarin and Peginterferon
3. Recent septic arthritis s/p arthroscopy [**2139-5-15**]. Currently on
Cefazolin IV 2000mg q8hr. Per patient, medication was started
since discharge from [**Hospital1 2025**] on [**2139-5-18**] and the last dose was last
night(Need medical record from [**Hospital1 2025**]) On Lovenox prophylaxis.
Social History:
Living at home with his father, denies current
cig smoking or alcohol in 23 years, but prior history of heroin
use.
Family History:
knee surgery in his father
Physical Exam:
Physical Exam on Admission:
VS: T: 97.5 HR 104 BPP 152/77 RR 17 02 96/RA
General: Middle age patient, Lying in bed, looks drowsy but
arousable
HEENT: no jaundice, no nuchal rigidity, OP clear, no carotid
bruits
Lung: clear, no crackles, no wheezing
Heart: Systolic murmur at USB
Ab: soft, NT/ND
Ext: R knee with sutures in place, warm to touch compared to
left
side, no erythema or drainage. L toes bandaged.
Neurologic Examination:
Mental status:
Level of Arousal: Awake. Drowsy throughout exam but easily
arousable to voice. Oriented to [**2139-6-5**] (thought date was 13
or 14?), knows hospital but not which one. Knows President
current and prior.
Attentiveness: refused to tell months backward but able to tell
days of week forward.
Language: fluent, moderate dysarthria, normal comprehension,
repetition, naming. No paraphasic errors.
Memory: very poor registration/recall (could not register more
than [**1-5**] words at a time), remote memory intact.
Praxis: No apraxia/dyspraxia
Calculation: incorrect (said 4 quarters in $1.25)
Neglect: no neglect
Cranial Nerves:
I: Not tested.
II: Pupils symmetric at 3 to 2 mm, equal, round and reactive to
light bilaterally, defect in VF at Left inferior
quadrant(examined with both eyes open)
III, IV, VI: EOMI, normal primary position, no ptosis
V, VII: Facial sensation intact, L upper and lower facial
weakness
VIII: Hearing intact to voice.
IX, X: Palatal elevation normal
[**Doctor First Name 81**]: Unable to move Lt trapezius and sternocleidomastoid, R side
full
XII: Tongue midline and no fasciculation
MOTOR:
Lying in bed, no tremor or abnormal movement
Tone and Bulk: Flaccid tone LUE but incrased tone LLE
D B T WE FE FF IP Q H AT G/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**] TF
R 5 5 5 5 5 5 5 - - 5 5 5 5
L 0 throughout
**Unable to examine R knee due to pain from septic arthritis
Reflexes:
B T Br Pa Ac
R 2 2 2 2 2
L 2 2 2 - 2
**Unable to examine R knee due to pain from septic arthritis
Toes downgoing on right, upgoing on left
Sensation:
Examined with difficulty because patient was drowsy
-decreased light touch L arm and leg, intact on face V1-3
-vibration intact
-Proprioception intact
-pain by pinprick - decrease sensation of LUE but intact both
LEs, intact abdominal/chest area
-no extinction to DSS
Coordination and Cerebellar Function: no dysmetria on FNF on the
right, intact finger to crease tapping on the right
Gait: not assessed
Physical Exam on Discharge:
Expired
Pertinent Results:
[**2139-6-23**] 10:22AM PT-16.2* PTT-33.6 INR(PT)-1.5*
[**2139-6-23**] 10:22AM PLT COUNT-106*
[**2139-6-23**] 10:22AM NEUTS-85.9* LYMPHS-10.6* MONOS-3.0 EOS-0.3
BASOS-0.3
[**2139-6-23**] 10:22AM WBC-13.1* RBC-3.16* HGB-10.4* HCT-29.5*
MCV-93 MCH-32.9* MCHC-35.2* RDW-14.5
[**2139-6-23**] 10:22AM CALCIUM-7.6* PHOSPHATE-2.6* MAGNESIUM-2.1
[**2139-6-23**] 10:22AM estGFR-Using this
[**2139-6-23**] 10:22AM GLUCOSE-108* UREA N-12 CREAT-0.5 SODIUM-133
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-25 ANION GAP-11
[**2139-6-23**] 12:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2139-6-23**] 12:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2139-6-23**] 12:30PM URINE UHOLD-HOLD
[**2139-6-23**] 12:30PM URINE HOURS-RANDOM
[**2139-6-23**] 11:46PM OSMOLAL-270*
[**2139-6-23**] 11:46PM SODIUM-131* POTASSIUM-3.9 CHLORIDE-100
[**2139-6-23**] 11:51PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2139-6-23**] 11:51PM URINE OSMOLAL-578
[**2139-6-23**] 11:51PM URINE HOURS-RANDOM SODIUM-75 POTASSIUM-55
CHLORIDE-75
Noncontrast head CT [**2139-6-23**]:
IMPRESSION:
1. 3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital
intraparenchymal hemorrhages with surrounding edema similar to
reference study.
2. Partial effacement of frontal [**Doctor Last Name 534**] and atrium of right
lateral ventricle with slight asymmetric enlargement of the
right temporal [**Doctor Last Name 534**], similar to prior.
Transthoracic echo [**2139-6-23**]:
IMPRESSION: no vegetations seen
MRI/A head and neck [**2139-6-23**]:
IMPRESSION:
1. Large intraparenchymal hemorrhage in the right centrum
semiovale with mass effect and midline shift. A small
hemorrhage is seen in the right posterior temporal region.
Restricted diffusion is seen surrounding the large
intraparenchymal hemorrhage. Increased signal on post-contrast
images could be suspicious for extravasation. The differential
diagnosis includes cerebritis with secondary involvement of the
vascular structures or a mycotic aneurysm.
2. Leptomeningeal enhancement suggests meningitis.
3. Soft tissue abscess identified in the posterior neck, soft
tissue
structures measuring 17-mm mm indicating metastatic abscess.
4. MRA of the neck is unremarkable.
5. MRA of the head is limited by motion, but no major vascular
occlusion
seen. The findings were discussed with Dr. [**Last Name (STitle) **] at the time
of
interpretation of this study on [**2139-6-24**] at 11:30 a.m.
CXR [**2139-6-24**]:
FINDINGS: In comparison with the study of [**6-23**], the tip of the
endotracheal tube measures approximately 3.8 cm above the
carina. Nasogastric tube extends into the stomach where it
crosses the lower margin of the image.
Continued enlargement of the cardiac silhouette with engorgement
of indistinct pulmonary vessels, consistent with elevated
pulmonary venous pressure. The apparent widening of the
mediastinum is not as well appreciated on the current study.
Bibasilar atelectatic changes are again seen.
Brief Hospital Course:
53 yo RHM with HIV, HCV, recent diagnosis of septic arthritis
who presented to an outside hospital with dense L hemiplegia and
dysarthria. Head CT demonstrated approx 3.2x3.4 cm R
frontoparietal IPH as well as small R occipital IPH. He was
transferred to [**Hospital1 18**] for further management. Repeat CT in ED
here appeared stable. He was admitted to the neuro ICU for close
monitoring and further investigation. There was concern for
septic emboli as a potential etiology of his IPH, in the setting
of septic arthritis and a systolic murmur. Echocardiogram showed
no evidence of vegetations. He was continued on cefazolin for
antibiotic coverage given his recent history of septic
arthritis. Lovenox and all antiplatelets/anticoagulants were
held. BP was monitored closely with a goal SBP of <160.
He underwent an MRI in the evening of [**6-23**], which demonstrated
enlargement of R frontoparietal hemorrhage with surrounding
edema and ~10mm midline shift. On exam he was less responsive
(although had also received ativan) with minimal withdrawal to
noxious on L. He was started on mannitol and neurosurgery was
[**Name (NI) 653**], who reviewed the images and recommended craniotomy.
His family initially consented to the procedure but after
further discussion regarding his likely poor prognosis with
dense L hemiparesis they declined and he was made CMO. He was
started on a morphine gtt and passed away at 2:06pm on [**2139-6-24**].
Family were at the bedside and declined autopsy.
Medications on Admission:
1. Paxil 40 mg tid
2. Abacavir 300 mg tid, Truvada 1 tab daily, Raltegravir 400 mg
[**Hospital1 **] for HARRT
3. Cefazolin 2 g IV tid
4. Ribavarin 200 mg tid and Peginterferon 180 mcg weekly for HCV
5. Lovenox 30 mg sc daily plan cont 12 days after discharge on
[**2139-5-18**]
6. Oxycodone 5 mg prn q4hr
7. Reglan 10 mg prn qid
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Intraparenchymal hemorrhage
Septic arthritis
Discharge Condition:
Expired
Discharge Instructions:
Mr. [**Known lastname 5230**] was admitted to [**Hospital1 69**]
on [**2139-6-23**] after experiencing sudden onset left sided weakness
at home. He was found to have two areas of bleeding in the right
side of his brain. He was admitted to the neuro ICU. An MRI was
performed which showed worsening of the bleeding with
compression of his brain. The option of surgery was discussed
with his family, but given the severity of the bleeding and his
poor prognosis the decision was made to forgo surgical
intervention and pursue comfort measures only. He was started on
a morphine drip and passed away peacefully at 2:06pm on [**2139-6-24**].
Family declined autopsy.
Followup Instructions:
n/a
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
| {
"clinical_findings": {
"I616": [
{
"icd_10_cm_code": "I61.6",
"icd_10_cm_code_description": "Multiple localized intraparenchymal hemorrhage",
"Monitoring": [
{
"text": "Repeat CT in ED here appeared stable.",
"page_numbers": [
1
]
},
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema and ~10mm midline shift",
"page_numbers": [
1
]
},
{
"text": "BP was monitored closely with a goal SBP of <160.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital\nintraparenchymal hemorrhages",
"page_numbers": [
1
]
},
{
"text": "Large intraparenchymal hemorrhage in the right centrum\nsemiovale",
"page_numbers": [
1
]
},
{
"text": "A small\nhemorrhage is seen in the right posterior temporal region",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Intraparenchymal hemorrhage",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "He was started on mannitol",
"page_numbers": [
1
]
},
{
"text": "recommended craniotomy. His family initially consented to the procedure but after\nfurther discussion regarding his likely poor prognosis with\ndense L hemiparesis they declined and he was made CMO.",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "intracranial hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital\nintraparenchymal hemorrhages",
"page_numbers": [
1
]
},
{
"evidence_text": "Large intraparenchymal hemorrhage in the right centrum\nsemiovale",
"page_numbers": [
1
]
},
{
"evidence_text": "small\nhemorrhage is seen in the right posterior temporal region",
"page_numbers": [
1
]
},
{
"evidence_text": "R\nfrontoparietal IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "R occipital IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "enlargement of R frontoparietal hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "Intraparenchymal hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "two areas of bleeding in the right\nside of his brain",
"page_numbers": [
1
]
},
{
"evidence_text": "worsening of the bleeding",
"page_numbers": [
1
]
}
],
"justification": "The entity 'IPH' and related terms like 'intracranial hemorrhage' and specific locations are documented in the Chief Complaint, HPI, imaging reports (CT, MRI), Brief Hospital Course, and Discharge Diagnosis. MEAT criteria are met via Evaluation (imaging findings), Monitoring (stability/enlargement on repeat imaging, BP monitoring), Assessment (listed as Discharge Diagnosis), and Treatment (Mannitol, discussion/decision regarding craniotomy and CMO). The code I61.6 is assigned for multiple localized intraparenchymal hemorrhages based on the documentation of hemorrhages in multiple distinct locations (frontal, occipital, centrum semiovale, temporal)."
}
],
"B20": [
{
"icd_10_cm_code": "B20",
"icd_10_cm_code_description": "Human immunodeficiency virus [HIV] disease",
"Monitoring": [
{
"text": "he\nreports seeing PCP monthly and recent CD4 count 600s.",
"page_numbers": [
1
]
}
],
"Evaluation": null,
"Assessment": null,
"Treatment": [
{
"text": "on Abacavir, Truvada and Raltegravir.",
"page_numbers": [
1
]
},
{
"text": "Abacavir 300 mg tid, Truvada 1 tab daily, Raltegravir 400 mg\n[**Hospital1 **] for HARRT",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HIV",
"page_numbers": [
1
]
},
{
"evidence_text": "HIV",
"page_numbers": [
1
]
},
{
"evidence_text": "HIV",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HIV' is documented in the HPI, PMH, and Brief Hospital Course. MEAT criteria are met via Monitoring (PCP visits, CD4 count) and Treatment (HARRT medications). The code B20 is assigned for Human immunodeficiency virus [HIV] disease."
}
],
"B182": [
{
"icd_10_cm_code": "B18.2",
"icd_10_cm_code_description": "Chronic viral hepatitis C",
"Monitoring": null,
"Evaluation": null,
"Assessment": null,
"Treatment": [
{
"text": "on Ribavarin and Peginterferon",
"page_numbers": [
1
]
},
{
"text": "Ribavarin 200 mg tid and Peginterferon 180 mcg weekly for HCV",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HCV",
"page_numbers": [
1
]
},
{
"evidence_text": "HCV",
"page_numbers": [
1
]
},
{
"evidence_text": "HCV",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HCV' is documented in the HPI, PMH, Brief Hospital Course, and Medications on Admission. MEAT criteria are met via Treatment (Ribavarin and Peginterferon). The code B18.2 is assigned for Chronic viral hepatitis C."
}
],
"G8194": [
{
"icd_10_cm_code": "G81.94",
"icd_10_cm_code_description": "Unspecified hemiplegia and hemiparesis affecting left dominant side",
"Monitoring": [
{
"text": "Reports that he cannot\nmove\nhis L extremities at all, which is stable from onset at 3am.",
"page_numbers": [
1
]
},
{
"text": "dense L hemiplegia",
"page_numbers": [
1
]
},
{
"text": "dense L hemiparesis",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "L upper and lower facial\nweakness",
"page_numbers": [
1
]
},
{
"text": "Unable to move Lt trapezius and sternocleidomastoid",
"page_numbers": [
1
]
},
{
"text": "Flaccid tone LUE",
"page_numbers": [
1
]
},
{
"text": "incrased tone LLE",
"page_numbers": [
1
]
},
{
"text": "L 0 throughout",
"page_numbers": [
1
]
},
{
"text": "upgoing on left",
"page_numbers": [
1
]
},
{
"text": "decreased light touch L arm and leg",
"page_numbers": [
1
]
},
{
"text": "decrease sensation of LUE",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "L hemiparesis",
"page_numbers": [
1
]
},
{
"evidence_text": "L hemiplegia",
"page_numbers": [
1
]
},
{
"evidence_text": "dense L hemiplegia",
"page_numbers": [
1
]
},
{
"evidence_text": "dense L hemiparesis",
"page_numbers": [
1
]
}
],
"justification": "The entities 'L hemiparesis' and 'L hemiplegia' are documented in the HPI and Brief Hospital Course. MEAT criteria are met via Monitoring (patient report of inability to move extremities, stability, description as 'dense') and Evaluation (detailed physical/neurologic exam findings including weakness, tone, motor strength, reflexes, sensation). The code G81.94 is assigned for unspecified hemiplegia and hemiparesis affecting the left side. Although the patient is right-handed, the documentation does not specify dominance in relation to the hemiplegia, so unspecified dominance is appropriate."
}
],
"G936": [
{
"icd_10_cm_code": "G93.6",
"icd_10_cm_code_description": "Cerebral edema",
"Monitoring": [
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "surrounding edema similar to\nreference study.",
"page_numbers": [
1
]
},
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "surrounding edema",
"page_numbers": [
1
]
},
{
"evidence_text": "surrounding\nedema",
"page_numbers": [
1
]
}
],
"justification": "The entity 'surrounding edema' (referring to cerebral edema) is documented in the CT and MRI reports and Brief Hospital Course. MEAT criteria are met via Evaluation (imaging findings) and Monitoring (enlargement noted on MRI). The code G93.6 is assigned for Cerebral edema."
}
],
"G935": [
{
"icd_10_cm_code": "G93.5",
"icd_10_cm_code_description": "Compression of brain",
"Monitoring": [
{
"text": "~10mm midline shift",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "mass effect and midline shift.",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "mass effect",
"page_numbers": [
1
]
},
{
"evidence_text": "midline shift",
"page_numbers": [
1
]
},
{
"evidence_text": "~10mm midline shift",
"page_numbers": [
1
]
},
{
"evidence_text": "compression of his brain",
"page_numbers": [
1
]
}
],
"justification": "The entities 'mass effect' and 'midline shift' are documented in the MRI report and Brief Hospital Course, indicating compression of the brain. MEAT criteria are met via Evaluation (MRI findings) and Monitoring (measurement of midline shift). The code G93.5 is assigned for Compression of brain, which covers both mass effect and midline shift."
}
],
"I76": [
{
"icd_10_cm_code": "I76",
"icd_10_cm_code_description": "Septic embolism",
"Monitoring": null,
"Evaluation": [
{
"text": "Echocardiogram showed\nno evidence of vegetations.",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "There was concern for\nseptic emboli as a potential etiology of his IPH, in the setting\nof septic arthritis and a systolic murmur.",
"page_numbers": [
1
]
}
],
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "septic emboli",
"page_numbers": [
1
]
}
],
"justification": "The entity 'septic emboli' is documented in the Brief Hospital Course as a potential etiology for the IPH. MEAT criteria are met via Assessment (considered as a potential cause) and Evaluation (echocardiogram performed to rule out endocarditis as a source). The code I76 is assigned for Septic embolism."
}
],
"I2729": [
{
"icd_10_cm_code": "I27.29",
"icd_10_cm_code_description": "Other secondary pulmonary hypertension",
"Monitoring": null,
"Evaluation": [
{
"text": "engorgement\nof indistinct pulmonary vessels, consistent with elevated\npulmonary venous pressure",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "elevated\npulmonary venous pressure",
"page_numbers": [
1
]
}
],
"justification": "The entity 'elevated pulmonary venous pressure' is documented in the CXR report. MEAT criteria are met via Evaluation (CXR finding). The code I27.29 is assigned for Other secondary pulmonary hypertension, as elevated pulmonary venous pressure is a cause of secondary pulmonary hypertension."
}
]
}
} |
Extract the ICD-10-CM code description for each clinical condition mentioned in the discharge summary. | Admission Date: [**2139-6-23**] Discharge Date: [**2139-6-24**]
Date of Birth: [**2086-1-10**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
L sided weakness and IPH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Name14 (STitle) 5229**] is a 53 yo Right-handed male patient with h/o HIV,
HCV, recent septic arthritis on Cefazoline IV and Lovenox
prophylaxis who was transferred from [**Hospital3 4107**] due to L
hemiparesis.
Last night, at 3AM, patient reports having L weakness when he
got up to use the bathroom( able to go to bathroom normally at
2AM). Patient states that he could not move his L arm and leg at
all and needed assistance from his father to go back to bed. He
was unable to sit or stand unsupported. He was aware of his
deficits, but did not want to go to the ED, because of a bad
experience recently at [**Hospital1 2025**]. Later in the morning, patient was
found to have L hemiplegia by visiting nurse and transferred to
[**Hospital3 4107**] and [**Hospital1 18**] due to intracranial hemorrhage on
CT-scan. At OSH, patient was normotensive, afebrile. He was
given
Ativan 2 mg per unclear reason, possibly anxiety, as patient
denies any convulsions. The patient was alert and oriented
during
ambulance ride, but became more drowsy, unclear about the timing
in relation to receiving Ativan.
Patient was evaluated by neurology team at 10AM. Appears to
be
drowsy but arousable and cooperative. Reports that he cannot
move
his L extremities at all, which is stable from onset at 3am.
ROS:
Positive for chills, sweats, chronic numbness of toes, R knee
pain
Negative fevers, headache, diplopia, vision loss, tingling, loss
bowel/bladder control, chest pain, SOB, N/V.
Past Medical History:
1. HIV on Abacavir, Truvada and Raltegravir. Diagnosed [**2125**], he
reports seeing PCP monthly and recent CD4 count 600s.
2. HCV on Ribavarin and Peginterferon
3. Recent septic arthritis s/p arthroscopy [**2139-5-15**]. Currently on
Cefazolin IV 2000mg q8hr. Per patient, medication was started
since discharge from [**Hospital1 2025**] on [**2139-5-18**] and the last dose was last
night(Need medical record from [**Hospital1 2025**]) On Lovenox prophylaxis.
Social History:
Living at home with his father, denies current
cig smoking or alcohol in 23 years, but prior history of heroin
use.
Family History:
knee surgery in his father
Physical Exam:
Physical Exam on Admission:
VS: T: 97.5 HR 104 BPP 152/77 RR 17 02 96/RA
General: Middle age patient, Lying in bed, looks drowsy but
arousable
HEENT: no jaundice, no nuchal rigidity, OP clear, no carotid
bruits
Lung: clear, no crackles, no wheezing
Heart: Systolic murmur at USB
Ab: soft, NT/ND
Ext: R knee with sutures in place, warm to touch compared to
left
side, no erythema or drainage. L toes bandaged.
Neurologic Examination:
Mental status:
Level of Arousal: Awake. Drowsy throughout exam but easily
arousable to voice. Oriented to [**2139-6-5**] (thought date was 13
or 14?), knows hospital but not which one. Knows President
current and prior.
Attentiveness: refused to tell months backward but able to tell
days of week forward.
Language: fluent, moderate dysarthria, normal comprehension,
repetition, naming. No paraphasic errors.
Memory: very poor registration/recall (could not register more
than [**1-5**] words at a time), remote memory intact.
Praxis: No apraxia/dyspraxia
Calculation: incorrect (said 4 quarters in $1.25)
Neglect: no neglect
Cranial Nerves:
I: Not tested.
II: Pupils symmetric at 3 to 2 mm, equal, round and reactive to
light bilaterally, defect in VF at Left inferior
quadrant(examined with both eyes open)
III, IV, VI: EOMI, normal primary position, no ptosis
V, VII: Facial sensation intact, L upper and lower facial
weakness
VIII: Hearing intact to voice.
IX, X: Palatal elevation normal
[**Doctor First Name 81**]: Unable to move Lt trapezius and sternocleidomastoid, R side
full
XII: Tongue midline and no fasciculation
MOTOR:
Lying in bed, no tremor or abnormal movement
Tone and Bulk: Flaccid tone LUE but incrased tone LLE
D B T WE FE FF IP Q H AT G/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**] TF
R 5 5 5 5 5 5 5 - - 5 5 5 5
L 0 throughout
**Unable to examine R knee due to pain from septic arthritis
Reflexes:
B T Br Pa Ac
R 2 2 2 2 2
L 2 2 2 - 2
**Unable to examine R knee due to pain from septic arthritis
Toes downgoing on right, upgoing on left
Sensation:
Examined with difficulty because patient was drowsy
-decreased light touch L arm and leg, intact on face V1-3
-vibration intact
-Proprioception intact
-pain by pinprick - decrease sensation of LUE but intact both
LEs, intact abdominal/chest area
-no extinction to DSS
Coordination and Cerebellar Function: no dysmetria on FNF on the
right, intact finger to crease tapping on the right
Gait: not assessed
Physical Exam on Discharge:
Expired
Pertinent Results:
[**2139-6-23**] 10:22AM PT-16.2* PTT-33.6 INR(PT)-1.5*
[**2139-6-23**] 10:22AM PLT COUNT-106*
[**2139-6-23**] 10:22AM NEUTS-85.9* LYMPHS-10.6* MONOS-3.0 EOS-0.3
BASOS-0.3
[**2139-6-23**] 10:22AM WBC-13.1* RBC-3.16* HGB-10.4* HCT-29.5*
MCV-93 MCH-32.9* MCHC-35.2* RDW-14.5
[**2139-6-23**] 10:22AM CALCIUM-7.6* PHOSPHATE-2.6* MAGNESIUM-2.1
[**2139-6-23**] 10:22AM estGFR-Using this
[**2139-6-23**] 10:22AM GLUCOSE-108* UREA N-12 CREAT-0.5 SODIUM-133
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-25 ANION GAP-11
[**2139-6-23**] 12:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2139-6-23**] 12:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2139-6-23**] 12:30PM URINE UHOLD-HOLD
[**2139-6-23**] 12:30PM URINE HOURS-RANDOM
[**2139-6-23**] 11:46PM OSMOLAL-270*
[**2139-6-23**] 11:46PM SODIUM-131* POTASSIUM-3.9 CHLORIDE-100
[**2139-6-23**] 11:51PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2139-6-23**] 11:51PM URINE OSMOLAL-578
[**2139-6-23**] 11:51PM URINE HOURS-RANDOM SODIUM-75 POTASSIUM-55
CHLORIDE-75
Noncontrast head CT [**2139-6-23**]:
IMPRESSION:
1. 3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital
intraparenchymal hemorrhages with surrounding edema similar to
reference study.
2. Partial effacement of frontal [**Doctor Last Name 534**] and atrium of right
lateral ventricle with slight asymmetric enlargement of the
right temporal [**Doctor Last Name 534**], similar to prior.
Transthoracic echo [**2139-6-23**]:
IMPRESSION: no vegetations seen
MRI/A head and neck [**2139-6-23**]:
IMPRESSION:
1. Large intraparenchymal hemorrhage in the right centrum
semiovale with mass effect and midline shift. A small
hemorrhage is seen in the right posterior temporal region.
Restricted diffusion is seen surrounding the large
intraparenchymal hemorrhage. Increased signal on post-contrast
images could be suspicious for extravasation. The differential
diagnosis includes cerebritis with secondary involvement of the
vascular structures or a mycotic aneurysm.
2. Leptomeningeal enhancement suggests meningitis.
3. Soft tissue abscess identified in the posterior neck, soft
tissue
structures measuring 17-mm mm indicating metastatic abscess.
4. MRA of the neck is unremarkable.
5. MRA of the head is limited by motion, but no major vascular
occlusion
seen. The findings were discussed with Dr. [**Last Name (STitle) **] at the time
of
interpretation of this study on [**2139-6-24**] at 11:30 a.m.
CXR [**2139-6-24**]:
FINDINGS: In comparison with the study of [**6-23**], the tip of the
endotracheal tube measures approximately 3.8 cm above the
carina. Nasogastric tube extends into the stomach where it
crosses the lower margin of the image.
Continued enlargement of the cardiac silhouette with engorgement
of indistinct pulmonary vessels, consistent with elevated
pulmonary venous pressure. The apparent widening of the
mediastinum is not as well appreciated on the current study.
Bibasilar atelectatic changes are again seen.
Brief Hospital Course:
53 yo RHM with HIV, HCV, recent diagnosis of septic arthritis
who presented to an outside hospital with dense L hemiplegia and
dysarthria. Head CT demonstrated approx 3.2x3.4 cm R
frontoparietal IPH as well as small R occipital IPH. He was
transferred to [**Hospital1 18**] for further management. Repeat CT in ED
here appeared stable. He was admitted to the neuro ICU for close
monitoring and further investigation. There was concern for
septic emboli as a potential etiology of his IPH, in the setting
of septic arthritis and a systolic murmur. Echocardiogram showed
no evidence of vegetations. He was continued on cefazolin for
antibiotic coverage given his recent history of septic
arthritis. Lovenox and all antiplatelets/anticoagulants were
held. BP was monitored closely with a goal SBP of <160.
He underwent an MRI in the evening of [**6-23**], which demonstrated
enlargement of R frontoparietal hemorrhage with surrounding
edema and ~10mm midline shift. On exam he was less responsive
(although had also received ativan) with minimal withdrawal to
noxious on L. He was started on mannitol and neurosurgery was
[**Name (NI) 653**], who reviewed the images and recommended craniotomy.
His family initially consented to the procedure but after
further discussion regarding his likely poor prognosis with
dense L hemiparesis they declined and he was made CMO. He was
started on a morphine gtt and passed away at 2:06pm on [**2139-6-24**].
Family were at the bedside and declined autopsy.
Medications on Admission:
1. Paxil 40 mg tid
2. Abacavir 300 mg tid, Truvada 1 tab daily, Raltegravir 400 mg
[**Hospital1 **] for HARRT
3. Cefazolin 2 g IV tid
4. Ribavarin 200 mg tid and Peginterferon 180 mcg weekly for HCV
5. Lovenox 30 mg sc daily plan cont 12 days after discharge on
[**2139-5-18**]
6. Oxycodone 5 mg prn q4hr
7. Reglan 10 mg prn qid
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Intraparenchymal hemorrhage
Septic arthritis
Discharge Condition:
Expired
Discharge Instructions:
Mr. [**Known lastname 5230**] was admitted to [**Hospital1 69**]
on [**2139-6-23**] after experiencing sudden onset left sided weakness
at home. He was found to have two areas of bleeding in the right
side of his brain. He was admitted to the neuro ICU. An MRI was
performed which showed worsening of the bleeding with
compression of his brain. The option of surgery was discussed
with his family, but given the severity of the bleeding and his
poor prognosis the decision was made to forgo surgical
intervention and pursue comfort measures only. He was started on
a morphine drip and passed away peacefully at 2:06pm on [**2139-6-24**].
Family declined autopsy.
Followup Instructions:
n/a
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
| {
"clinical_findings": {
"I616": [
{
"icd_10_cm_code": "I61.6",
"icd_10_cm_code_description": "Multiple localized intraparenchymal hemorrhage",
"Monitoring": [
{
"text": "Repeat CT in ED here appeared stable.",
"page_numbers": [
1
]
},
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema and ~10mm midline shift",
"page_numbers": [
1
]
},
{
"text": "BP was monitored closely with a goal SBP of <160.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital\nintraparenchymal hemorrhages",
"page_numbers": [
1
]
},
{
"text": "Large intraparenchymal hemorrhage in the right centrum\nsemiovale",
"page_numbers": [
1
]
},
{
"text": "A small\nhemorrhage is seen in the right posterior temporal region",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Intraparenchymal hemorrhage",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "He was started on mannitol",
"page_numbers": [
1
]
},
{
"text": "recommended craniotomy. His family initially consented to the procedure but after\nfurther discussion regarding his likely poor prognosis with\ndense L hemiparesis they declined and he was made CMO.",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "intracranial hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital\nintraparenchymal hemorrhages",
"page_numbers": [
1
]
},
{
"evidence_text": "Large intraparenchymal hemorrhage in the right centrum\nsemiovale",
"page_numbers": [
1
]
},
{
"evidence_text": "small\nhemorrhage is seen in the right posterior temporal region",
"page_numbers": [
1
]
},
{
"evidence_text": "R\nfrontoparietal IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "R occipital IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "enlargement of R frontoparietal hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "Intraparenchymal hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "two areas of bleeding in the right\nside of his brain",
"page_numbers": [
1
]
},
{
"evidence_text": "worsening of the bleeding",
"page_numbers": [
1
]
}
],
"justification": "The entity 'IPH' and related terms like 'intracranial hemorrhage' and specific locations are documented in the Chief Complaint, HPI, imaging reports (CT, MRI), Brief Hospital Course, and Discharge Diagnosis. MEAT criteria are met via Evaluation (imaging findings), Monitoring (stability/enlargement on repeat imaging, BP monitoring), Assessment (listed as Discharge Diagnosis), and Treatment (Mannitol, discussion/decision regarding craniotomy and CMO). The code I61.6 is assigned for multiple localized intraparenchymal hemorrhages based on the documentation of hemorrhages in multiple distinct locations (frontal, occipital, centrum semiovale, temporal)."
}
],
"B20": [
{
"icd_10_cm_code": "B20",
"icd_10_cm_code_description": "Human immunodeficiency virus [HIV] disease",
"Monitoring": [
{
"text": "he\nreports seeing PCP monthly and recent CD4 count 600s.",
"page_numbers": [
1
]
}
],
"Evaluation": null,
"Assessment": null,
"Treatment": [
{
"text": "on Abacavir, Truvada and Raltegravir.",
"page_numbers": [
1
]
},
{
"text": "Abacavir 300 mg tid, Truvada 1 tab daily, Raltegravir 400 mg\n[**Hospital1 **] for HARRT",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HIV",
"page_numbers": [
1
]
},
{
"evidence_text": "HIV",
"page_numbers": [
1
]
},
{
"evidence_text": "HIV",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HIV' is documented in the HPI, PMH, and Brief Hospital Course. MEAT criteria are met via Monitoring (PCP visits, CD4 count) and Treatment (HARRT medications). The code B20 is assigned for Human immunodeficiency virus [HIV] disease."
}
],
"B182": [
{
"icd_10_cm_code": "B18.2",
"icd_10_cm_code_description": "Chronic viral hepatitis C",
"Monitoring": null,
"Evaluation": null,
"Assessment": null,
"Treatment": [
{
"text": "on Ribavarin and Peginterferon",
"page_numbers": [
1
]
},
{
"text": "Ribavarin 200 mg tid and Peginterferon 180 mcg weekly for HCV",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HCV",
"page_numbers": [
1
]
},
{
"evidence_text": "HCV",
"page_numbers": [
1
]
},
{
"evidence_text": "HCV",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HCV' is documented in the HPI, PMH, Brief Hospital Course, and Medications on Admission. MEAT criteria are met via Treatment (Ribavarin and Peginterferon). The code B18.2 is assigned for Chronic viral hepatitis C."
}
],
"G8194": [
{
"icd_10_cm_code": "G81.94",
"icd_10_cm_code_description": "Unspecified hemiplegia and hemiparesis affecting left dominant side",
"Monitoring": [
{
"text": "Reports that he cannot\nmove\nhis L extremities at all, which is stable from onset at 3am.",
"page_numbers": [
1
]
},
{
"text": "dense L hemiplegia",
"page_numbers": [
1
]
},
{
"text": "dense L hemiparesis",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "L upper and lower facial\nweakness",
"page_numbers": [
1
]
},
{
"text": "Unable to move Lt trapezius and sternocleidomastoid",
"page_numbers": [
1
]
},
{
"text": "Flaccid tone LUE",
"page_numbers": [
1
]
},
{
"text": "incrased tone LLE",
"page_numbers": [
1
]
},
{
"text": "L 0 throughout",
"page_numbers": [
1
]
},
{
"text": "upgoing on left",
"page_numbers": [
1
]
},
{
"text": "decreased light touch L arm and leg",
"page_numbers": [
1
]
},
{
"text": "decrease sensation of LUE",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "L hemiparesis",
"page_numbers": [
1
]
},
{
"evidence_text": "L hemiplegia",
"page_numbers": [
1
]
},
{
"evidence_text": "dense L hemiplegia",
"page_numbers": [
1
]
},
{
"evidence_text": "dense L hemiparesis",
"page_numbers": [
1
]
}
],
"justification": "The entities 'L hemiparesis' and 'L hemiplegia' are documented in the HPI and Brief Hospital Course. MEAT criteria are met via Monitoring (patient report of inability to move extremities, stability, description as 'dense') and Evaluation (detailed physical/neurologic exam findings including weakness, tone, motor strength, reflexes, sensation). The code G81.94 is assigned for unspecified hemiplegia and hemiparesis affecting the left side. Although the patient is right-handed, the documentation does not specify dominance in relation to the hemiplegia, so unspecified dominance is appropriate."
}
],
"G936": [
{
"icd_10_cm_code": "G93.6",
"icd_10_cm_code_description": "Cerebral edema",
"Monitoring": [
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "surrounding edema similar to\nreference study.",
"page_numbers": [
1
]
},
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "surrounding edema",
"page_numbers": [
1
]
},
{
"evidence_text": "surrounding\nedema",
"page_numbers": [
1
]
}
],
"justification": "The entity 'surrounding edema' (referring to cerebral edema) is documented in the CT and MRI reports and Brief Hospital Course. MEAT criteria are met via Evaluation (imaging findings) and Monitoring (enlargement noted on MRI). The code G93.6 is assigned for Cerebral edema."
}
],
"G935": [
{
"icd_10_cm_code": "G93.5",
"icd_10_cm_code_description": "Compression of brain",
"Monitoring": [
{
"text": "~10mm midline shift",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "mass effect and midline shift.",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "mass effect",
"page_numbers": [
1
]
},
{
"evidence_text": "midline shift",
"page_numbers": [
1
]
},
{
"evidence_text": "~10mm midline shift",
"page_numbers": [
1
]
},
{
"evidence_text": "compression of his brain",
"page_numbers": [
1
]
}
],
"justification": "The entities 'mass effect' and 'midline shift' are documented in the MRI report and Brief Hospital Course, indicating compression of the brain. MEAT criteria are met via Evaluation (MRI findings) and Monitoring (measurement of midline shift). The code G93.5 is assigned for Compression of brain, which covers both mass effect and midline shift."
}
],
"I76": [
{
"icd_10_cm_code": "I76",
"icd_10_cm_code_description": "Septic embolism",
"Monitoring": null,
"Evaluation": [
{
"text": "Echocardiogram showed\nno evidence of vegetations.",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "There was concern for\nseptic emboli as a potential etiology of his IPH, in the setting\nof septic arthritis and a systolic murmur.",
"page_numbers": [
1
]
}
],
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "septic emboli",
"page_numbers": [
1
]
}
],
"justification": "The entity 'septic emboli' is documented in the Brief Hospital Course as a potential etiology for the IPH. MEAT criteria are met via Assessment (considered as a potential cause) and Evaluation (echocardiogram performed to rule out endocarditis as a source). The code I76 is assigned for Septic embolism."
}
],
"I2729": [
{
"icd_10_cm_code": "I27.29",
"icd_10_cm_code_description": "Other secondary pulmonary hypertension",
"Monitoring": null,
"Evaluation": [
{
"text": "engorgement\nof indistinct pulmonary vessels, consistent with elevated\npulmonary venous pressure",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "elevated\npulmonary venous pressure",
"page_numbers": [
1
]
}
],
"justification": "The entity 'elevated pulmonary venous pressure' is documented in the CXR report. MEAT criteria are met via Evaluation (CXR finding). The code I27.29 is assigned for Other secondary pulmonary hypertension, as elevated pulmonary venous pressure is a cause of secondary pulmonary hypertension."
}
]
}
} |
Extract only the monitoring information related to each clinical condition, such as vital signs, labs, or telemetry data. | Admission Date: [**2139-6-23**] Discharge Date: [**2139-6-24**]
Date of Birth: [**2086-1-10**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
L sided weakness and IPH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Name14 (STitle) 5229**] is a 53 yo Right-handed male patient with h/o HIV,
HCV, recent septic arthritis on Cefazoline IV and Lovenox
prophylaxis who was transferred from [**Hospital3 4107**] due to L
hemiparesis.
Last night, at 3AM, patient reports having L weakness when he
got up to use the bathroom( able to go to bathroom normally at
2AM). Patient states that he could not move his L arm and leg at
all and needed assistance from his father to go back to bed. He
was unable to sit or stand unsupported. He was aware of his
deficits, but did not want to go to the ED, because of a bad
experience recently at [**Hospital1 2025**]. Later in the morning, patient was
found to have L hemiplegia by visiting nurse and transferred to
[**Hospital3 4107**] and [**Hospital1 18**] due to intracranial hemorrhage on
CT-scan. At OSH, patient was normotensive, afebrile. He was
given
Ativan 2 mg per unclear reason, possibly anxiety, as patient
denies any convulsions. The patient was alert and oriented
during
ambulance ride, but became more drowsy, unclear about the timing
in relation to receiving Ativan.
Patient was evaluated by neurology team at 10AM. Appears to
be
drowsy but arousable and cooperative. Reports that he cannot
move
his L extremities at all, which is stable from onset at 3am.
ROS:
Positive for chills, sweats, chronic numbness of toes, R knee
pain
Negative fevers, headache, diplopia, vision loss, tingling, loss
bowel/bladder control, chest pain, SOB, N/V.
Past Medical History:
1. HIV on Abacavir, Truvada and Raltegravir. Diagnosed [**2125**], he
reports seeing PCP monthly and recent CD4 count 600s.
2. HCV on Ribavarin and Peginterferon
3. Recent septic arthritis s/p arthroscopy [**2139-5-15**]. Currently on
Cefazolin IV 2000mg q8hr. Per patient, medication was started
since discharge from [**Hospital1 2025**] on [**2139-5-18**] and the last dose was last
night(Need medical record from [**Hospital1 2025**]) On Lovenox prophylaxis.
Social History:
Living at home with his father, denies current
cig smoking or alcohol in 23 years, but prior history of heroin
use.
Family History:
knee surgery in his father
Physical Exam:
Physical Exam on Admission:
VS: T: 97.5 HR 104 BPP 152/77 RR 17 02 96/RA
General: Middle age patient, Lying in bed, looks drowsy but
arousable
HEENT: no jaundice, no nuchal rigidity, OP clear, no carotid
bruits
Lung: clear, no crackles, no wheezing
Heart: Systolic murmur at USB
Ab: soft, NT/ND
Ext: R knee with sutures in place, warm to touch compared to
left
side, no erythema or drainage. L toes bandaged.
Neurologic Examination:
Mental status:
Level of Arousal: Awake. Drowsy throughout exam but easily
arousable to voice. Oriented to [**2139-6-5**] (thought date was 13
or 14?), knows hospital but not which one. Knows President
current and prior.
Attentiveness: refused to tell months backward but able to tell
days of week forward.
Language: fluent, moderate dysarthria, normal comprehension,
repetition, naming. No paraphasic errors.
Memory: very poor registration/recall (could not register more
than [**1-5**] words at a time), remote memory intact.
Praxis: No apraxia/dyspraxia
Calculation: incorrect (said 4 quarters in $1.25)
Neglect: no neglect
Cranial Nerves:
I: Not tested.
II: Pupils symmetric at 3 to 2 mm, equal, round and reactive to
light bilaterally, defect in VF at Left inferior
quadrant(examined with both eyes open)
III, IV, VI: EOMI, normal primary position, no ptosis
V, VII: Facial sensation intact, L upper and lower facial
weakness
VIII: Hearing intact to voice.
IX, X: Palatal elevation normal
[**Doctor First Name 81**]: Unable to move Lt trapezius and sternocleidomastoid, R side
full
XII: Tongue midline and no fasciculation
MOTOR:
Lying in bed, no tremor or abnormal movement
Tone and Bulk: Flaccid tone LUE but incrased tone LLE
D B T WE FE FF IP Q H AT G/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**] TF
R 5 5 5 5 5 5 5 - - 5 5 5 5
L 0 throughout
**Unable to examine R knee due to pain from septic arthritis
Reflexes:
B T Br Pa Ac
R 2 2 2 2 2
L 2 2 2 - 2
**Unable to examine R knee due to pain from septic arthritis
Toes downgoing on right, upgoing on left
Sensation:
Examined with difficulty because patient was drowsy
-decreased light touch L arm and leg, intact on face V1-3
-vibration intact
-Proprioception intact
-pain by pinprick - decrease sensation of LUE but intact both
LEs, intact abdominal/chest area
-no extinction to DSS
Coordination and Cerebellar Function: no dysmetria on FNF on the
right, intact finger to crease tapping on the right
Gait: not assessed
Physical Exam on Discharge:
Expired
Pertinent Results:
[**2139-6-23**] 10:22AM PT-16.2* PTT-33.6 INR(PT)-1.5*
[**2139-6-23**] 10:22AM PLT COUNT-106*
[**2139-6-23**] 10:22AM NEUTS-85.9* LYMPHS-10.6* MONOS-3.0 EOS-0.3
BASOS-0.3
[**2139-6-23**] 10:22AM WBC-13.1* RBC-3.16* HGB-10.4* HCT-29.5*
MCV-93 MCH-32.9* MCHC-35.2* RDW-14.5
[**2139-6-23**] 10:22AM CALCIUM-7.6* PHOSPHATE-2.6* MAGNESIUM-2.1
[**2139-6-23**] 10:22AM estGFR-Using this
[**2139-6-23**] 10:22AM GLUCOSE-108* UREA N-12 CREAT-0.5 SODIUM-133
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-25 ANION GAP-11
[**2139-6-23**] 12:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2139-6-23**] 12:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2139-6-23**] 12:30PM URINE UHOLD-HOLD
[**2139-6-23**] 12:30PM URINE HOURS-RANDOM
[**2139-6-23**] 11:46PM OSMOLAL-270*
[**2139-6-23**] 11:46PM SODIUM-131* POTASSIUM-3.9 CHLORIDE-100
[**2139-6-23**] 11:51PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2139-6-23**] 11:51PM URINE OSMOLAL-578
[**2139-6-23**] 11:51PM URINE HOURS-RANDOM SODIUM-75 POTASSIUM-55
CHLORIDE-75
Noncontrast head CT [**2139-6-23**]:
IMPRESSION:
1. 3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital
intraparenchymal hemorrhages with surrounding edema similar to
reference study.
2. Partial effacement of frontal [**Doctor Last Name 534**] and atrium of right
lateral ventricle with slight asymmetric enlargement of the
right temporal [**Doctor Last Name 534**], similar to prior.
Transthoracic echo [**2139-6-23**]:
IMPRESSION: no vegetations seen
MRI/A head and neck [**2139-6-23**]:
IMPRESSION:
1. Large intraparenchymal hemorrhage in the right centrum
semiovale with mass effect and midline shift. A small
hemorrhage is seen in the right posterior temporal region.
Restricted diffusion is seen surrounding the large
intraparenchymal hemorrhage. Increased signal on post-contrast
images could be suspicious for extravasation. The differential
diagnosis includes cerebritis with secondary involvement of the
vascular structures or a mycotic aneurysm.
2. Leptomeningeal enhancement suggests meningitis.
3. Soft tissue abscess identified in the posterior neck, soft
tissue
structures measuring 17-mm mm indicating metastatic abscess.
4. MRA of the neck is unremarkable.
5. MRA of the head is limited by motion, but no major vascular
occlusion
seen. The findings were discussed with Dr. [**Last Name (STitle) **] at the time
of
interpretation of this study on [**2139-6-24**] at 11:30 a.m.
CXR [**2139-6-24**]:
FINDINGS: In comparison with the study of [**6-23**], the tip of the
endotracheal tube measures approximately 3.8 cm above the
carina. Nasogastric tube extends into the stomach where it
crosses the lower margin of the image.
Continued enlargement of the cardiac silhouette with engorgement
of indistinct pulmonary vessels, consistent with elevated
pulmonary venous pressure. The apparent widening of the
mediastinum is not as well appreciated on the current study.
Bibasilar atelectatic changes are again seen.
Brief Hospital Course:
53 yo RHM with HIV, HCV, recent diagnosis of septic arthritis
who presented to an outside hospital with dense L hemiplegia and
dysarthria. Head CT demonstrated approx 3.2x3.4 cm R
frontoparietal IPH as well as small R occipital IPH. He was
transferred to [**Hospital1 18**] for further management. Repeat CT in ED
here appeared stable. He was admitted to the neuro ICU for close
monitoring and further investigation. There was concern for
septic emboli as a potential etiology of his IPH, in the setting
of septic arthritis and a systolic murmur. Echocardiogram showed
no evidence of vegetations. He was continued on cefazolin for
antibiotic coverage given his recent history of septic
arthritis. Lovenox and all antiplatelets/anticoagulants were
held. BP was monitored closely with a goal SBP of <160.
He underwent an MRI in the evening of [**6-23**], which demonstrated
enlargement of R frontoparietal hemorrhage with surrounding
edema and ~10mm midline shift. On exam he was less responsive
(although had also received ativan) with minimal withdrawal to
noxious on L. He was started on mannitol and neurosurgery was
[**Name (NI) 653**], who reviewed the images and recommended craniotomy.
His family initially consented to the procedure but after
further discussion regarding his likely poor prognosis with
dense L hemiparesis they declined and he was made CMO. He was
started on a morphine gtt and passed away at 2:06pm on [**2139-6-24**].
Family were at the bedside and declined autopsy.
Medications on Admission:
1. Paxil 40 mg tid
2. Abacavir 300 mg tid, Truvada 1 tab daily, Raltegravir 400 mg
[**Hospital1 **] for HARRT
3. Cefazolin 2 g IV tid
4. Ribavarin 200 mg tid and Peginterferon 180 mcg weekly for HCV
5. Lovenox 30 mg sc daily plan cont 12 days after discharge on
[**2139-5-18**]
6. Oxycodone 5 mg prn q4hr
7. Reglan 10 mg prn qid
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Intraparenchymal hemorrhage
Septic arthritis
Discharge Condition:
Expired
Discharge Instructions:
Mr. [**Known lastname 5230**] was admitted to [**Hospital1 69**]
on [**2139-6-23**] after experiencing sudden onset left sided weakness
at home. He was found to have two areas of bleeding in the right
side of his brain. He was admitted to the neuro ICU. An MRI was
performed which showed worsening of the bleeding with
compression of his brain. The option of surgery was discussed
with his family, but given the severity of the bleeding and his
poor prognosis the decision was made to forgo surgical
intervention and pursue comfort measures only. He was started on
a morphine drip and passed away peacefully at 2:06pm on [**2139-6-24**].
Family declined autopsy.
Followup Instructions:
n/a
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
| {
"clinical_findings": {
"I616": [
{
"icd_10_cm_code": "I61.6",
"icd_10_cm_code_description": "Multiple localized intraparenchymal hemorrhage",
"Monitoring": [
{
"text": "Repeat CT in ED here appeared stable.",
"page_numbers": [
1
]
},
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema and ~10mm midline shift",
"page_numbers": [
1
]
},
{
"text": "BP was monitored closely with a goal SBP of <160.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital\nintraparenchymal hemorrhages",
"page_numbers": [
1
]
},
{
"text": "Large intraparenchymal hemorrhage in the right centrum\nsemiovale",
"page_numbers": [
1
]
},
{
"text": "A small\nhemorrhage is seen in the right posterior temporal region",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Intraparenchymal hemorrhage",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "He was started on mannitol",
"page_numbers": [
1
]
},
{
"text": "recommended craniotomy. His family initially consented to the procedure but after\nfurther discussion regarding his likely poor prognosis with\ndense L hemiparesis they declined and he was made CMO.",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "intracranial hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital\nintraparenchymal hemorrhages",
"page_numbers": [
1
]
},
{
"evidence_text": "Large intraparenchymal hemorrhage in the right centrum\nsemiovale",
"page_numbers": [
1
]
},
{
"evidence_text": "small\nhemorrhage is seen in the right posterior temporal region",
"page_numbers": [
1
]
},
{
"evidence_text": "R\nfrontoparietal IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "R occipital IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "enlargement of R frontoparietal hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "Intraparenchymal hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "two areas of bleeding in the right\nside of his brain",
"page_numbers": [
1
]
},
{
"evidence_text": "worsening of the bleeding",
"page_numbers": [
1
]
}
],
"justification": "The entity 'IPH' and related terms like 'intracranial hemorrhage' and specific locations are documented in the Chief Complaint, HPI, imaging reports (CT, MRI), Brief Hospital Course, and Discharge Diagnosis. MEAT criteria are met via Evaluation (imaging findings), Monitoring (stability/enlargement on repeat imaging, BP monitoring), Assessment (listed as Discharge Diagnosis), and Treatment (Mannitol, discussion/decision regarding craniotomy and CMO). The code I61.6 is assigned for multiple localized intraparenchymal hemorrhages based on the documentation of hemorrhages in multiple distinct locations (frontal, occipital, centrum semiovale, temporal)."
}
],
"B20": [
{
"icd_10_cm_code": "B20",
"icd_10_cm_code_description": "Human immunodeficiency virus [HIV] disease",
"Monitoring": [
{
"text": "he\nreports seeing PCP monthly and recent CD4 count 600s.",
"page_numbers": [
1
]
}
],
"Evaluation": null,
"Assessment": null,
"Treatment": [
{
"text": "on Abacavir, Truvada and Raltegravir.",
"page_numbers": [
1
]
},
{
"text": "Abacavir 300 mg tid, Truvada 1 tab daily, Raltegravir 400 mg\n[**Hospital1 **] for HARRT",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HIV",
"page_numbers": [
1
]
},
{
"evidence_text": "HIV",
"page_numbers": [
1
]
},
{
"evidence_text": "HIV",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HIV' is documented in the HPI, PMH, and Brief Hospital Course. MEAT criteria are met via Monitoring (PCP visits, CD4 count) and Treatment (HARRT medications). The code B20 is assigned for Human immunodeficiency virus [HIV] disease."
}
],
"B182": [
{
"icd_10_cm_code": "B18.2",
"icd_10_cm_code_description": "Chronic viral hepatitis C",
"Monitoring": null,
"Evaluation": null,
"Assessment": null,
"Treatment": [
{
"text": "on Ribavarin and Peginterferon",
"page_numbers": [
1
]
},
{
"text": "Ribavarin 200 mg tid and Peginterferon 180 mcg weekly for HCV",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HCV",
"page_numbers": [
1
]
},
{
"evidence_text": "HCV",
"page_numbers": [
1
]
},
{
"evidence_text": "HCV",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HCV' is documented in the HPI, PMH, Brief Hospital Course, and Medications on Admission. MEAT criteria are met via Treatment (Ribavarin and Peginterferon). The code B18.2 is assigned for Chronic viral hepatitis C."
}
],
"G8194": [
{
"icd_10_cm_code": "G81.94",
"icd_10_cm_code_description": "Unspecified hemiplegia and hemiparesis affecting left dominant side",
"Monitoring": [
{
"text": "Reports that he cannot\nmove\nhis L extremities at all, which is stable from onset at 3am.",
"page_numbers": [
1
]
},
{
"text": "dense L hemiplegia",
"page_numbers": [
1
]
},
{
"text": "dense L hemiparesis",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "L upper and lower facial\nweakness",
"page_numbers": [
1
]
},
{
"text": "Unable to move Lt trapezius and sternocleidomastoid",
"page_numbers": [
1
]
},
{
"text": "Flaccid tone LUE",
"page_numbers": [
1
]
},
{
"text": "incrased tone LLE",
"page_numbers": [
1
]
},
{
"text": "L 0 throughout",
"page_numbers": [
1
]
},
{
"text": "upgoing on left",
"page_numbers": [
1
]
},
{
"text": "decreased light touch L arm and leg",
"page_numbers": [
1
]
},
{
"text": "decrease sensation of LUE",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "L hemiparesis",
"page_numbers": [
1
]
},
{
"evidence_text": "L hemiplegia",
"page_numbers": [
1
]
},
{
"evidence_text": "dense L hemiplegia",
"page_numbers": [
1
]
},
{
"evidence_text": "dense L hemiparesis",
"page_numbers": [
1
]
}
],
"justification": "The entities 'L hemiparesis' and 'L hemiplegia' are documented in the HPI and Brief Hospital Course. MEAT criteria are met via Monitoring (patient report of inability to move extremities, stability, description as 'dense') and Evaluation (detailed physical/neurologic exam findings including weakness, tone, motor strength, reflexes, sensation). The code G81.94 is assigned for unspecified hemiplegia and hemiparesis affecting the left side. Although the patient is right-handed, the documentation does not specify dominance in relation to the hemiplegia, so unspecified dominance is appropriate."
}
],
"G936": [
{
"icd_10_cm_code": "G93.6",
"icd_10_cm_code_description": "Cerebral edema",
"Monitoring": [
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "surrounding edema similar to\nreference study.",
"page_numbers": [
1
]
},
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "surrounding edema",
"page_numbers": [
1
]
},
{
"evidence_text": "surrounding\nedema",
"page_numbers": [
1
]
}
],
"justification": "The entity 'surrounding edema' (referring to cerebral edema) is documented in the CT and MRI reports and Brief Hospital Course. MEAT criteria are met via Evaluation (imaging findings) and Monitoring (enlargement noted on MRI). The code G93.6 is assigned for Cerebral edema."
}
],
"G935": [
{
"icd_10_cm_code": "G93.5",
"icd_10_cm_code_description": "Compression of brain",
"Monitoring": [
{
"text": "~10mm midline shift",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "mass effect and midline shift.",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "mass effect",
"page_numbers": [
1
]
},
{
"evidence_text": "midline shift",
"page_numbers": [
1
]
},
{
"evidence_text": "~10mm midline shift",
"page_numbers": [
1
]
},
{
"evidence_text": "compression of his brain",
"page_numbers": [
1
]
}
],
"justification": "The entities 'mass effect' and 'midline shift' are documented in the MRI report and Brief Hospital Course, indicating compression of the brain. MEAT criteria are met via Evaluation (MRI findings) and Monitoring (measurement of midline shift). The code G93.5 is assigned for Compression of brain, which covers both mass effect and midline shift."
}
],
"I76": [
{
"icd_10_cm_code": "I76",
"icd_10_cm_code_description": "Septic embolism",
"Monitoring": null,
"Evaluation": [
{
"text": "Echocardiogram showed\nno evidence of vegetations.",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "There was concern for\nseptic emboli as a potential etiology of his IPH, in the setting\nof septic arthritis and a systolic murmur.",
"page_numbers": [
1
]
}
],
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "septic emboli",
"page_numbers": [
1
]
}
],
"justification": "The entity 'septic emboli' is documented in the Brief Hospital Course as a potential etiology for the IPH. MEAT criteria are met via Assessment (considered as a potential cause) and Evaluation (echocardiogram performed to rule out endocarditis as a source). The code I76 is assigned for Septic embolism."
}
],
"I2729": [
{
"icd_10_cm_code": "I27.29",
"icd_10_cm_code_description": "Other secondary pulmonary hypertension",
"Monitoring": null,
"Evaluation": [
{
"text": "engorgement\nof indistinct pulmonary vessels, consistent with elevated\npulmonary venous pressure",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "elevated\npulmonary venous pressure",
"page_numbers": [
1
]
}
],
"justification": "The entity 'elevated pulmonary venous pressure' is documented in the CXR report. MEAT criteria are met via Evaluation (CXR finding). The code I27.29 is assigned for Other secondary pulmonary hypertension, as elevated pulmonary venous pressure is a cause of secondary pulmonary hypertension."
}
]
}
} |
Extract only the clinical evaluation methods used for each condition, such as imaging, physical examination, or biopsy. | Admission Date: [**2139-6-23**] Discharge Date: [**2139-6-24**]
Date of Birth: [**2086-1-10**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
L sided weakness and IPH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Name14 (STitle) 5229**] is a 53 yo Right-handed male patient with h/o HIV,
HCV, recent septic arthritis on Cefazoline IV and Lovenox
prophylaxis who was transferred from [**Hospital3 4107**] due to L
hemiparesis.
Last night, at 3AM, patient reports having L weakness when he
got up to use the bathroom( able to go to bathroom normally at
2AM). Patient states that he could not move his L arm and leg at
all and needed assistance from his father to go back to bed. He
was unable to sit or stand unsupported. He was aware of his
deficits, but did not want to go to the ED, because of a bad
experience recently at [**Hospital1 2025**]. Later in the morning, patient was
found to have L hemiplegia by visiting nurse and transferred to
[**Hospital3 4107**] and [**Hospital1 18**] due to intracranial hemorrhage on
CT-scan. At OSH, patient was normotensive, afebrile. He was
given
Ativan 2 mg per unclear reason, possibly anxiety, as patient
denies any convulsions. The patient was alert and oriented
during
ambulance ride, but became more drowsy, unclear about the timing
in relation to receiving Ativan.
Patient was evaluated by neurology team at 10AM. Appears to
be
drowsy but arousable and cooperative. Reports that he cannot
move
his L extremities at all, which is stable from onset at 3am.
ROS:
Positive for chills, sweats, chronic numbness of toes, R knee
pain
Negative fevers, headache, diplopia, vision loss, tingling, loss
bowel/bladder control, chest pain, SOB, N/V.
Past Medical History:
1. HIV on Abacavir, Truvada and Raltegravir. Diagnosed [**2125**], he
reports seeing PCP monthly and recent CD4 count 600s.
2. HCV on Ribavarin and Peginterferon
3. Recent septic arthritis s/p arthroscopy [**2139-5-15**]. Currently on
Cefazolin IV 2000mg q8hr. Per patient, medication was started
since discharge from [**Hospital1 2025**] on [**2139-5-18**] and the last dose was last
night(Need medical record from [**Hospital1 2025**]) On Lovenox prophylaxis.
Social History:
Living at home with his father, denies current
cig smoking or alcohol in 23 years, but prior history of heroin
use.
Family History:
knee surgery in his father
Physical Exam:
Physical Exam on Admission:
VS: T: 97.5 HR 104 BPP 152/77 RR 17 02 96/RA
General: Middle age patient, Lying in bed, looks drowsy but
arousable
HEENT: no jaundice, no nuchal rigidity, OP clear, no carotid
bruits
Lung: clear, no crackles, no wheezing
Heart: Systolic murmur at USB
Ab: soft, NT/ND
Ext: R knee with sutures in place, warm to touch compared to
left
side, no erythema or drainage. L toes bandaged.
Neurologic Examination:
Mental status:
Level of Arousal: Awake. Drowsy throughout exam but easily
arousable to voice. Oriented to [**2139-6-5**] (thought date was 13
or 14?), knows hospital but not which one. Knows President
current and prior.
Attentiveness: refused to tell months backward but able to tell
days of week forward.
Language: fluent, moderate dysarthria, normal comprehension,
repetition, naming. No paraphasic errors.
Memory: very poor registration/recall (could not register more
than [**1-5**] words at a time), remote memory intact.
Praxis: No apraxia/dyspraxia
Calculation: incorrect (said 4 quarters in $1.25)
Neglect: no neglect
Cranial Nerves:
I: Not tested.
II: Pupils symmetric at 3 to 2 mm, equal, round and reactive to
light bilaterally, defect in VF at Left inferior
quadrant(examined with both eyes open)
III, IV, VI: EOMI, normal primary position, no ptosis
V, VII: Facial sensation intact, L upper and lower facial
weakness
VIII: Hearing intact to voice.
IX, X: Palatal elevation normal
[**Doctor First Name 81**]: Unable to move Lt trapezius and sternocleidomastoid, R side
full
XII: Tongue midline and no fasciculation
MOTOR:
Lying in bed, no tremor or abnormal movement
Tone and Bulk: Flaccid tone LUE but incrased tone LLE
D B T WE FE FF IP Q H AT G/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**] TF
R 5 5 5 5 5 5 5 - - 5 5 5 5
L 0 throughout
**Unable to examine R knee due to pain from septic arthritis
Reflexes:
B T Br Pa Ac
R 2 2 2 2 2
L 2 2 2 - 2
**Unable to examine R knee due to pain from septic arthritis
Toes downgoing on right, upgoing on left
Sensation:
Examined with difficulty because patient was drowsy
-decreased light touch L arm and leg, intact on face V1-3
-vibration intact
-Proprioception intact
-pain by pinprick - decrease sensation of LUE but intact both
LEs, intact abdominal/chest area
-no extinction to DSS
Coordination and Cerebellar Function: no dysmetria on FNF on the
right, intact finger to crease tapping on the right
Gait: not assessed
Physical Exam on Discharge:
Expired
Pertinent Results:
[**2139-6-23**] 10:22AM PT-16.2* PTT-33.6 INR(PT)-1.5*
[**2139-6-23**] 10:22AM PLT COUNT-106*
[**2139-6-23**] 10:22AM NEUTS-85.9* LYMPHS-10.6* MONOS-3.0 EOS-0.3
BASOS-0.3
[**2139-6-23**] 10:22AM WBC-13.1* RBC-3.16* HGB-10.4* HCT-29.5*
MCV-93 MCH-32.9* MCHC-35.2* RDW-14.5
[**2139-6-23**] 10:22AM CALCIUM-7.6* PHOSPHATE-2.6* MAGNESIUM-2.1
[**2139-6-23**] 10:22AM estGFR-Using this
[**2139-6-23**] 10:22AM GLUCOSE-108* UREA N-12 CREAT-0.5 SODIUM-133
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-25 ANION GAP-11
[**2139-6-23**] 12:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2139-6-23**] 12:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2139-6-23**] 12:30PM URINE UHOLD-HOLD
[**2139-6-23**] 12:30PM URINE HOURS-RANDOM
[**2139-6-23**] 11:46PM OSMOLAL-270*
[**2139-6-23**] 11:46PM SODIUM-131* POTASSIUM-3.9 CHLORIDE-100
[**2139-6-23**] 11:51PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2139-6-23**] 11:51PM URINE OSMOLAL-578
[**2139-6-23**] 11:51PM URINE HOURS-RANDOM SODIUM-75 POTASSIUM-55
CHLORIDE-75
Noncontrast head CT [**2139-6-23**]:
IMPRESSION:
1. 3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital
intraparenchymal hemorrhages with surrounding edema similar to
reference study.
2. Partial effacement of frontal [**Doctor Last Name 534**] and atrium of right
lateral ventricle with slight asymmetric enlargement of the
right temporal [**Doctor Last Name 534**], similar to prior.
Transthoracic echo [**2139-6-23**]:
IMPRESSION: no vegetations seen
MRI/A head and neck [**2139-6-23**]:
IMPRESSION:
1. Large intraparenchymal hemorrhage in the right centrum
semiovale with mass effect and midline shift. A small
hemorrhage is seen in the right posterior temporal region.
Restricted diffusion is seen surrounding the large
intraparenchymal hemorrhage. Increased signal on post-contrast
images could be suspicious for extravasation. The differential
diagnosis includes cerebritis with secondary involvement of the
vascular structures or a mycotic aneurysm.
2. Leptomeningeal enhancement suggests meningitis.
3. Soft tissue abscess identified in the posterior neck, soft
tissue
structures measuring 17-mm mm indicating metastatic abscess.
4. MRA of the neck is unremarkable.
5. MRA of the head is limited by motion, but no major vascular
occlusion
seen. The findings were discussed with Dr. [**Last Name (STitle) **] at the time
of
interpretation of this study on [**2139-6-24**] at 11:30 a.m.
CXR [**2139-6-24**]:
FINDINGS: In comparison with the study of [**6-23**], the tip of the
endotracheal tube measures approximately 3.8 cm above the
carina. Nasogastric tube extends into the stomach where it
crosses the lower margin of the image.
Continued enlargement of the cardiac silhouette with engorgement
of indistinct pulmonary vessels, consistent with elevated
pulmonary venous pressure. The apparent widening of the
mediastinum is not as well appreciated on the current study.
Bibasilar atelectatic changes are again seen.
Brief Hospital Course:
53 yo RHM with HIV, HCV, recent diagnosis of septic arthritis
who presented to an outside hospital with dense L hemiplegia and
dysarthria. Head CT demonstrated approx 3.2x3.4 cm R
frontoparietal IPH as well as small R occipital IPH. He was
transferred to [**Hospital1 18**] for further management. Repeat CT in ED
here appeared stable. He was admitted to the neuro ICU for close
monitoring and further investigation. There was concern for
septic emboli as a potential etiology of his IPH, in the setting
of septic arthritis and a systolic murmur. Echocardiogram showed
no evidence of vegetations. He was continued on cefazolin for
antibiotic coverage given his recent history of septic
arthritis. Lovenox and all antiplatelets/anticoagulants were
held. BP was monitored closely with a goal SBP of <160.
He underwent an MRI in the evening of [**6-23**], which demonstrated
enlargement of R frontoparietal hemorrhage with surrounding
edema and ~10mm midline shift. On exam he was less responsive
(although had also received ativan) with minimal withdrawal to
noxious on L. He was started on mannitol and neurosurgery was
[**Name (NI) 653**], who reviewed the images and recommended craniotomy.
His family initially consented to the procedure but after
further discussion regarding his likely poor prognosis with
dense L hemiparesis they declined and he was made CMO. He was
started on a morphine gtt and passed away at 2:06pm on [**2139-6-24**].
Family were at the bedside and declined autopsy.
Medications on Admission:
1. Paxil 40 mg tid
2. Abacavir 300 mg tid, Truvada 1 tab daily, Raltegravir 400 mg
[**Hospital1 **] for HARRT
3. Cefazolin 2 g IV tid
4. Ribavarin 200 mg tid and Peginterferon 180 mcg weekly for HCV
5. Lovenox 30 mg sc daily plan cont 12 days after discharge on
[**2139-5-18**]
6. Oxycodone 5 mg prn q4hr
7. Reglan 10 mg prn qid
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Intraparenchymal hemorrhage
Septic arthritis
Discharge Condition:
Expired
Discharge Instructions:
Mr. [**Known lastname 5230**] was admitted to [**Hospital1 69**]
on [**2139-6-23**] after experiencing sudden onset left sided weakness
at home. He was found to have two areas of bleeding in the right
side of his brain. He was admitted to the neuro ICU. An MRI was
performed which showed worsening of the bleeding with
compression of his brain. The option of surgery was discussed
with his family, but given the severity of the bleeding and his
poor prognosis the decision was made to forgo surgical
intervention and pursue comfort measures only. He was started on
a morphine drip and passed away peacefully at 2:06pm on [**2139-6-24**].
Family declined autopsy.
Followup Instructions:
n/a
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
| {
"clinical_findings": {
"I616": [
{
"icd_10_cm_code": "I61.6",
"icd_10_cm_code_description": "Multiple localized intraparenchymal hemorrhage",
"Monitoring": [
{
"text": "Repeat CT in ED here appeared stable.",
"page_numbers": [
1
]
},
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema and ~10mm midline shift",
"page_numbers": [
1
]
},
{
"text": "BP was monitored closely with a goal SBP of <160.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital\nintraparenchymal hemorrhages",
"page_numbers": [
1
]
},
{
"text": "Large intraparenchymal hemorrhage in the right centrum\nsemiovale",
"page_numbers": [
1
]
},
{
"text": "A small\nhemorrhage is seen in the right posterior temporal region",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Intraparenchymal hemorrhage",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "He was started on mannitol",
"page_numbers": [
1
]
},
{
"text": "recommended craniotomy. His family initially consented to the procedure but after\nfurther discussion regarding his likely poor prognosis with\ndense L hemiparesis they declined and he was made CMO.",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "intracranial hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital\nintraparenchymal hemorrhages",
"page_numbers": [
1
]
},
{
"evidence_text": "Large intraparenchymal hemorrhage in the right centrum\nsemiovale",
"page_numbers": [
1
]
},
{
"evidence_text": "small\nhemorrhage is seen in the right posterior temporal region",
"page_numbers": [
1
]
},
{
"evidence_text": "R\nfrontoparietal IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "R occipital IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "enlargement of R frontoparietal hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "Intraparenchymal hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "two areas of bleeding in the right\nside of his brain",
"page_numbers": [
1
]
},
{
"evidence_text": "worsening of the bleeding",
"page_numbers": [
1
]
}
],
"justification": "The entity 'IPH' and related terms like 'intracranial hemorrhage' and specific locations are documented in the Chief Complaint, HPI, imaging reports (CT, MRI), Brief Hospital Course, and Discharge Diagnosis. MEAT criteria are met via Evaluation (imaging findings), Monitoring (stability/enlargement on repeat imaging, BP monitoring), Assessment (listed as Discharge Diagnosis), and Treatment (Mannitol, discussion/decision regarding craniotomy and CMO). The code I61.6 is assigned for multiple localized intraparenchymal hemorrhages based on the documentation of hemorrhages in multiple distinct locations (frontal, occipital, centrum semiovale, temporal)."
}
],
"B20": [
{
"icd_10_cm_code": "B20",
"icd_10_cm_code_description": "Human immunodeficiency virus [HIV] disease",
"Monitoring": [
{
"text": "he\nreports seeing PCP monthly and recent CD4 count 600s.",
"page_numbers": [
1
]
}
],
"Evaluation": null,
"Assessment": null,
"Treatment": [
{
"text": "on Abacavir, Truvada and Raltegravir.",
"page_numbers": [
1
]
},
{
"text": "Abacavir 300 mg tid, Truvada 1 tab daily, Raltegravir 400 mg\n[**Hospital1 **] for HARRT",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HIV",
"page_numbers": [
1
]
},
{
"evidence_text": "HIV",
"page_numbers": [
1
]
},
{
"evidence_text": "HIV",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HIV' is documented in the HPI, PMH, and Brief Hospital Course. MEAT criteria are met via Monitoring (PCP visits, CD4 count) and Treatment (HARRT medications). The code B20 is assigned for Human immunodeficiency virus [HIV] disease."
}
],
"B182": [
{
"icd_10_cm_code": "B18.2",
"icd_10_cm_code_description": "Chronic viral hepatitis C",
"Monitoring": null,
"Evaluation": null,
"Assessment": null,
"Treatment": [
{
"text": "on Ribavarin and Peginterferon",
"page_numbers": [
1
]
},
{
"text": "Ribavarin 200 mg tid and Peginterferon 180 mcg weekly for HCV",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HCV",
"page_numbers": [
1
]
},
{
"evidence_text": "HCV",
"page_numbers": [
1
]
},
{
"evidence_text": "HCV",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HCV' is documented in the HPI, PMH, Brief Hospital Course, and Medications on Admission. MEAT criteria are met via Treatment (Ribavarin and Peginterferon). The code B18.2 is assigned for Chronic viral hepatitis C."
}
],
"G8194": [
{
"icd_10_cm_code": "G81.94",
"icd_10_cm_code_description": "Unspecified hemiplegia and hemiparesis affecting left dominant side",
"Monitoring": [
{
"text": "Reports that he cannot\nmove\nhis L extremities at all, which is stable from onset at 3am.",
"page_numbers": [
1
]
},
{
"text": "dense L hemiplegia",
"page_numbers": [
1
]
},
{
"text": "dense L hemiparesis",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "L upper and lower facial\nweakness",
"page_numbers": [
1
]
},
{
"text": "Unable to move Lt trapezius and sternocleidomastoid",
"page_numbers": [
1
]
},
{
"text": "Flaccid tone LUE",
"page_numbers": [
1
]
},
{
"text": "incrased tone LLE",
"page_numbers": [
1
]
},
{
"text": "L 0 throughout",
"page_numbers": [
1
]
},
{
"text": "upgoing on left",
"page_numbers": [
1
]
},
{
"text": "decreased light touch L arm and leg",
"page_numbers": [
1
]
},
{
"text": "decrease sensation of LUE",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "L hemiparesis",
"page_numbers": [
1
]
},
{
"evidence_text": "L hemiplegia",
"page_numbers": [
1
]
},
{
"evidence_text": "dense L hemiplegia",
"page_numbers": [
1
]
},
{
"evidence_text": "dense L hemiparesis",
"page_numbers": [
1
]
}
],
"justification": "The entities 'L hemiparesis' and 'L hemiplegia' are documented in the HPI and Brief Hospital Course. MEAT criteria are met via Monitoring (patient report of inability to move extremities, stability, description as 'dense') and Evaluation (detailed physical/neurologic exam findings including weakness, tone, motor strength, reflexes, sensation). The code G81.94 is assigned for unspecified hemiplegia and hemiparesis affecting the left side. Although the patient is right-handed, the documentation does not specify dominance in relation to the hemiplegia, so unspecified dominance is appropriate."
}
],
"G936": [
{
"icd_10_cm_code": "G93.6",
"icd_10_cm_code_description": "Cerebral edema",
"Monitoring": [
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "surrounding edema similar to\nreference study.",
"page_numbers": [
1
]
},
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "surrounding edema",
"page_numbers": [
1
]
},
{
"evidence_text": "surrounding\nedema",
"page_numbers": [
1
]
}
],
"justification": "The entity 'surrounding edema' (referring to cerebral edema) is documented in the CT and MRI reports and Brief Hospital Course. MEAT criteria are met via Evaluation (imaging findings) and Monitoring (enlargement noted on MRI). The code G93.6 is assigned for Cerebral edema."
}
],
"G935": [
{
"icd_10_cm_code": "G93.5",
"icd_10_cm_code_description": "Compression of brain",
"Monitoring": [
{
"text": "~10mm midline shift",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "mass effect and midline shift.",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "mass effect",
"page_numbers": [
1
]
},
{
"evidence_text": "midline shift",
"page_numbers": [
1
]
},
{
"evidence_text": "~10mm midline shift",
"page_numbers": [
1
]
},
{
"evidence_text": "compression of his brain",
"page_numbers": [
1
]
}
],
"justification": "The entities 'mass effect' and 'midline shift' are documented in the MRI report and Brief Hospital Course, indicating compression of the brain. MEAT criteria are met via Evaluation (MRI findings) and Monitoring (measurement of midline shift). The code G93.5 is assigned for Compression of brain, which covers both mass effect and midline shift."
}
],
"I76": [
{
"icd_10_cm_code": "I76",
"icd_10_cm_code_description": "Septic embolism",
"Monitoring": null,
"Evaluation": [
{
"text": "Echocardiogram showed\nno evidence of vegetations.",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "There was concern for\nseptic emboli as a potential etiology of his IPH, in the setting\nof septic arthritis and a systolic murmur.",
"page_numbers": [
1
]
}
],
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "septic emboli",
"page_numbers": [
1
]
}
],
"justification": "The entity 'septic emboli' is documented in the Brief Hospital Course as a potential etiology for the IPH. MEAT criteria are met via Assessment (considered as a potential cause) and Evaluation (echocardiogram performed to rule out endocarditis as a source). The code I76 is assigned for Septic embolism."
}
],
"I2729": [
{
"icd_10_cm_code": "I27.29",
"icd_10_cm_code_description": "Other secondary pulmonary hypertension",
"Monitoring": null,
"Evaluation": [
{
"text": "engorgement\nof indistinct pulmonary vessels, consistent with elevated\npulmonary venous pressure",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "elevated\npulmonary venous pressure",
"page_numbers": [
1
]
}
],
"justification": "The entity 'elevated pulmonary venous pressure' is documented in the CXR report. MEAT criteria are met via Evaluation (CXR finding). The code I27.29 is assigned for Other secondary pulmonary hypertension, as elevated pulmonary venous pressure is a cause of secondary pulmonary hypertension."
}
]
}
} |
Extract only the clinical assessment findings for each condition, including diagnostic conclusions and staging. | Admission Date: [**2139-6-23**] Discharge Date: [**2139-6-24**]
Date of Birth: [**2086-1-10**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
L sided weakness and IPH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Name14 (STitle) 5229**] is a 53 yo Right-handed male patient with h/o HIV,
HCV, recent septic arthritis on Cefazoline IV and Lovenox
prophylaxis who was transferred from [**Hospital3 4107**] due to L
hemiparesis.
Last night, at 3AM, patient reports having L weakness when he
got up to use the bathroom( able to go to bathroom normally at
2AM). Patient states that he could not move his L arm and leg at
all and needed assistance from his father to go back to bed. He
was unable to sit or stand unsupported. He was aware of his
deficits, but did not want to go to the ED, because of a bad
experience recently at [**Hospital1 2025**]. Later in the morning, patient was
found to have L hemiplegia by visiting nurse and transferred to
[**Hospital3 4107**] and [**Hospital1 18**] due to intracranial hemorrhage on
CT-scan. At OSH, patient was normotensive, afebrile. He was
given
Ativan 2 mg per unclear reason, possibly anxiety, as patient
denies any convulsions. The patient was alert and oriented
during
ambulance ride, but became more drowsy, unclear about the timing
in relation to receiving Ativan.
Patient was evaluated by neurology team at 10AM. Appears to
be
drowsy but arousable and cooperative. Reports that he cannot
move
his L extremities at all, which is stable from onset at 3am.
ROS:
Positive for chills, sweats, chronic numbness of toes, R knee
pain
Negative fevers, headache, diplopia, vision loss, tingling, loss
bowel/bladder control, chest pain, SOB, N/V.
Past Medical History:
1. HIV on Abacavir, Truvada and Raltegravir. Diagnosed [**2125**], he
reports seeing PCP monthly and recent CD4 count 600s.
2. HCV on Ribavarin and Peginterferon
3. Recent septic arthritis s/p arthroscopy [**2139-5-15**]. Currently on
Cefazolin IV 2000mg q8hr. Per patient, medication was started
since discharge from [**Hospital1 2025**] on [**2139-5-18**] and the last dose was last
night(Need medical record from [**Hospital1 2025**]) On Lovenox prophylaxis.
Social History:
Living at home with his father, denies current
cig smoking or alcohol in 23 years, but prior history of heroin
use.
Family History:
knee surgery in his father
Physical Exam:
Physical Exam on Admission:
VS: T: 97.5 HR 104 BPP 152/77 RR 17 02 96/RA
General: Middle age patient, Lying in bed, looks drowsy but
arousable
HEENT: no jaundice, no nuchal rigidity, OP clear, no carotid
bruits
Lung: clear, no crackles, no wheezing
Heart: Systolic murmur at USB
Ab: soft, NT/ND
Ext: R knee with sutures in place, warm to touch compared to
left
side, no erythema or drainage. L toes bandaged.
Neurologic Examination:
Mental status:
Level of Arousal: Awake. Drowsy throughout exam but easily
arousable to voice. Oriented to [**2139-6-5**] (thought date was 13
or 14?), knows hospital but not which one. Knows President
current and prior.
Attentiveness: refused to tell months backward but able to tell
days of week forward.
Language: fluent, moderate dysarthria, normal comprehension,
repetition, naming. No paraphasic errors.
Memory: very poor registration/recall (could not register more
than [**1-5**] words at a time), remote memory intact.
Praxis: No apraxia/dyspraxia
Calculation: incorrect (said 4 quarters in $1.25)
Neglect: no neglect
Cranial Nerves:
I: Not tested.
II: Pupils symmetric at 3 to 2 mm, equal, round and reactive to
light bilaterally, defect in VF at Left inferior
quadrant(examined with both eyes open)
III, IV, VI: EOMI, normal primary position, no ptosis
V, VII: Facial sensation intact, L upper and lower facial
weakness
VIII: Hearing intact to voice.
IX, X: Palatal elevation normal
[**Doctor First Name 81**]: Unable to move Lt trapezius and sternocleidomastoid, R side
full
XII: Tongue midline and no fasciculation
MOTOR:
Lying in bed, no tremor or abnormal movement
Tone and Bulk: Flaccid tone LUE but incrased tone LLE
D B T WE FE FF IP Q H AT G/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**] TF
R 5 5 5 5 5 5 5 - - 5 5 5 5
L 0 throughout
**Unable to examine R knee due to pain from septic arthritis
Reflexes:
B T Br Pa Ac
R 2 2 2 2 2
L 2 2 2 - 2
**Unable to examine R knee due to pain from septic arthritis
Toes downgoing on right, upgoing on left
Sensation:
Examined with difficulty because patient was drowsy
-decreased light touch L arm and leg, intact on face V1-3
-vibration intact
-Proprioception intact
-pain by pinprick - decrease sensation of LUE but intact both
LEs, intact abdominal/chest area
-no extinction to DSS
Coordination and Cerebellar Function: no dysmetria on FNF on the
right, intact finger to crease tapping on the right
Gait: not assessed
Physical Exam on Discharge:
Expired
Pertinent Results:
[**2139-6-23**] 10:22AM PT-16.2* PTT-33.6 INR(PT)-1.5*
[**2139-6-23**] 10:22AM PLT COUNT-106*
[**2139-6-23**] 10:22AM NEUTS-85.9* LYMPHS-10.6* MONOS-3.0 EOS-0.3
BASOS-0.3
[**2139-6-23**] 10:22AM WBC-13.1* RBC-3.16* HGB-10.4* HCT-29.5*
MCV-93 MCH-32.9* MCHC-35.2* RDW-14.5
[**2139-6-23**] 10:22AM CALCIUM-7.6* PHOSPHATE-2.6* MAGNESIUM-2.1
[**2139-6-23**] 10:22AM estGFR-Using this
[**2139-6-23**] 10:22AM GLUCOSE-108* UREA N-12 CREAT-0.5 SODIUM-133
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-25 ANION GAP-11
[**2139-6-23**] 12:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2139-6-23**] 12:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2139-6-23**] 12:30PM URINE UHOLD-HOLD
[**2139-6-23**] 12:30PM URINE HOURS-RANDOM
[**2139-6-23**] 11:46PM OSMOLAL-270*
[**2139-6-23**] 11:46PM SODIUM-131* POTASSIUM-3.9 CHLORIDE-100
[**2139-6-23**] 11:51PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2139-6-23**] 11:51PM URINE OSMOLAL-578
[**2139-6-23**] 11:51PM URINE HOURS-RANDOM SODIUM-75 POTASSIUM-55
CHLORIDE-75
Noncontrast head CT [**2139-6-23**]:
IMPRESSION:
1. 3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital
intraparenchymal hemorrhages with surrounding edema similar to
reference study.
2. Partial effacement of frontal [**Doctor Last Name 534**] and atrium of right
lateral ventricle with slight asymmetric enlargement of the
right temporal [**Doctor Last Name 534**], similar to prior.
Transthoracic echo [**2139-6-23**]:
IMPRESSION: no vegetations seen
MRI/A head and neck [**2139-6-23**]:
IMPRESSION:
1. Large intraparenchymal hemorrhage in the right centrum
semiovale with mass effect and midline shift. A small
hemorrhage is seen in the right posterior temporal region.
Restricted diffusion is seen surrounding the large
intraparenchymal hemorrhage. Increased signal on post-contrast
images could be suspicious for extravasation. The differential
diagnosis includes cerebritis with secondary involvement of the
vascular structures or a mycotic aneurysm.
2. Leptomeningeal enhancement suggests meningitis.
3. Soft tissue abscess identified in the posterior neck, soft
tissue
structures measuring 17-mm mm indicating metastatic abscess.
4. MRA of the neck is unremarkable.
5. MRA of the head is limited by motion, but no major vascular
occlusion
seen. The findings were discussed with Dr. [**Last Name (STitle) **] at the time
of
interpretation of this study on [**2139-6-24**] at 11:30 a.m.
CXR [**2139-6-24**]:
FINDINGS: In comparison with the study of [**6-23**], the tip of the
endotracheal tube measures approximately 3.8 cm above the
carina. Nasogastric tube extends into the stomach where it
crosses the lower margin of the image.
Continued enlargement of the cardiac silhouette with engorgement
of indistinct pulmonary vessels, consistent with elevated
pulmonary venous pressure. The apparent widening of the
mediastinum is not as well appreciated on the current study.
Bibasilar atelectatic changes are again seen.
Brief Hospital Course:
53 yo RHM with HIV, HCV, recent diagnosis of septic arthritis
who presented to an outside hospital with dense L hemiplegia and
dysarthria. Head CT demonstrated approx 3.2x3.4 cm R
frontoparietal IPH as well as small R occipital IPH. He was
transferred to [**Hospital1 18**] for further management. Repeat CT in ED
here appeared stable. He was admitted to the neuro ICU for close
monitoring and further investigation. There was concern for
septic emboli as a potential etiology of his IPH, in the setting
of septic arthritis and a systolic murmur. Echocardiogram showed
no evidence of vegetations. He was continued on cefazolin for
antibiotic coverage given his recent history of septic
arthritis. Lovenox and all antiplatelets/anticoagulants were
held. BP was monitored closely with a goal SBP of <160.
He underwent an MRI in the evening of [**6-23**], which demonstrated
enlargement of R frontoparietal hemorrhage with surrounding
edema and ~10mm midline shift. On exam he was less responsive
(although had also received ativan) with minimal withdrawal to
noxious on L. He was started on mannitol and neurosurgery was
[**Name (NI) 653**], who reviewed the images and recommended craniotomy.
His family initially consented to the procedure but after
further discussion regarding his likely poor prognosis with
dense L hemiparesis they declined and he was made CMO. He was
started on a morphine gtt and passed away at 2:06pm on [**2139-6-24**].
Family were at the bedside and declined autopsy.
Medications on Admission:
1. Paxil 40 mg tid
2. Abacavir 300 mg tid, Truvada 1 tab daily, Raltegravir 400 mg
[**Hospital1 **] for HARRT
3. Cefazolin 2 g IV tid
4. Ribavarin 200 mg tid and Peginterferon 180 mcg weekly for HCV
5. Lovenox 30 mg sc daily plan cont 12 days after discharge on
[**2139-5-18**]
6. Oxycodone 5 mg prn q4hr
7. Reglan 10 mg prn qid
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Intraparenchymal hemorrhage
Septic arthritis
Discharge Condition:
Expired
Discharge Instructions:
Mr. [**Known lastname 5230**] was admitted to [**Hospital1 69**]
on [**2139-6-23**] after experiencing sudden onset left sided weakness
at home. He was found to have two areas of bleeding in the right
side of his brain. He was admitted to the neuro ICU. An MRI was
performed which showed worsening of the bleeding with
compression of his brain. The option of surgery was discussed
with his family, but given the severity of the bleeding and his
poor prognosis the decision was made to forgo surgical
intervention and pursue comfort measures only. He was started on
a morphine drip and passed away peacefully at 2:06pm on [**2139-6-24**].
Family declined autopsy.
Followup Instructions:
n/a
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
| {
"clinical_findings": {
"I616": [
{
"icd_10_cm_code": "I61.6",
"icd_10_cm_code_description": "Multiple localized intraparenchymal hemorrhage",
"Monitoring": [
{
"text": "Repeat CT in ED here appeared stable.",
"page_numbers": [
1
]
},
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema and ~10mm midline shift",
"page_numbers": [
1
]
},
{
"text": "BP was monitored closely with a goal SBP of <160.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital\nintraparenchymal hemorrhages",
"page_numbers": [
1
]
},
{
"text": "Large intraparenchymal hemorrhage in the right centrum\nsemiovale",
"page_numbers": [
1
]
},
{
"text": "A small\nhemorrhage is seen in the right posterior temporal region",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Intraparenchymal hemorrhage",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "He was started on mannitol",
"page_numbers": [
1
]
},
{
"text": "recommended craniotomy. His family initially consented to the procedure but after\nfurther discussion regarding his likely poor prognosis with\ndense L hemiparesis they declined and he was made CMO.",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "intracranial hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital\nintraparenchymal hemorrhages",
"page_numbers": [
1
]
},
{
"evidence_text": "Large intraparenchymal hemorrhage in the right centrum\nsemiovale",
"page_numbers": [
1
]
},
{
"evidence_text": "small\nhemorrhage is seen in the right posterior temporal region",
"page_numbers": [
1
]
},
{
"evidence_text": "R\nfrontoparietal IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "R occipital IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "enlargement of R frontoparietal hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "Intraparenchymal hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "two areas of bleeding in the right\nside of his brain",
"page_numbers": [
1
]
},
{
"evidence_text": "worsening of the bleeding",
"page_numbers": [
1
]
}
],
"justification": "The entity 'IPH' and related terms like 'intracranial hemorrhage' and specific locations are documented in the Chief Complaint, HPI, imaging reports (CT, MRI), Brief Hospital Course, and Discharge Diagnosis. MEAT criteria are met via Evaluation (imaging findings), Monitoring (stability/enlargement on repeat imaging, BP monitoring), Assessment (listed as Discharge Diagnosis), and Treatment (Mannitol, discussion/decision regarding craniotomy and CMO). The code I61.6 is assigned for multiple localized intraparenchymal hemorrhages based on the documentation of hemorrhages in multiple distinct locations (frontal, occipital, centrum semiovale, temporal)."
}
],
"B20": [
{
"icd_10_cm_code": "B20",
"icd_10_cm_code_description": "Human immunodeficiency virus [HIV] disease",
"Monitoring": [
{
"text": "he\nreports seeing PCP monthly and recent CD4 count 600s.",
"page_numbers": [
1
]
}
],
"Evaluation": null,
"Assessment": null,
"Treatment": [
{
"text": "on Abacavir, Truvada and Raltegravir.",
"page_numbers": [
1
]
},
{
"text": "Abacavir 300 mg tid, Truvada 1 tab daily, Raltegravir 400 mg\n[**Hospital1 **] for HARRT",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HIV",
"page_numbers": [
1
]
},
{
"evidence_text": "HIV",
"page_numbers": [
1
]
},
{
"evidence_text": "HIV",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HIV' is documented in the HPI, PMH, and Brief Hospital Course. MEAT criteria are met via Monitoring (PCP visits, CD4 count) and Treatment (HARRT medications). The code B20 is assigned for Human immunodeficiency virus [HIV] disease."
}
],
"B182": [
{
"icd_10_cm_code": "B18.2",
"icd_10_cm_code_description": "Chronic viral hepatitis C",
"Monitoring": null,
"Evaluation": null,
"Assessment": null,
"Treatment": [
{
"text": "on Ribavarin and Peginterferon",
"page_numbers": [
1
]
},
{
"text": "Ribavarin 200 mg tid and Peginterferon 180 mcg weekly for HCV",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HCV",
"page_numbers": [
1
]
},
{
"evidence_text": "HCV",
"page_numbers": [
1
]
},
{
"evidence_text": "HCV",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HCV' is documented in the HPI, PMH, Brief Hospital Course, and Medications on Admission. MEAT criteria are met via Treatment (Ribavarin and Peginterferon). The code B18.2 is assigned for Chronic viral hepatitis C."
}
],
"G8194": [
{
"icd_10_cm_code": "G81.94",
"icd_10_cm_code_description": "Unspecified hemiplegia and hemiparesis affecting left dominant side",
"Monitoring": [
{
"text": "Reports that he cannot\nmove\nhis L extremities at all, which is stable from onset at 3am.",
"page_numbers": [
1
]
},
{
"text": "dense L hemiplegia",
"page_numbers": [
1
]
},
{
"text": "dense L hemiparesis",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "L upper and lower facial\nweakness",
"page_numbers": [
1
]
},
{
"text": "Unable to move Lt trapezius and sternocleidomastoid",
"page_numbers": [
1
]
},
{
"text": "Flaccid tone LUE",
"page_numbers": [
1
]
},
{
"text": "incrased tone LLE",
"page_numbers": [
1
]
},
{
"text": "L 0 throughout",
"page_numbers": [
1
]
},
{
"text": "upgoing on left",
"page_numbers": [
1
]
},
{
"text": "decreased light touch L arm and leg",
"page_numbers": [
1
]
},
{
"text": "decrease sensation of LUE",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "L hemiparesis",
"page_numbers": [
1
]
},
{
"evidence_text": "L hemiplegia",
"page_numbers": [
1
]
},
{
"evidence_text": "dense L hemiplegia",
"page_numbers": [
1
]
},
{
"evidence_text": "dense L hemiparesis",
"page_numbers": [
1
]
}
],
"justification": "The entities 'L hemiparesis' and 'L hemiplegia' are documented in the HPI and Brief Hospital Course. MEAT criteria are met via Monitoring (patient report of inability to move extremities, stability, description as 'dense') and Evaluation (detailed physical/neurologic exam findings including weakness, tone, motor strength, reflexes, sensation). The code G81.94 is assigned for unspecified hemiplegia and hemiparesis affecting the left side. Although the patient is right-handed, the documentation does not specify dominance in relation to the hemiplegia, so unspecified dominance is appropriate."
}
],
"G936": [
{
"icd_10_cm_code": "G93.6",
"icd_10_cm_code_description": "Cerebral edema",
"Monitoring": [
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "surrounding edema similar to\nreference study.",
"page_numbers": [
1
]
},
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "surrounding edema",
"page_numbers": [
1
]
},
{
"evidence_text": "surrounding\nedema",
"page_numbers": [
1
]
}
],
"justification": "The entity 'surrounding edema' (referring to cerebral edema) is documented in the CT and MRI reports and Brief Hospital Course. MEAT criteria are met via Evaluation (imaging findings) and Monitoring (enlargement noted on MRI). The code G93.6 is assigned for Cerebral edema."
}
],
"G935": [
{
"icd_10_cm_code": "G93.5",
"icd_10_cm_code_description": "Compression of brain",
"Monitoring": [
{
"text": "~10mm midline shift",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "mass effect and midline shift.",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "mass effect",
"page_numbers": [
1
]
},
{
"evidence_text": "midline shift",
"page_numbers": [
1
]
},
{
"evidence_text": "~10mm midline shift",
"page_numbers": [
1
]
},
{
"evidence_text": "compression of his brain",
"page_numbers": [
1
]
}
],
"justification": "The entities 'mass effect' and 'midline shift' are documented in the MRI report and Brief Hospital Course, indicating compression of the brain. MEAT criteria are met via Evaluation (MRI findings) and Monitoring (measurement of midline shift). The code G93.5 is assigned for Compression of brain, which covers both mass effect and midline shift."
}
],
"I76": [
{
"icd_10_cm_code": "I76",
"icd_10_cm_code_description": "Septic embolism",
"Monitoring": null,
"Evaluation": [
{
"text": "Echocardiogram showed\nno evidence of vegetations.",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "There was concern for\nseptic emboli as a potential etiology of his IPH, in the setting\nof septic arthritis and a systolic murmur.",
"page_numbers": [
1
]
}
],
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "septic emboli",
"page_numbers": [
1
]
}
],
"justification": "The entity 'septic emboli' is documented in the Brief Hospital Course as a potential etiology for the IPH. MEAT criteria are met via Assessment (considered as a potential cause) and Evaluation (echocardiogram performed to rule out endocarditis as a source). The code I76 is assigned for Septic embolism."
}
],
"I2729": [
{
"icd_10_cm_code": "I27.29",
"icd_10_cm_code_description": "Other secondary pulmonary hypertension",
"Monitoring": null,
"Evaluation": [
{
"text": "engorgement\nof indistinct pulmonary vessels, consistent with elevated\npulmonary venous pressure",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "elevated\npulmonary venous pressure",
"page_numbers": [
1
]
}
],
"justification": "The entity 'elevated pulmonary venous pressure' is documented in the CXR report. MEAT criteria are met via Evaluation (CXR finding). The code I27.29 is assigned for Other secondary pulmonary hypertension, as elevated pulmonary venous pressure is a cause of secondary pulmonary hypertension."
}
]
}
} |
Extract only the treatment or intervention given for each condition, including surgeries, procedures, and medications. | Admission Date: [**2139-6-23**] Discharge Date: [**2139-6-24**]
Date of Birth: [**2086-1-10**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
L sided weakness and IPH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Name14 (STitle) 5229**] is a 53 yo Right-handed male patient with h/o HIV,
HCV, recent septic arthritis on Cefazoline IV and Lovenox
prophylaxis who was transferred from [**Hospital3 4107**] due to L
hemiparesis.
Last night, at 3AM, patient reports having L weakness when he
got up to use the bathroom( able to go to bathroom normally at
2AM). Patient states that he could not move his L arm and leg at
all and needed assistance from his father to go back to bed. He
was unable to sit or stand unsupported. He was aware of his
deficits, but did not want to go to the ED, because of a bad
experience recently at [**Hospital1 2025**]. Later in the morning, patient was
found to have L hemiplegia by visiting nurse and transferred to
[**Hospital3 4107**] and [**Hospital1 18**] due to intracranial hemorrhage on
CT-scan. At OSH, patient was normotensive, afebrile. He was
given
Ativan 2 mg per unclear reason, possibly anxiety, as patient
denies any convulsions. The patient was alert and oriented
during
ambulance ride, but became more drowsy, unclear about the timing
in relation to receiving Ativan.
Patient was evaluated by neurology team at 10AM. Appears to
be
drowsy but arousable and cooperative. Reports that he cannot
move
his L extremities at all, which is stable from onset at 3am.
ROS:
Positive for chills, sweats, chronic numbness of toes, R knee
pain
Negative fevers, headache, diplopia, vision loss, tingling, loss
bowel/bladder control, chest pain, SOB, N/V.
Past Medical History:
1. HIV on Abacavir, Truvada and Raltegravir. Diagnosed [**2125**], he
reports seeing PCP monthly and recent CD4 count 600s.
2. HCV on Ribavarin and Peginterferon
3. Recent septic arthritis s/p arthroscopy [**2139-5-15**]. Currently on
Cefazolin IV 2000mg q8hr. Per patient, medication was started
since discharge from [**Hospital1 2025**] on [**2139-5-18**] and the last dose was last
night(Need medical record from [**Hospital1 2025**]) On Lovenox prophylaxis.
Social History:
Living at home with his father, denies current
cig smoking or alcohol in 23 years, but prior history of heroin
use.
Family History:
knee surgery in his father
Physical Exam:
Physical Exam on Admission:
VS: T: 97.5 HR 104 BPP 152/77 RR 17 02 96/RA
General: Middle age patient, Lying in bed, looks drowsy but
arousable
HEENT: no jaundice, no nuchal rigidity, OP clear, no carotid
bruits
Lung: clear, no crackles, no wheezing
Heart: Systolic murmur at USB
Ab: soft, NT/ND
Ext: R knee with sutures in place, warm to touch compared to
left
side, no erythema or drainage. L toes bandaged.
Neurologic Examination:
Mental status:
Level of Arousal: Awake. Drowsy throughout exam but easily
arousable to voice. Oriented to [**2139-6-5**] (thought date was 13
or 14?), knows hospital but not which one. Knows President
current and prior.
Attentiveness: refused to tell months backward but able to tell
days of week forward.
Language: fluent, moderate dysarthria, normal comprehension,
repetition, naming. No paraphasic errors.
Memory: very poor registration/recall (could not register more
than [**1-5**] words at a time), remote memory intact.
Praxis: No apraxia/dyspraxia
Calculation: incorrect (said 4 quarters in $1.25)
Neglect: no neglect
Cranial Nerves:
I: Not tested.
II: Pupils symmetric at 3 to 2 mm, equal, round and reactive to
light bilaterally, defect in VF at Left inferior
quadrant(examined with both eyes open)
III, IV, VI: EOMI, normal primary position, no ptosis
V, VII: Facial sensation intact, L upper and lower facial
weakness
VIII: Hearing intact to voice.
IX, X: Palatal elevation normal
[**Doctor First Name 81**]: Unable to move Lt trapezius and sternocleidomastoid, R side
full
XII: Tongue midline and no fasciculation
MOTOR:
Lying in bed, no tremor or abnormal movement
Tone and Bulk: Flaccid tone LUE but incrased tone LLE
D B T WE FE FF IP Q H AT G/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**] TF
R 5 5 5 5 5 5 5 - - 5 5 5 5
L 0 throughout
**Unable to examine R knee due to pain from septic arthritis
Reflexes:
B T Br Pa Ac
R 2 2 2 2 2
L 2 2 2 - 2
**Unable to examine R knee due to pain from septic arthritis
Toes downgoing on right, upgoing on left
Sensation:
Examined with difficulty because patient was drowsy
-decreased light touch L arm and leg, intact on face V1-3
-vibration intact
-Proprioception intact
-pain by pinprick - decrease sensation of LUE but intact both
LEs, intact abdominal/chest area
-no extinction to DSS
Coordination and Cerebellar Function: no dysmetria on FNF on the
right, intact finger to crease tapping on the right
Gait: not assessed
Physical Exam on Discharge:
Expired
Pertinent Results:
[**2139-6-23**] 10:22AM PT-16.2* PTT-33.6 INR(PT)-1.5*
[**2139-6-23**] 10:22AM PLT COUNT-106*
[**2139-6-23**] 10:22AM NEUTS-85.9* LYMPHS-10.6* MONOS-3.0 EOS-0.3
BASOS-0.3
[**2139-6-23**] 10:22AM WBC-13.1* RBC-3.16* HGB-10.4* HCT-29.5*
MCV-93 MCH-32.9* MCHC-35.2* RDW-14.5
[**2139-6-23**] 10:22AM CALCIUM-7.6* PHOSPHATE-2.6* MAGNESIUM-2.1
[**2139-6-23**] 10:22AM estGFR-Using this
[**2139-6-23**] 10:22AM GLUCOSE-108* UREA N-12 CREAT-0.5 SODIUM-133
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-25 ANION GAP-11
[**2139-6-23**] 12:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2139-6-23**] 12:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2139-6-23**] 12:30PM URINE UHOLD-HOLD
[**2139-6-23**] 12:30PM URINE HOURS-RANDOM
[**2139-6-23**] 11:46PM OSMOLAL-270*
[**2139-6-23**] 11:46PM SODIUM-131* POTASSIUM-3.9 CHLORIDE-100
[**2139-6-23**] 11:51PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2139-6-23**] 11:51PM URINE OSMOLAL-578
[**2139-6-23**] 11:51PM URINE HOURS-RANDOM SODIUM-75 POTASSIUM-55
CHLORIDE-75
Noncontrast head CT [**2139-6-23**]:
IMPRESSION:
1. 3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital
intraparenchymal hemorrhages with surrounding edema similar to
reference study.
2. Partial effacement of frontal [**Doctor Last Name 534**] and atrium of right
lateral ventricle with slight asymmetric enlargement of the
right temporal [**Doctor Last Name 534**], similar to prior.
Transthoracic echo [**2139-6-23**]:
IMPRESSION: no vegetations seen
MRI/A head and neck [**2139-6-23**]:
IMPRESSION:
1. Large intraparenchymal hemorrhage in the right centrum
semiovale with mass effect and midline shift. A small
hemorrhage is seen in the right posterior temporal region.
Restricted diffusion is seen surrounding the large
intraparenchymal hemorrhage. Increased signal on post-contrast
images could be suspicious for extravasation. The differential
diagnosis includes cerebritis with secondary involvement of the
vascular structures or a mycotic aneurysm.
2. Leptomeningeal enhancement suggests meningitis.
3. Soft tissue abscess identified in the posterior neck, soft
tissue
structures measuring 17-mm mm indicating metastatic abscess.
4. MRA of the neck is unremarkable.
5. MRA of the head is limited by motion, but no major vascular
occlusion
seen. The findings were discussed with Dr. [**Last Name (STitle) **] at the time
of
interpretation of this study on [**2139-6-24**] at 11:30 a.m.
CXR [**2139-6-24**]:
FINDINGS: In comparison with the study of [**6-23**], the tip of the
endotracheal tube measures approximately 3.8 cm above the
carina. Nasogastric tube extends into the stomach where it
crosses the lower margin of the image.
Continued enlargement of the cardiac silhouette with engorgement
of indistinct pulmonary vessels, consistent with elevated
pulmonary venous pressure. The apparent widening of the
mediastinum is not as well appreciated on the current study.
Bibasilar atelectatic changes are again seen.
Brief Hospital Course:
53 yo RHM with HIV, HCV, recent diagnosis of septic arthritis
who presented to an outside hospital with dense L hemiplegia and
dysarthria. Head CT demonstrated approx 3.2x3.4 cm R
frontoparietal IPH as well as small R occipital IPH. He was
transferred to [**Hospital1 18**] for further management. Repeat CT in ED
here appeared stable. He was admitted to the neuro ICU for close
monitoring and further investigation. There was concern for
septic emboli as a potential etiology of his IPH, in the setting
of septic arthritis and a systolic murmur. Echocardiogram showed
no evidence of vegetations. He was continued on cefazolin for
antibiotic coverage given his recent history of septic
arthritis. Lovenox and all antiplatelets/anticoagulants were
held. BP was monitored closely with a goal SBP of <160.
He underwent an MRI in the evening of [**6-23**], which demonstrated
enlargement of R frontoparietal hemorrhage with surrounding
edema and ~10mm midline shift. On exam he was less responsive
(although had also received ativan) with minimal withdrawal to
noxious on L. He was started on mannitol and neurosurgery was
[**Name (NI) 653**], who reviewed the images and recommended craniotomy.
His family initially consented to the procedure but after
further discussion regarding his likely poor prognosis with
dense L hemiparesis they declined and he was made CMO. He was
started on a morphine gtt and passed away at 2:06pm on [**2139-6-24**].
Family were at the bedside and declined autopsy.
Medications on Admission:
1. Paxil 40 mg tid
2. Abacavir 300 mg tid, Truvada 1 tab daily, Raltegravir 400 mg
[**Hospital1 **] for HARRT
3. Cefazolin 2 g IV tid
4. Ribavarin 200 mg tid and Peginterferon 180 mcg weekly for HCV
5. Lovenox 30 mg sc daily plan cont 12 days after discharge on
[**2139-5-18**]
6. Oxycodone 5 mg prn q4hr
7. Reglan 10 mg prn qid
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Intraparenchymal hemorrhage
Septic arthritis
Discharge Condition:
Expired
Discharge Instructions:
Mr. [**Known lastname 5230**] was admitted to [**Hospital1 69**]
on [**2139-6-23**] after experiencing sudden onset left sided weakness
at home. He was found to have two areas of bleeding in the right
side of his brain. He was admitted to the neuro ICU. An MRI was
performed which showed worsening of the bleeding with
compression of his brain. The option of surgery was discussed
with his family, but given the severity of the bleeding and his
poor prognosis the decision was made to forgo surgical
intervention and pursue comfort measures only. He was started on
a morphine drip and passed away peacefully at 2:06pm on [**2139-6-24**].
Family declined autopsy.
Followup Instructions:
n/a
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
| {
"clinical_findings": {
"I616": [
{
"icd_10_cm_code": "I61.6",
"icd_10_cm_code_description": "Multiple localized intraparenchymal hemorrhage",
"Monitoring": [
{
"text": "Repeat CT in ED here appeared stable.",
"page_numbers": [
1
]
},
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema and ~10mm midline shift",
"page_numbers": [
1
]
},
{
"text": "BP was monitored closely with a goal SBP of <160.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital\nintraparenchymal hemorrhages",
"page_numbers": [
1
]
},
{
"text": "Large intraparenchymal hemorrhage in the right centrum\nsemiovale",
"page_numbers": [
1
]
},
{
"text": "A small\nhemorrhage is seen in the right posterior temporal region",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Intraparenchymal hemorrhage",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "He was started on mannitol",
"page_numbers": [
1
]
},
{
"text": "recommended craniotomy. His family initially consented to the procedure but after\nfurther discussion regarding his likely poor prognosis with\ndense L hemiparesis they declined and he was made CMO.",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "intracranial hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital\nintraparenchymal hemorrhages",
"page_numbers": [
1
]
},
{
"evidence_text": "Large intraparenchymal hemorrhage in the right centrum\nsemiovale",
"page_numbers": [
1
]
},
{
"evidence_text": "small\nhemorrhage is seen in the right posterior temporal region",
"page_numbers": [
1
]
},
{
"evidence_text": "R\nfrontoparietal IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "R occipital IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "enlargement of R frontoparietal hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "Intraparenchymal hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "two areas of bleeding in the right\nside of his brain",
"page_numbers": [
1
]
},
{
"evidence_text": "worsening of the bleeding",
"page_numbers": [
1
]
}
],
"justification": "The entity 'IPH' and related terms like 'intracranial hemorrhage' and specific locations are documented in the Chief Complaint, HPI, imaging reports (CT, MRI), Brief Hospital Course, and Discharge Diagnosis. MEAT criteria are met via Evaluation (imaging findings), Monitoring (stability/enlargement on repeat imaging, BP monitoring), Assessment (listed as Discharge Diagnosis), and Treatment (Mannitol, discussion/decision regarding craniotomy and CMO). The code I61.6 is assigned for multiple localized intraparenchymal hemorrhages based on the documentation of hemorrhages in multiple distinct locations (frontal, occipital, centrum semiovale, temporal)."
}
],
"B20": [
{
"icd_10_cm_code": "B20",
"icd_10_cm_code_description": "Human immunodeficiency virus [HIV] disease",
"Monitoring": [
{
"text": "he\nreports seeing PCP monthly and recent CD4 count 600s.",
"page_numbers": [
1
]
}
],
"Evaluation": null,
"Assessment": null,
"Treatment": [
{
"text": "on Abacavir, Truvada and Raltegravir.",
"page_numbers": [
1
]
},
{
"text": "Abacavir 300 mg tid, Truvada 1 tab daily, Raltegravir 400 mg\n[**Hospital1 **] for HARRT",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HIV",
"page_numbers": [
1
]
},
{
"evidence_text": "HIV",
"page_numbers": [
1
]
},
{
"evidence_text": "HIV",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HIV' is documented in the HPI, PMH, and Brief Hospital Course. MEAT criteria are met via Monitoring (PCP visits, CD4 count) and Treatment (HARRT medications). The code B20 is assigned for Human immunodeficiency virus [HIV] disease."
}
],
"B182": [
{
"icd_10_cm_code": "B18.2",
"icd_10_cm_code_description": "Chronic viral hepatitis C",
"Monitoring": null,
"Evaluation": null,
"Assessment": null,
"Treatment": [
{
"text": "on Ribavarin and Peginterferon",
"page_numbers": [
1
]
},
{
"text": "Ribavarin 200 mg tid and Peginterferon 180 mcg weekly for HCV",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HCV",
"page_numbers": [
1
]
},
{
"evidence_text": "HCV",
"page_numbers": [
1
]
},
{
"evidence_text": "HCV",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HCV' is documented in the HPI, PMH, Brief Hospital Course, and Medications on Admission. MEAT criteria are met via Treatment (Ribavarin and Peginterferon). The code B18.2 is assigned for Chronic viral hepatitis C."
}
],
"G8194": [
{
"icd_10_cm_code": "G81.94",
"icd_10_cm_code_description": "Unspecified hemiplegia and hemiparesis affecting left dominant side",
"Monitoring": [
{
"text": "Reports that he cannot\nmove\nhis L extremities at all, which is stable from onset at 3am.",
"page_numbers": [
1
]
},
{
"text": "dense L hemiplegia",
"page_numbers": [
1
]
},
{
"text": "dense L hemiparesis",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "L upper and lower facial\nweakness",
"page_numbers": [
1
]
},
{
"text": "Unable to move Lt trapezius and sternocleidomastoid",
"page_numbers": [
1
]
},
{
"text": "Flaccid tone LUE",
"page_numbers": [
1
]
},
{
"text": "incrased tone LLE",
"page_numbers": [
1
]
},
{
"text": "L 0 throughout",
"page_numbers": [
1
]
},
{
"text": "upgoing on left",
"page_numbers": [
1
]
},
{
"text": "decreased light touch L arm and leg",
"page_numbers": [
1
]
},
{
"text": "decrease sensation of LUE",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "L hemiparesis",
"page_numbers": [
1
]
},
{
"evidence_text": "L hemiplegia",
"page_numbers": [
1
]
},
{
"evidence_text": "dense L hemiplegia",
"page_numbers": [
1
]
},
{
"evidence_text": "dense L hemiparesis",
"page_numbers": [
1
]
}
],
"justification": "The entities 'L hemiparesis' and 'L hemiplegia' are documented in the HPI and Brief Hospital Course. MEAT criteria are met via Monitoring (patient report of inability to move extremities, stability, description as 'dense') and Evaluation (detailed physical/neurologic exam findings including weakness, tone, motor strength, reflexes, sensation). The code G81.94 is assigned for unspecified hemiplegia and hemiparesis affecting the left side. Although the patient is right-handed, the documentation does not specify dominance in relation to the hemiplegia, so unspecified dominance is appropriate."
}
],
"G936": [
{
"icd_10_cm_code": "G93.6",
"icd_10_cm_code_description": "Cerebral edema",
"Monitoring": [
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "surrounding edema similar to\nreference study.",
"page_numbers": [
1
]
},
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "surrounding edema",
"page_numbers": [
1
]
},
{
"evidence_text": "surrounding\nedema",
"page_numbers": [
1
]
}
],
"justification": "The entity 'surrounding edema' (referring to cerebral edema) is documented in the CT and MRI reports and Brief Hospital Course. MEAT criteria are met via Evaluation (imaging findings) and Monitoring (enlargement noted on MRI). The code G93.6 is assigned for Cerebral edema."
}
],
"G935": [
{
"icd_10_cm_code": "G93.5",
"icd_10_cm_code_description": "Compression of brain",
"Monitoring": [
{
"text": "~10mm midline shift",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "mass effect and midline shift.",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "mass effect",
"page_numbers": [
1
]
},
{
"evidence_text": "midline shift",
"page_numbers": [
1
]
},
{
"evidence_text": "~10mm midline shift",
"page_numbers": [
1
]
},
{
"evidence_text": "compression of his brain",
"page_numbers": [
1
]
}
],
"justification": "The entities 'mass effect' and 'midline shift' are documented in the MRI report and Brief Hospital Course, indicating compression of the brain. MEAT criteria are met via Evaluation (MRI findings) and Monitoring (measurement of midline shift). The code G93.5 is assigned for Compression of brain, which covers both mass effect and midline shift."
}
],
"I76": [
{
"icd_10_cm_code": "I76",
"icd_10_cm_code_description": "Septic embolism",
"Monitoring": null,
"Evaluation": [
{
"text": "Echocardiogram showed\nno evidence of vegetations.",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "There was concern for\nseptic emboli as a potential etiology of his IPH, in the setting\nof septic arthritis and a systolic murmur.",
"page_numbers": [
1
]
}
],
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "septic emboli",
"page_numbers": [
1
]
}
],
"justification": "The entity 'septic emboli' is documented in the Brief Hospital Course as a potential etiology for the IPH. MEAT criteria are met via Assessment (considered as a potential cause) and Evaluation (echocardiogram performed to rule out endocarditis as a source). The code I76 is assigned for Septic embolism."
}
],
"I2729": [
{
"icd_10_cm_code": "I27.29",
"icd_10_cm_code_description": "Other secondary pulmonary hypertension",
"Monitoring": null,
"Evaluation": [
{
"text": "engorgement\nof indistinct pulmonary vessels, consistent with elevated\npulmonary venous pressure",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "elevated\npulmonary venous pressure",
"page_numbers": [
1
]
}
],
"justification": "The entity 'elevated pulmonary venous pressure' is documented in the CXR report. MEAT criteria are met via Evaluation (CXR finding). The code I27.29 is assigned for Other secondary pulmonary hypertension, as elevated pulmonary venous pressure is a cause of secondary pulmonary hypertension."
}
]
}
} |
Extract only the evidence from the discharge summary that supports the existence of each condition. | Admission Date: [**2139-6-23**] Discharge Date: [**2139-6-24**]
Date of Birth: [**2086-1-10**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
L sided weakness and IPH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Name14 (STitle) 5229**] is a 53 yo Right-handed male patient with h/o HIV,
HCV, recent septic arthritis on Cefazoline IV and Lovenox
prophylaxis who was transferred from [**Hospital3 4107**] due to L
hemiparesis.
Last night, at 3AM, patient reports having L weakness when he
got up to use the bathroom( able to go to bathroom normally at
2AM). Patient states that he could not move his L arm and leg at
all and needed assistance from his father to go back to bed. He
was unable to sit or stand unsupported. He was aware of his
deficits, but did not want to go to the ED, because of a bad
experience recently at [**Hospital1 2025**]. Later in the morning, patient was
found to have L hemiplegia by visiting nurse and transferred to
[**Hospital3 4107**] and [**Hospital1 18**] due to intracranial hemorrhage on
CT-scan. At OSH, patient was normotensive, afebrile. He was
given
Ativan 2 mg per unclear reason, possibly anxiety, as patient
denies any convulsions. The patient was alert and oriented
during
ambulance ride, but became more drowsy, unclear about the timing
in relation to receiving Ativan.
Patient was evaluated by neurology team at 10AM. Appears to
be
drowsy but arousable and cooperative. Reports that he cannot
move
his L extremities at all, which is stable from onset at 3am.
ROS:
Positive for chills, sweats, chronic numbness of toes, R knee
pain
Negative fevers, headache, diplopia, vision loss, tingling, loss
bowel/bladder control, chest pain, SOB, N/V.
Past Medical History:
1. HIV on Abacavir, Truvada and Raltegravir. Diagnosed [**2125**], he
reports seeing PCP monthly and recent CD4 count 600s.
2. HCV on Ribavarin and Peginterferon
3. Recent septic arthritis s/p arthroscopy [**2139-5-15**]. Currently on
Cefazolin IV 2000mg q8hr. Per patient, medication was started
since discharge from [**Hospital1 2025**] on [**2139-5-18**] and the last dose was last
night(Need medical record from [**Hospital1 2025**]) On Lovenox prophylaxis.
Social History:
Living at home with his father, denies current
cig smoking or alcohol in 23 years, but prior history of heroin
use.
Family History:
knee surgery in his father
Physical Exam:
Physical Exam on Admission:
VS: T: 97.5 HR 104 BPP 152/77 RR 17 02 96/RA
General: Middle age patient, Lying in bed, looks drowsy but
arousable
HEENT: no jaundice, no nuchal rigidity, OP clear, no carotid
bruits
Lung: clear, no crackles, no wheezing
Heart: Systolic murmur at USB
Ab: soft, NT/ND
Ext: R knee with sutures in place, warm to touch compared to
left
side, no erythema or drainage. L toes bandaged.
Neurologic Examination:
Mental status:
Level of Arousal: Awake. Drowsy throughout exam but easily
arousable to voice. Oriented to [**2139-6-5**] (thought date was 13
or 14?), knows hospital but not which one. Knows President
current and prior.
Attentiveness: refused to tell months backward but able to tell
days of week forward.
Language: fluent, moderate dysarthria, normal comprehension,
repetition, naming. No paraphasic errors.
Memory: very poor registration/recall (could not register more
than [**1-5**] words at a time), remote memory intact.
Praxis: No apraxia/dyspraxia
Calculation: incorrect (said 4 quarters in $1.25)
Neglect: no neglect
Cranial Nerves:
I: Not tested.
II: Pupils symmetric at 3 to 2 mm, equal, round and reactive to
light bilaterally, defect in VF at Left inferior
quadrant(examined with both eyes open)
III, IV, VI: EOMI, normal primary position, no ptosis
V, VII: Facial sensation intact, L upper and lower facial
weakness
VIII: Hearing intact to voice.
IX, X: Palatal elevation normal
[**Doctor First Name 81**]: Unable to move Lt trapezius and sternocleidomastoid, R side
full
XII: Tongue midline and no fasciculation
MOTOR:
Lying in bed, no tremor or abnormal movement
Tone and Bulk: Flaccid tone LUE but incrased tone LLE
D B T WE FE FF IP Q H AT G/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**] TF
R 5 5 5 5 5 5 5 - - 5 5 5 5
L 0 throughout
**Unable to examine R knee due to pain from septic arthritis
Reflexes:
B T Br Pa Ac
R 2 2 2 2 2
L 2 2 2 - 2
**Unable to examine R knee due to pain from septic arthritis
Toes downgoing on right, upgoing on left
Sensation:
Examined with difficulty because patient was drowsy
-decreased light touch L arm and leg, intact on face V1-3
-vibration intact
-Proprioception intact
-pain by pinprick - decrease sensation of LUE but intact both
LEs, intact abdominal/chest area
-no extinction to DSS
Coordination and Cerebellar Function: no dysmetria on FNF on the
right, intact finger to crease tapping on the right
Gait: not assessed
Physical Exam on Discharge:
Expired
Pertinent Results:
[**2139-6-23**] 10:22AM PT-16.2* PTT-33.6 INR(PT)-1.5*
[**2139-6-23**] 10:22AM PLT COUNT-106*
[**2139-6-23**] 10:22AM NEUTS-85.9* LYMPHS-10.6* MONOS-3.0 EOS-0.3
BASOS-0.3
[**2139-6-23**] 10:22AM WBC-13.1* RBC-3.16* HGB-10.4* HCT-29.5*
MCV-93 MCH-32.9* MCHC-35.2* RDW-14.5
[**2139-6-23**] 10:22AM CALCIUM-7.6* PHOSPHATE-2.6* MAGNESIUM-2.1
[**2139-6-23**] 10:22AM estGFR-Using this
[**2139-6-23**] 10:22AM GLUCOSE-108* UREA N-12 CREAT-0.5 SODIUM-133
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-25 ANION GAP-11
[**2139-6-23**] 12:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2139-6-23**] 12:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2139-6-23**] 12:30PM URINE UHOLD-HOLD
[**2139-6-23**] 12:30PM URINE HOURS-RANDOM
[**2139-6-23**] 11:46PM OSMOLAL-270*
[**2139-6-23**] 11:46PM SODIUM-131* POTASSIUM-3.9 CHLORIDE-100
[**2139-6-23**] 11:51PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2139-6-23**] 11:51PM URINE OSMOLAL-578
[**2139-6-23**] 11:51PM URINE HOURS-RANDOM SODIUM-75 POTASSIUM-55
CHLORIDE-75
Noncontrast head CT [**2139-6-23**]:
IMPRESSION:
1. 3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital
intraparenchymal hemorrhages with surrounding edema similar to
reference study.
2. Partial effacement of frontal [**Doctor Last Name 534**] and atrium of right
lateral ventricle with slight asymmetric enlargement of the
right temporal [**Doctor Last Name 534**], similar to prior.
Transthoracic echo [**2139-6-23**]:
IMPRESSION: no vegetations seen
MRI/A head and neck [**2139-6-23**]:
IMPRESSION:
1. Large intraparenchymal hemorrhage in the right centrum
semiovale with mass effect and midline shift. A small
hemorrhage is seen in the right posterior temporal region.
Restricted diffusion is seen surrounding the large
intraparenchymal hemorrhage. Increased signal on post-contrast
images could be suspicious for extravasation. The differential
diagnosis includes cerebritis with secondary involvement of the
vascular structures or a mycotic aneurysm.
2. Leptomeningeal enhancement suggests meningitis.
3. Soft tissue abscess identified in the posterior neck, soft
tissue
structures measuring 17-mm mm indicating metastatic abscess.
4. MRA of the neck is unremarkable.
5. MRA of the head is limited by motion, but no major vascular
occlusion
seen. The findings were discussed with Dr. [**Last Name (STitle) **] at the time
of
interpretation of this study on [**2139-6-24**] at 11:30 a.m.
CXR [**2139-6-24**]:
FINDINGS: In comparison with the study of [**6-23**], the tip of the
endotracheal tube measures approximately 3.8 cm above the
carina. Nasogastric tube extends into the stomach where it
crosses the lower margin of the image.
Continued enlargement of the cardiac silhouette with engorgement
of indistinct pulmonary vessels, consistent with elevated
pulmonary venous pressure. The apparent widening of the
mediastinum is not as well appreciated on the current study.
Bibasilar atelectatic changes are again seen.
Brief Hospital Course:
53 yo RHM with HIV, HCV, recent diagnosis of septic arthritis
who presented to an outside hospital with dense L hemiplegia and
dysarthria. Head CT demonstrated approx 3.2x3.4 cm R
frontoparietal IPH as well as small R occipital IPH. He was
transferred to [**Hospital1 18**] for further management. Repeat CT in ED
here appeared stable. He was admitted to the neuro ICU for close
monitoring and further investigation. There was concern for
septic emboli as a potential etiology of his IPH, in the setting
of septic arthritis and a systolic murmur. Echocardiogram showed
no evidence of vegetations. He was continued on cefazolin for
antibiotic coverage given his recent history of septic
arthritis. Lovenox and all antiplatelets/anticoagulants were
held. BP was monitored closely with a goal SBP of <160.
He underwent an MRI in the evening of [**6-23**], which demonstrated
enlargement of R frontoparietal hemorrhage with surrounding
edema and ~10mm midline shift. On exam he was less responsive
(although had also received ativan) with minimal withdrawal to
noxious on L. He was started on mannitol and neurosurgery was
[**Name (NI) 653**], who reviewed the images and recommended craniotomy.
His family initially consented to the procedure but after
further discussion regarding his likely poor prognosis with
dense L hemiparesis they declined and he was made CMO. He was
started on a morphine gtt and passed away at 2:06pm on [**2139-6-24**].
Family were at the bedside and declined autopsy.
Medications on Admission:
1. Paxil 40 mg tid
2. Abacavir 300 mg tid, Truvada 1 tab daily, Raltegravir 400 mg
[**Hospital1 **] for HARRT
3. Cefazolin 2 g IV tid
4. Ribavarin 200 mg tid and Peginterferon 180 mcg weekly for HCV
5. Lovenox 30 mg sc daily plan cont 12 days after discharge on
[**2139-5-18**]
6. Oxycodone 5 mg prn q4hr
7. Reglan 10 mg prn qid
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Intraparenchymal hemorrhage
Septic arthritis
Discharge Condition:
Expired
Discharge Instructions:
Mr. [**Known lastname 5230**] was admitted to [**Hospital1 69**]
on [**2139-6-23**] after experiencing sudden onset left sided weakness
at home. He was found to have two areas of bleeding in the right
side of his brain. He was admitted to the neuro ICU. An MRI was
performed which showed worsening of the bleeding with
compression of his brain. The option of surgery was discussed
with his family, but given the severity of the bleeding and his
poor prognosis the decision was made to forgo surgical
intervention and pursue comfort measures only. He was started on
a morphine drip and passed away peacefully at 2:06pm on [**2139-6-24**].
Family declined autopsy.
Followup Instructions:
n/a
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
| {
"clinical_findings": {
"I616": [
{
"icd_10_cm_code": "I61.6",
"icd_10_cm_code_description": "Multiple localized intraparenchymal hemorrhage",
"Monitoring": [
{
"text": "Repeat CT in ED here appeared stable.",
"page_numbers": [
1
]
},
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema and ~10mm midline shift",
"page_numbers": [
1
]
},
{
"text": "BP was monitored closely with a goal SBP of <160.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital\nintraparenchymal hemorrhages",
"page_numbers": [
1
]
},
{
"text": "Large intraparenchymal hemorrhage in the right centrum\nsemiovale",
"page_numbers": [
1
]
},
{
"text": "A small\nhemorrhage is seen in the right posterior temporal region",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Intraparenchymal hemorrhage",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "He was started on mannitol",
"page_numbers": [
1
]
},
{
"text": "recommended craniotomy. His family initially consented to the procedure but after\nfurther discussion regarding his likely poor prognosis with\ndense L hemiparesis they declined and he was made CMO.",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "intracranial hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital\nintraparenchymal hemorrhages",
"page_numbers": [
1
]
},
{
"evidence_text": "Large intraparenchymal hemorrhage in the right centrum\nsemiovale",
"page_numbers": [
1
]
},
{
"evidence_text": "small\nhemorrhage is seen in the right posterior temporal region",
"page_numbers": [
1
]
},
{
"evidence_text": "R\nfrontoparietal IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "R occipital IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "enlargement of R frontoparietal hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "Intraparenchymal hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "two areas of bleeding in the right\nside of his brain",
"page_numbers": [
1
]
},
{
"evidence_text": "worsening of the bleeding",
"page_numbers": [
1
]
}
],
"justification": "The entity 'IPH' and related terms like 'intracranial hemorrhage' and specific locations are documented in the Chief Complaint, HPI, imaging reports (CT, MRI), Brief Hospital Course, and Discharge Diagnosis. MEAT criteria are met via Evaluation (imaging findings), Monitoring (stability/enlargement on repeat imaging, BP monitoring), Assessment (listed as Discharge Diagnosis), and Treatment (Mannitol, discussion/decision regarding craniotomy and CMO). The code I61.6 is assigned for multiple localized intraparenchymal hemorrhages based on the documentation of hemorrhages in multiple distinct locations (frontal, occipital, centrum semiovale, temporal)."
}
],
"B20": [
{
"icd_10_cm_code": "B20",
"icd_10_cm_code_description": "Human immunodeficiency virus [HIV] disease",
"Monitoring": [
{
"text": "he\nreports seeing PCP monthly and recent CD4 count 600s.",
"page_numbers": [
1
]
}
],
"Evaluation": null,
"Assessment": null,
"Treatment": [
{
"text": "on Abacavir, Truvada and Raltegravir.",
"page_numbers": [
1
]
},
{
"text": "Abacavir 300 mg tid, Truvada 1 tab daily, Raltegravir 400 mg\n[**Hospital1 **] for HARRT",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HIV",
"page_numbers": [
1
]
},
{
"evidence_text": "HIV",
"page_numbers": [
1
]
},
{
"evidence_text": "HIV",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HIV' is documented in the HPI, PMH, and Brief Hospital Course. MEAT criteria are met via Monitoring (PCP visits, CD4 count) and Treatment (HARRT medications). The code B20 is assigned for Human immunodeficiency virus [HIV] disease."
}
],
"B182": [
{
"icd_10_cm_code": "B18.2",
"icd_10_cm_code_description": "Chronic viral hepatitis C",
"Monitoring": null,
"Evaluation": null,
"Assessment": null,
"Treatment": [
{
"text": "on Ribavarin and Peginterferon",
"page_numbers": [
1
]
},
{
"text": "Ribavarin 200 mg tid and Peginterferon 180 mcg weekly for HCV",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HCV",
"page_numbers": [
1
]
},
{
"evidence_text": "HCV",
"page_numbers": [
1
]
},
{
"evidence_text": "HCV",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HCV' is documented in the HPI, PMH, Brief Hospital Course, and Medications on Admission. MEAT criteria are met via Treatment (Ribavarin and Peginterferon). The code B18.2 is assigned for Chronic viral hepatitis C."
}
],
"G8194": [
{
"icd_10_cm_code": "G81.94",
"icd_10_cm_code_description": "Unspecified hemiplegia and hemiparesis affecting left dominant side",
"Monitoring": [
{
"text": "Reports that he cannot\nmove\nhis L extremities at all, which is stable from onset at 3am.",
"page_numbers": [
1
]
},
{
"text": "dense L hemiplegia",
"page_numbers": [
1
]
},
{
"text": "dense L hemiparesis",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "L upper and lower facial\nweakness",
"page_numbers": [
1
]
},
{
"text": "Unable to move Lt trapezius and sternocleidomastoid",
"page_numbers": [
1
]
},
{
"text": "Flaccid tone LUE",
"page_numbers": [
1
]
},
{
"text": "incrased tone LLE",
"page_numbers": [
1
]
},
{
"text": "L 0 throughout",
"page_numbers": [
1
]
},
{
"text": "upgoing on left",
"page_numbers": [
1
]
},
{
"text": "decreased light touch L arm and leg",
"page_numbers": [
1
]
},
{
"text": "decrease sensation of LUE",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "L hemiparesis",
"page_numbers": [
1
]
},
{
"evidence_text": "L hemiplegia",
"page_numbers": [
1
]
},
{
"evidence_text": "dense L hemiplegia",
"page_numbers": [
1
]
},
{
"evidence_text": "dense L hemiparesis",
"page_numbers": [
1
]
}
],
"justification": "The entities 'L hemiparesis' and 'L hemiplegia' are documented in the HPI and Brief Hospital Course. MEAT criteria are met via Monitoring (patient report of inability to move extremities, stability, description as 'dense') and Evaluation (detailed physical/neurologic exam findings including weakness, tone, motor strength, reflexes, sensation). The code G81.94 is assigned for unspecified hemiplegia and hemiparesis affecting the left side. Although the patient is right-handed, the documentation does not specify dominance in relation to the hemiplegia, so unspecified dominance is appropriate."
}
],
"G936": [
{
"icd_10_cm_code": "G93.6",
"icd_10_cm_code_description": "Cerebral edema",
"Monitoring": [
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "surrounding edema similar to\nreference study.",
"page_numbers": [
1
]
},
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "surrounding edema",
"page_numbers": [
1
]
},
{
"evidence_text": "surrounding\nedema",
"page_numbers": [
1
]
}
],
"justification": "The entity 'surrounding edema' (referring to cerebral edema) is documented in the CT and MRI reports and Brief Hospital Course. MEAT criteria are met via Evaluation (imaging findings) and Monitoring (enlargement noted on MRI). The code G93.6 is assigned for Cerebral edema."
}
],
"G935": [
{
"icd_10_cm_code": "G93.5",
"icd_10_cm_code_description": "Compression of brain",
"Monitoring": [
{
"text": "~10mm midline shift",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "mass effect and midline shift.",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "mass effect",
"page_numbers": [
1
]
},
{
"evidence_text": "midline shift",
"page_numbers": [
1
]
},
{
"evidence_text": "~10mm midline shift",
"page_numbers": [
1
]
},
{
"evidence_text": "compression of his brain",
"page_numbers": [
1
]
}
],
"justification": "The entities 'mass effect' and 'midline shift' are documented in the MRI report and Brief Hospital Course, indicating compression of the brain. MEAT criteria are met via Evaluation (MRI findings) and Monitoring (measurement of midline shift). The code G93.5 is assigned for Compression of brain, which covers both mass effect and midline shift."
}
],
"I76": [
{
"icd_10_cm_code": "I76",
"icd_10_cm_code_description": "Septic embolism",
"Monitoring": null,
"Evaluation": [
{
"text": "Echocardiogram showed\nno evidence of vegetations.",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "There was concern for\nseptic emboli as a potential etiology of his IPH, in the setting\nof septic arthritis and a systolic murmur.",
"page_numbers": [
1
]
}
],
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "septic emboli",
"page_numbers": [
1
]
}
],
"justification": "The entity 'septic emboli' is documented in the Brief Hospital Course as a potential etiology for the IPH. MEAT criteria are met via Assessment (considered as a potential cause) and Evaluation (echocardiogram performed to rule out endocarditis as a source). The code I76 is assigned for Septic embolism."
}
],
"I2729": [
{
"icd_10_cm_code": "I27.29",
"icd_10_cm_code_description": "Other secondary pulmonary hypertension",
"Monitoring": null,
"Evaluation": [
{
"text": "engorgement\nof indistinct pulmonary vessels, consistent with elevated\npulmonary venous pressure",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "elevated\npulmonary venous pressure",
"page_numbers": [
1
]
}
],
"justification": "The entity 'elevated pulmonary venous pressure' is documented in the CXR report. MEAT criteria are met via Evaluation (CXR finding). The code I27.29 is assigned for Other secondary pulmonary hypertension, as elevated pulmonary venous pressure is a cause of secondary pulmonary hypertension."
}
]
}
} |
Extract only the text-based justification for assigning the ICD-10-CM code to each condition. | Admission Date: [**2139-6-23**] Discharge Date: [**2139-6-24**]
Date of Birth: [**2086-1-10**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
L sided weakness and IPH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Name14 (STitle) 5229**] is a 53 yo Right-handed male patient with h/o HIV,
HCV, recent septic arthritis on Cefazoline IV and Lovenox
prophylaxis who was transferred from [**Hospital3 4107**] due to L
hemiparesis.
Last night, at 3AM, patient reports having L weakness when he
got up to use the bathroom( able to go to bathroom normally at
2AM). Patient states that he could not move his L arm and leg at
all and needed assistance from his father to go back to bed. He
was unable to sit or stand unsupported. He was aware of his
deficits, but did not want to go to the ED, because of a bad
experience recently at [**Hospital1 2025**]. Later in the morning, patient was
found to have L hemiplegia by visiting nurse and transferred to
[**Hospital3 4107**] and [**Hospital1 18**] due to intracranial hemorrhage on
CT-scan. At OSH, patient was normotensive, afebrile. He was
given
Ativan 2 mg per unclear reason, possibly anxiety, as patient
denies any convulsions. The patient was alert and oriented
during
ambulance ride, but became more drowsy, unclear about the timing
in relation to receiving Ativan.
Patient was evaluated by neurology team at 10AM. Appears to
be
drowsy but arousable and cooperative. Reports that he cannot
move
his L extremities at all, which is stable from onset at 3am.
ROS:
Positive for chills, sweats, chronic numbness of toes, R knee
pain
Negative fevers, headache, diplopia, vision loss, tingling, loss
bowel/bladder control, chest pain, SOB, N/V.
Past Medical History:
1. HIV on Abacavir, Truvada and Raltegravir. Diagnosed [**2125**], he
reports seeing PCP monthly and recent CD4 count 600s.
2. HCV on Ribavarin and Peginterferon
3. Recent septic arthritis s/p arthroscopy [**2139-5-15**]. Currently on
Cefazolin IV 2000mg q8hr. Per patient, medication was started
since discharge from [**Hospital1 2025**] on [**2139-5-18**] and the last dose was last
night(Need medical record from [**Hospital1 2025**]) On Lovenox prophylaxis.
Social History:
Living at home with his father, denies current
cig smoking or alcohol in 23 years, but prior history of heroin
use.
Family History:
knee surgery in his father
Physical Exam:
Physical Exam on Admission:
VS: T: 97.5 HR 104 BPP 152/77 RR 17 02 96/RA
General: Middle age patient, Lying in bed, looks drowsy but
arousable
HEENT: no jaundice, no nuchal rigidity, OP clear, no carotid
bruits
Lung: clear, no crackles, no wheezing
Heart: Systolic murmur at USB
Ab: soft, NT/ND
Ext: R knee with sutures in place, warm to touch compared to
left
side, no erythema or drainage. L toes bandaged.
Neurologic Examination:
Mental status:
Level of Arousal: Awake. Drowsy throughout exam but easily
arousable to voice. Oriented to [**2139-6-5**] (thought date was 13
or 14?), knows hospital but not which one. Knows President
current and prior.
Attentiveness: refused to tell months backward but able to tell
days of week forward.
Language: fluent, moderate dysarthria, normal comprehension,
repetition, naming. No paraphasic errors.
Memory: very poor registration/recall (could not register more
than [**1-5**] words at a time), remote memory intact.
Praxis: No apraxia/dyspraxia
Calculation: incorrect (said 4 quarters in $1.25)
Neglect: no neglect
Cranial Nerves:
I: Not tested.
II: Pupils symmetric at 3 to 2 mm, equal, round and reactive to
light bilaterally, defect in VF at Left inferior
quadrant(examined with both eyes open)
III, IV, VI: EOMI, normal primary position, no ptosis
V, VII: Facial sensation intact, L upper and lower facial
weakness
VIII: Hearing intact to voice.
IX, X: Palatal elevation normal
[**Doctor First Name 81**]: Unable to move Lt trapezius and sternocleidomastoid, R side
full
XII: Tongue midline and no fasciculation
MOTOR:
Lying in bed, no tremor or abnormal movement
Tone and Bulk: Flaccid tone LUE but incrased tone LLE
D B T WE FE FF IP Q H AT G/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**] TF
R 5 5 5 5 5 5 5 - - 5 5 5 5
L 0 throughout
**Unable to examine R knee due to pain from septic arthritis
Reflexes:
B T Br Pa Ac
R 2 2 2 2 2
L 2 2 2 - 2
**Unable to examine R knee due to pain from septic arthritis
Toes downgoing on right, upgoing on left
Sensation:
Examined with difficulty because patient was drowsy
-decreased light touch L arm and leg, intact on face V1-3
-vibration intact
-Proprioception intact
-pain by pinprick - decrease sensation of LUE but intact both
LEs, intact abdominal/chest area
-no extinction to DSS
Coordination and Cerebellar Function: no dysmetria on FNF on the
right, intact finger to crease tapping on the right
Gait: not assessed
Physical Exam on Discharge:
Expired
Pertinent Results:
[**2139-6-23**] 10:22AM PT-16.2* PTT-33.6 INR(PT)-1.5*
[**2139-6-23**] 10:22AM PLT COUNT-106*
[**2139-6-23**] 10:22AM NEUTS-85.9* LYMPHS-10.6* MONOS-3.0 EOS-0.3
BASOS-0.3
[**2139-6-23**] 10:22AM WBC-13.1* RBC-3.16* HGB-10.4* HCT-29.5*
MCV-93 MCH-32.9* MCHC-35.2* RDW-14.5
[**2139-6-23**] 10:22AM CALCIUM-7.6* PHOSPHATE-2.6* MAGNESIUM-2.1
[**2139-6-23**] 10:22AM estGFR-Using this
[**2139-6-23**] 10:22AM GLUCOSE-108* UREA N-12 CREAT-0.5 SODIUM-133
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-25 ANION GAP-11
[**2139-6-23**] 12:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2139-6-23**] 12:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2139-6-23**] 12:30PM URINE UHOLD-HOLD
[**2139-6-23**] 12:30PM URINE HOURS-RANDOM
[**2139-6-23**] 11:46PM OSMOLAL-270*
[**2139-6-23**] 11:46PM SODIUM-131* POTASSIUM-3.9 CHLORIDE-100
[**2139-6-23**] 11:51PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2139-6-23**] 11:51PM URINE OSMOLAL-578
[**2139-6-23**] 11:51PM URINE HOURS-RANDOM SODIUM-75 POTASSIUM-55
CHLORIDE-75
Noncontrast head CT [**2139-6-23**]:
IMPRESSION:
1. 3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital
intraparenchymal hemorrhages with surrounding edema similar to
reference study.
2. Partial effacement of frontal [**Doctor Last Name 534**] and atrium of right
lateral ventricle with slight asymmetric enlargement of the
right temporal [**Doctor Last Name 534**], similar to prior.
Transthoracic echo [**2139-6-23**]:
IMPRESSION: no vegetations seen
MRI/A head and neck [**2139-6-23**]:
IMPRESSION:
1. Large intraparenchymal hemorrhage in the right centrum
semiovale with mass effect and midline shift. A small
hemorrhage is seen in the right posterior temporal region.
Restricted diffusion is seen surrounding the large
intraparenchymal hemorrhage. Increased signal on post-contrast
images could be suspicious for extravasation. The differential
diagnosis includes cerebritis with secondary involvement of the
vascular structures or a mycotic aneurysm.
2. Leptomeningeal enhancement suggests meningitis.
3. Soft tissue abscess identified in the posterior neck, soft
tissue
structures measuring 17-mm mm indicating metastatic abscess.
4. MRA of the neck is unremarkable.
5. MRA of the head is limited by motion, but no major vascular
occlusion
seen. The findings were discussed with Dr. [**Last Name (STitle) **] at the time
of
interpretation of this study on [**2139-6-24**] at 11:30 a.m.
CXR [**2139-6-24**]:
FINDINGS: In comparison with the study of [**6-23**], the tip of the
endotracheal tube measures approximately 3.8 cm above the
carina. Nasogastric tube extends into the stomach where it
crosses the lower margin of the image.
Continued enlargement of the cardiac silhouette with engorgement
of indistinct pulmonary vessels, consistent with elevated
pulmonary venous pressure. The apparent widening of the
mediastinum is not as well appreciated on the current study.
Bibasilar atelectatic changes are again seen.
Brief Hospital Course:
53 yo RHM with HIV, HCV, recent diagnosis of septic arthritis
who presented to an outside hospital with dense L hemiplegia and
dysarthria. Head CT demonstrated approx 3.2x3.4 cm R
frontoparietal IPH as well as small R occipital IPH. He was
transferred to [**Hospital1 18**] for further management. Repeat CT in ED
here appeared stable. He was admitted to the neuro ICU for close
monitoring and further investigation. There was concern for
septic emboli as a potential etiology of his IPH, in the setting
of septic arthritis and a systolic murmur. Echocardiogram showed
no evidence of vegetations. He was continued on cefazolin for
antibiotic coverage given his recent history of septic
arthritis. Lovenox and all antiplatelets/anticoagulants were
held. BP was monitored closely with a goal SBP of <160.
He underwent an MRI in the evening of [**6-23**], which demonstrated
enlargement of R frontoparietal hemorrhage with surrounding
edema and ~10mm midline shift. On exam he was less responsive
(although had also received ativan) with minimal withdrawal to
noxious on L. He was started on mannitol and neurosurgery was
[**Name (NI) 653**], who reviewed the images and recommended craniotomy.
His family initially consented to the procedure but after
further discussion regarding his likely poor prognosis with
dense L hemiparesis they declined and he was made CMO. He was
started on a morphine gtt and passed away at 2:06pm on [**2139-6-24**].
Family were at the bedside and declined autopsy.
Medications on Admission:
1. Paxil 40 mg tid
2. Abacavir 300 mg tid, Truvada 1 tab daily, Raltegravir 400 mg
[**Hospital1 **] for HARRT
3. Cefazolin 2 g IV tid
4. Ribavarin 200 mg tid and Peginterferon 180 mcg weekly for HCV
5. Lovenox 30 mg sc daily plan cont 12 days after discharge on
[**2139-5-18**]
6. Oxycodone 5 mg prn q4hr
7. Reglan 10 mg prn qid
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Intraparenchymal hemorrhage
Septic arthritis
Discharge Condition:
Expired
Discharge Instructions:
Mr. [**Known lastname 5230**] was admitted to [**Hospital1 69**]
on [**2139-6-23**] after experiencing sudden onset left sided weakness
at home. He was found to have two areas of bleeding in the right
side of his brain. He was admitted to the neuro ICU. An MRI was
performed which showed worsening of the bleeding with
compression of his brain. The option of surgery was discussed
with his family, but given the severity of the bleeding and his
poor prognosis the decision was made to forgo surgical
intervention and pursue comfort measures only. He was started on
a morphine drip and passed away peacefully at 2:06pm on [**2139-6-24**].
Family declined autopsy.
Followup Instructions:
n/a
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
| {
"clinical_findings": {
"I616": [
{
"icd_10_cm_code": "I61.6",
"icd_10_cm_code_description": "Multiple localized intraparenchymal hemorrhage",
"Monitoring": [
{
"text": "Repeat CT in ED here appeared stable.",
"page_numbers": [
1
]
},
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema and ~10mm midline shift",
"page_numbers": [
1
]
},
{
"text": "BP was monitored closely with a goal SBP of <160.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital\nintraparenchymal hemorrhages",
"page_numbers": [
1
]
},
{
"text": "Large intraparenchymal hemorrhage in the right centrum\nsemiovale",
"page_numbers": [
1
]
},
{
"text": "A small\nhemorrhage is seen in the right posterior temporal region",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Intraparenchymal hemorrhage",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "He was started on mannitol",
"page_numbers": [
1
]
},
{
"text": "recommended craniotomy. His family initially consented to the procedure but after\nfurther discussion regarding his likely poor prognosis with\ndense L hemiparesis they declined and he was made CMO.",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "intracranial hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "3.7 x 2.6 right frontal and 1.8 x 1.7 cm right occipital\nintraparenchymal hemorrhages",
"page_numbers": [
1
]
},
{
"evidence_text": "Large intraparenchymal hemorrhage in the right centrum\nsemiovale",
"page_numbers": [
1
]
},
{
"evidence_text": "small\nhemorrhage is seen in the right posterior temporal region",
"page_numbers": [
1
]
},
{
"evidence_text": "R\nfrontoparietal IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "R occipital IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "IPH",
"page_numbers": [
1
]
},
{
"evidence_text": "enlargement of R frontoparietal hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "Intraparenchymal hemorrhage",
"page_numbers": [
1
]
},
{
"evidence_text": "two areas of bleeding in the right\nside of his brain",
"page_numbers": [
1
]
},
{
"evidence_text": "worsening of the bleeding",
"page_numbers": [
1
]
}
],
"justification": "The entity 'IPH' and related terms like 'intracranial hemorrhage' and specific locations are documented in the Chief Complaint, HPI, imaging reports (CT, MRI), Brief Hospital Course, and Discharge Diagnosis. MEAT criteria are met via Evaluation (imaging findings), Monitoring (stability/enlargement on repeat imaging, BP monitoring), Assessment (listed as Discharge Diagnosis), and Treatment (Mannitol, discussion/decision regarding craniotomy and CMO). The code I61.6 is assigned for multiple localized intraparenchymal hemorrhages based on the documentation of hemorrhages in multiple distinct locations (frontal, occipital, centrum semiovale, temporal)."
}
],
"B20": [
{
"icd_10_cm_code": "B20",
"icd_10_cm_code_description": "Human immunodeficiency virus [HIV] disease",
"Monitoring": [
{
"text": "he\nreports seeing PCP monthly and recent CD4 count 600s.",
"page_numbers": [
1
]
}
],
"Evaluation": null,
"Assessment": null,
"Treatment": [
{
"text": "on Abacavir, Truvada and Raltegravir.",
"page_numbers": [
1
]
},
{
"text": "Abacavir 300 mg tid, Truvada 1 tab daily, Raltegravir 400 mg\n[**Hospital1 **] for HARRT",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HIV",
"page_numbers": [
1
]
},
{
"evidence_text": "HIV",
"page_numbers": [
1
]
},
{
"evidence_text": "HIV",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HIV' is documented in the HPI, PMH, and Brief Hospital Course. MEAT criteria are met via Monitoring (PCP visits, CD4 count) and Treatment (HARRT medications). The code B20 is assigned for Human immunodeficiency virus [HIV] disease."
}
],
"B182": [
{
"icd_10_cm_code": "B18.2",
"icd_10_cm_code_description": "Chronic viral hepatitis C",
"Monitoring": null,
"Evaluation": null,
"Assessment": null,
"Treatment": [
{
"text": "on Ribavarin and Peginterferon",
"page_numbers": [
1
]
},
{
"text": "Ribavarin 200 mg tid and Peginterferon 180 mcg weekly for HCV",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HCV",
"page_numbers": [
1
]
},
{
"evidence_text": "HCV",
"page_numbers": [
1
]
},
{
"evidence_text": "HCV",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HCV' is documented in the HPI, PMH, Brief Hospital Course, and Medications on Admission. MEAT criteria are met via Treatment (Ribavarin and Peginterferon). The code B18.2 is assigned for Chronic viral hepatitis C."
}
],
"G8194": [
{
"icd_10_cm_code": "G81.94",
"icd_10_cm_code_description": "Unspecified hemiplegia and hemiparesis affecting left dominant side",
"Monitoring": [
{
"text": "Reports that he cannot\nmove\nhis L extremities at all, which is stable from onset at 3am.",
"page_numbers": [
1
]
},
{
"text": "dense L hemiplegia",
"page_numbers": [
1
]
},
{
"text": "dense L hemiparesis",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "L upper and lower facial\nweakness",
"page_numbers": [
1
]
},
{
"text": "Unable to move Lt trapezius and sternocleidomastoid",
"page_numbers": [
1
]
},
{
"text": "Flaccid tone LUE",
"page_numbers": [
1
]
},
{
"text": "incrased tone LLE",
"page_numbers": [
1
]
},
{
"text": "L 0 throughout",
"page_numbers": [
1
]
},
{
"text": "upgoing on left",
"page_numbers": [
1
]
},
{
"text": "decreased light touch L arm and leg",
"page_numbers": [
1
]
},
{
"text": "decrease sensation of LUE",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "L hemiparesis",
"page_numbers": [
1
]
},
{
"evidence_text": "L hemiplegia",
"page_numbers": [
1
]
},
{
"evidence_text": "dense L hemiplegia",
"page_numbers": [
1
]
},
{
"evidence_text": "dense L hemiparesis",
"page_numbers": [
1
]
}
],
"justification": "The entities 'L hemiparesis' and 'L hemiplegia' are documented in the HPI and Brief Hospital Course. MEAT criteria are met via Monitoring (patient report of inability to move extremities, stability, description as 'dense') and Evaluation (detailed physical/neurologic exam findings including weakness, tone, motor strength, reflexes, sensation). The code G81.94 is assigned for unspecified hemiplegia and hemiparesis affecting the left side. Although the patient is right-handed, the documentation does not specify dominance in relation to the hemiplegia, so unspecified dominance is appropriate."
}
],
"G936": [
{
"icd_10_cm_code": "G93.6",
"icd_10_cm_code_description": "Cerebral edema",
"Monitoring": [
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "surrounding edema similar to\nreference study.",
"page_numbers": [
1
]
},
{
"text": "enlargement of R frontoparietal hemorrhage with surrounding\nedema",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "surrounding edema",
"page_numbers": [
1
]
},
{
"evidence_text": "surrounding\nedema",
"page_numbers": [
1
]
}
],
"justification": "The entity 'surrounding edema' (referring to cerebral edema) is documented in the CT and MRI reports and Brief Hospital Course. MEAT criteria are met via Evaluation (imaging findings) and Monitoring (enlargement noted on MRI). The code G93.6 is assigned for Cerebral edema."
}
],
"G935": [
{
"icd_10_cm_code": "G93.5",
"icd_10_cm_code_description": "Compression of brain",
"Monitoring": [
{
"text": "~10mm midline shift",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "mass effect and midline shift.",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "mass effect",
"page_numbers": [
1
]
},
{
"evidence_text": "midline shift",
"page_numbers": [
1
]
},
{
"evidence_text": "~10mm midline shift",
"page_numbers": [
1
]
},
{
"evidence_text": "compression of his brain",
"page_numbers": [
1
]
}
],
"justification": "The entities 'mass effect' and 'midline shift' are documented in the MRI report and Brief Hospital Course, indicating compression of the brain. MEAT criteria are met via Evaluation (MRI findings) and Monitoring (measurement of midline shift). The code G93.5 is assigned for Compression of brain, which covers both mass effect and midline shift."
}
],
"I76": [
{
"icd_10_cm_code": "I76",
"icd_10_cm_code_description": "Septic embolism",
"Monitoring": null,
"Evaluation": [
{
"text": "Echocardiogram showed\nno evidence of vegetations.",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "There was concern for\nseptic emboli as a potential etiology of his IPH, in the setting\nof septic arthritis and a systolic murmur.",
"page_numbers": [
1
]
}
],
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "septic emboli",
"page_numbers": [
1
]
}
],
"justification": "The entity 'septic emboli' is documented in the Brief Hospital Course as a potential etiology for the IPH. MEAT criteria are met via Assessment (considered as a potential cause) and Evaluation (echocardiogram performed to rule out endocarditis as a source). The code I76 is assigned for Septic embolism."
}
],
"I2729": [
{
"icd_10_cm_code": "I27.29",
"icd_10_cm_code_description": "Other secondary pulmonary hypertension",
"Monitoring": null,
"Evaluation": [
{
"text": "engorgement\nof indistinct pulmonary vessels, consistent with elevated\npulmonary venous pressure",
"page_numbers": [
1
]
}
],
"Assessment": null,
"Treatment": null,
"condition_evidence": [
{
"evidence_text": "elevated\npulmonary venous pressure",
"page_numbers": [
1
]
}
],
"justification": "The entity 'elevated pulmonary venous pressure' is documented in the CXR report. MEAT criteria are met via Evaluation (CXR finding). The code I27.29 is assigned for Other secondary pulmonary hypertension, as elevated pulmonary venous pressure is a cause of secondary pulmonary hypertension."
}
]
}
} |
Extract the ICD-10-CM code assigned to each clinical condition mentioned in the discharge summary. | Admission Date: [**2151-6-7**] Discharge Date: [**2151-6-14**]
Date of Birth: [**2073-10-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on Exertion with abnormal stress test
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 3(LIMA->LAD, SVG->LCX, OM1)
[**2151-6-7**]
History of Present Illness:
This 77F has a history of HTN had increased DOE and had a +ETT.
She underwent cardiac cath on [**2151-6-2**] at [**Hospital1 18**] which revealed:
LVEF of 80%, 60%LM [**Last Name (un) 2435**]., 70% mid LAD, 80% LCX, 80%OM1, 60% RCA.
She is now admitted for elective CABG.
Past Medical History:
Hypertension
Diverticulosis
Cervical cancer
R breast cancer-s/p R mastectomy [**2137**]
Skin cancer s/p removal
Social History:
Lives alone
Cigs: none
ETOH: occasional
Family History:
+CAD
Physical Exam:
Elderly WF in NAD
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+= bilat. without bruits.
Lungs: Clear to A+P
CV: RRR without R/G/M, nl. S1, S2
Abd: +BS, soft, nontender without masses or hepatosplenomegaly.
Ext.: no C/C/E, pulses 2+= bilat.
Neuro: nonfocal
Pertinent Results:
Echo [**6-7**]: PRE-CPB: Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Trivial mitral regurgitation
is seen. There is a small pericardial effusion. POST-CPB No
changes from pre-CPB
CXR [**6-13**]: Tiny right apical pneumothorax and small layering
bilateral pleural effusion are unchanged. Moderate cardiomegaly
stable. Lateral view shows subcutaneous emphysema in the right
anterior thoracoabdominal wall is unchanged. Left lower lobe
atelectasis has improved. Moderate cardiomegaly is stable.
[**2151-6-7**] 11:44AM BLOOD WBC-5.7 RBC-1.43*# Hgb-4.4*# Hct-12.7*#
MCV-89 MCH-30.4 MCHC-34.3 RDW-13.1 Plt Ct-73*#
[**2151-6-7**] 12:54PM BLOOD WBC-13.2* RBC-3.90* Hgb-11.7* Hct-33.3*
MCV-85 MCH-29.9 MCHC-35.0 RDW-13.1 Plt Ct-145*
[**2151-6-12**] 05:20AM BLOOD WBC-9.5 RBC-2.94* Hgb-8.9* Hct-25.8*
MCV-88 MCH-30.2 MCHC-34.4 RDW-13.5 Plt Ct-269
[**2151-6-7**] 12:54PM BLOOD PT-14.8* PTT-37.3* INR(PT)-1.3*
[**2151-6-7**] 12:54PM BLOOD UreaN-16 Creat-0.7 Cl-113* HCO3-22
[**2151-6-12**] 05:20AM BLOOD Glucose-115* UreaN-16 Creat-0.8 Na-140
K-4.7 Cl-101 HCO3-31 AnGap-13
Brief Hospital Course:
The patient was a same day admit and on [**6-7**] and she underwent a
Coronary Artery Bypass Graft x 3(LIMA->LAD, SVG->LCX, OM1). She
tolerated the procedure well and was transferred to the CSRU for
invasive monitoring in stable condition on Propofol and Neo. She
was weaned from sedation, awoke neurologically intact and was
extubated on the postop night. On post-op day one she was
transferred to the floor. Beta blockers and diuretics were
initiated. Diuretics were adjusted towards pre-op weight. Her
chest tubes were removed on post-op day two and epicardial
pacing wires on post-op day three. Following chest tube removal,
a small right-sided apical pneumothorax was seen. On post-op day
four a right-side chest tube was placed with serial chest x-rays
throughout rest of hospital course. Besides from the small
pneumothorax, she made a good recovery. Her chest tube was
removed on post-op day six and the post-pull chest x-ray
revealed no pneumothorax. Physical therapy followed patient
during entire post-op course for strength and mobility. She
appeared to be doing well and was discharged on post-op day
seven.
Medications on Admission:
ASA 325 mg PO daily
Atenolol 25 mg PO daily
Zocor 40 mg PO daily
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days.
8. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Graft x 3
PMH: Hypertension, Diverticulosis, Cervical Cancer, R Breast
Cancer s/p Mastectomy, Skin Cancer s/p removal
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use lotions, creams, or powders on wounds. Do not take
bath.
Call our office for sternal drainage, temp>101.5.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5763**] Follow-up
appointment should be in 1 week
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) 5764**],[**First Name3 (LF) **] E. [**Telephone/Fax (1) 4105**] Follow-up
appointment should be in 2 weeks
Completed by:[**2151-6-14**] | {
"clinical_findings": {
"I119": [
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "PMH: Hypertension",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "Atenolol 25 mg PO daily",
"page_numbers": [
1
]
},
{
"text": "Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.",
"page_numbers": [
2
]
},
{
"text": "Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days.",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. This condition meets MEAT criteria based on documentation in the Assessment section (listed in Discharge Diagnosis under PMH) and Treatment section (patient is on Atenolol and Furosemide, medications commonly used for hypertension)."
},
{
"icd_10_cm_code": "I51.7",
"icd_10_cm_code_description": "Cardiomegaly",
"Monitoring": [
{
"text": "Moderate cardiomegaly stable.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "CXR [**6-13**]: Tiny right apical pneumothorax and small layering bilateral pleural effusion are unchanged. Moderate cardiomegaly stable.",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "Moderate cardiomegaly",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I51.7 is assigned for Cardiomegaly, documented as moderate cardiomegaly. This condition meets MEAT criteria based on documentation in the Monitoring section (status stable) and Evaluation section (CXR findings)."
}
]
}
} |
Extract the ICD-10-CM code description for each clinical condition mentioned in the discharge summary. | Admission Date: [**2151-6-7**] Discharge Date: [**2151-6-14**]
Date of Birth: [**2073-10-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on Exertion with abnormal stress test
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 3(LIMA->LAD, SVG->LCX, OM1)
[**2151-6-7**]
History of Present Illness:
This 77F has a history of HTN had increased DOE and had a +ETT.
She underwent cardiac cath on [**2151-6-2**] at [**Hospital1 18**] which revealed:
LVEF of 80%, 60%LM [**Last Name (un) 2435**]., 70% mid LAD, 80% LCX, 80%OM1, 60% RCA.
She is now admitted for elective CABG.
Past Medical History:
Hypertension
Diverticulosis
Cervical cancer
R breast cancer-s/p R mastectomy [**2137**]
Skin cancer s/p removal
Social History:
Lives alone
Cigs: none
ETOH: occasional
Family History:
+CAD
Physical Exam:
Elderly WF in NAD
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+= bilat. without bruits.
Lungs: Clear to A+P
CV: RRR without R/G/M, nl. S1, S2
Abd: +BS, soft, nontender without masses or hepatosplenomegaly.
Ext.: no C/C/E, pulses 2+= bilat.
Neuro: nonfocal
Pertinent Results:
Echo [**6-7**]: PRE-CPB: Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Trivial mitral regurgitation
is seen. There is a small pericardial effusion. POST-CPB No
changes from pre-CPB
CXR [**6-13**]: Tiny right apical pneumothorax and small layering
bilateral pleural effusion are unchanged. Moderate cardiomegaly
stable. Lateral view shows subcutaneous emphysema in the right
anterior thoracoabdominal wall is unchanged. Left lower lobe
atelectasis has improved. Moderate cardiomegaly is stable.
[**2151-6-7**] 11:44AM BLOOD WBC-5.7 RBC-1.43*# Hgb-4.4*# Hct-12.7*#
MCV-89 MCH-30.4 MCHC-34.3 RDW-13.1 Plt Ct-73*#
[**2151-6-7**] 12:54PM BLOOD WBC-13.2* RBC-3.90* Hgb-11.7* Hct-33.3*
MCV-85 MCH-29.9 MCHC-35.0 RDW-13.1 Plt Ct-145*
[**2151-6-12**] 05:20AM BLOOD WBC-9.5 RBC-2.94* Hgb-8.9* Hct-25.8*
MCV-88 MCH-30.2 MCHC-34.4 RDW-13.5 Plt Ct-269
[**2151-6-7**] 12:54PM BLOOD PT-14.8* PTT-37.3* INR(PT)-1.3*
[**2151-6-7**] 12:54PM BLOOD UreaN-16 Creat-0.7 Cl-113* HCO3-22
[**2151-6-12**] 05:20AM BLOOD Glucose-115* UreaN-16 Creat-0.8 Na-140
K-4.7 Cl-101 HCO3-31 AnGap-13
Brief Hospital Course:
The patient was a same day admit and on [**6-7**] and she underwent a
Coronary Artery Bypass Graft x 3(LIMA->LAD, SVG->LCX, OM1). She
tolerated the procedure well and was transferred to the CSRU for
invasive monitoring in stable condition on Propofol and Neo. She
was weaned from sedation, awoke neurologically intact and was
extubated on the postop night. On post-op day one she was
transferred to the floor. Beta blockers and diuretics were
initiated. Diuretics were adjusted towards pre-op weight. Her
chest tubes were removed on post-op day two and epicardial
pacing wires on post-op day three. Following chest tube removal,
a small right-sided apical pneumothorax was seen. On post-op day
four a right-side chest tube was placed with serial chest x-rays
throughout rest of hospital course. Besides from the small
pneumothorax, she made a good recovery. Her chest tube was
removed on post-op day six and the post-pull chest x-ray
revealed no pneumothorax. Physical therapy followed patient
during entire post-op course for strength and mobility. She
appeared to be doing well and was discharged on post-op day
seven.
Medications on Admission:
ASA 325 mg PO daily
Atenolol 25 mg PO daily
Zocor 40 mg PO daily
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days.
8. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Graft x 3
PMH: Hypertension, Diverticulosis, Cervical Cancer, R Breast
Cancer s/p Mastectomy, Skin Cancer s/p removal
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use lotions, creams, or powders on wounds. Do not take
bath.
Call our office for sternal drainage, temp>101.5.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5763**] Follow-up
appointment should be in 1 week
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) 5764**],[**First Name3 (LF) **] E. [**Telephone/Fax (1) 4105**] Follow-up
appointment should be in 2 weeks
Completed by:[**2151-6-14**] | {
"clinical_findings": {
"I119": [
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "PMH: Hypertension",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "Atenolol 25 mg PO daily",
"page_numbers": [
1
]
},
{
"text": "Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.",
"page_numbers": [
2
]
},
{
"text": "Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days.",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. This condition meets MEAT criteria based on documentation in the Assessment section (listed in Discharge Diagnosis under PMH) and Treatment section (patient is on Atenolol and Furosemide, medications commonly used for hypertension)."
},
{
"icd_10_cm_code": "I51.7",
"icd_10_cm_code_description": "Cardiomegaly",
"Monitoring": [
{
"text": "Moderate cardiomegaly stable.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "CXR [**6-13**]: Tiny right apical pneumothorax and small layering bilateral pleural effusion are unchanged. Moderate cardiomegaly stable.",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "Moderate cardiomegaly",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I51.7 is assigned for Cardiomegaly, documented as moderate cardiomegaly. This condition meets MEAT criteria based on documentation in the Monitoring section (status stable) and Evaluation section (CXR findings)."
}
]
}
} |
Extract only the monitoring information related to each clinical condition, such as vital signs, labs, or telemetry data. | Admission Date: [**2151-6-7**] Discharge Date: [**2151-6-14**]
Date of Birth: [**2073-10-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on Exertion with abnormal stress test
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 3(LIMA->LAD, SVG->LCX, OM1)
[**2151-6-7**]
History of Present Illness:
This 77F has a history of HTN had increased DOE and had a +ETT.
She underwent cardiac cath on [**2151-6-2**] at [**Hospital1 18**] which revealed:
LVEF of 80%, 60%LM [**Last Name (un) 2435**]., 70% mid LAD, 80% LCX, 80%OM1, 60% RCA.
She is now admitted for elective CABG.
Past Medical History:
Hypertension
Diverticulosis
Cervical cancer
R breast cancer-s/p R mastectomy [**2137**]
Skin cancer s/p removal
Social History:
Lives alone
Cigs: none
ETOH: occasional
Family History:
+CAD
Physical Exam:
Elderly WF in NAD
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+= bilat. without bruits.
Lungs: Clear to A+P
CV: RRR without R/G/M, nl. S1, S2
Abd: +BS, soft, nontender without masses or hepatosplenomegaly.
Ext.: no C/C/E, pulses 2+= bilat.
Neuro: nonfocal
Pertinent Results:
Echo [**6-7**]: PRE-CPB: Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Trivial mitral regurgitation
is seen. There is a small pericardial effusion. POST-CPB No
changes from pre-CPB
CXR [**6-13**]: Tiny right apical pneumothorax and small layering
bilateral pleural effusion are unchanged. Moderate cardiomegaly
stable. Lateral view shows subcutaneous emphysema in the right
anterior thoracoabdominal wall is unchanged. Left lower lobe
atelectasis has improved. Moderate cardiomegaly is stable.
[**2151-6-7**] 11:44AM BLOOD WBC-5.7 RBC-1.43*# Hgb-4.4*# Hct-12.7*#
MCV-89 MCH-30.4 MCHC-34.3 RDW-13.1 Plt Ct-73*#
[**2151-6-7**] 12:54PM BLOOD WBC-13.2* RBC-3.90* Hgb-11.7* Hct-33.3*
MCV-85 MCH-29.9 MCHC-35.0 RDW-13.1 Plt Ct-145*
[**2151-6-12**] 05:20AM BLOOD WBC-9.5 RBC-2.94* Hgb-8.9* Hct-25.8*
MCV-88 MCH-30.2 MCHC-34.4 RDW-13.5 Plt Ct-269
[**2151-6-7**] 12:54PM BLOOD PT-14.8* PTT-37.3* INR(PT)-1.3*
[**2151-6-7**] 12:54PM BLOOD UreaN-16 Creat-0.7 Cl-113* HCO3-22
[**2151-6-12**] 05:20AM BLOOD Glucose-115* UreaN-16 Creat-0.8 Na-140
K-4.7 Cl-101 HCO3-31 AnGap-13
Brief Hospital Course:
The patient was a same day admit and on [**6-7**] and she underwent a
Coronary Artery Bypass Graft x 3(LIMA->LAD, SVG->LCX, OM1). She
tolerated the procedure well and was transferred to the CSRU for
invasive monitoring in stable condition on Propofol and Neo. She
was weaned from sedation, awoke neurologically intact and was
extubated on the postop night. On post-op day one she was
transferred to the floor. Beta blockers and diuretics were
initiated. Diuretics were adjusted towards pre-op weight. Her
chest tubes were removed on post-op day two and epicardial
pacing wires on post-op day three. Following chest tube removal,
a small right-sided apical pneumothorax was seen. On post-op day
four a right-side chest tube was placed with serial chest x-rays
throughout rest of hospital course. Besides from the small
pneumothorax, she made a good recovery. Her chest tube was
removed on post-op day six and the post-pull chest x-ray
revealed no pneumothorax. Physical therapy followed patient
during entire post-op course for strength and mobility. She
appeared to be doing well and was discharged on post-op day
seven.
Medications on Admission:
ASA 325 mg PO daily
Atenolol 25 mg PO daily
Zocor 40 mg PO daily
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days.
8. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Graft x 3
PMH: Hypertension, Diverticulosis, Cervical Cancer, R Breast
Cancer s/p Mastectomy, Skin Cancer s/p removal
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use lotions, creams, or powders on wounds. Do not take
bath.
Call our office for sternal drainage, temp>101.5.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5763**] Follow-up
appointment should be in 1 week
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) 5764**],[**First Name3 (LF) **] E. [**Telephone/Fax (1) 4105**] Follow-up
appointment should be in 2 weeks
Completed by:[**2151-6-14**] | {
"clinical_findings": {
"I119": [
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "PMH: Hypertension",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "Atenolol 25 mg PO daily",
"page_numbers": [
1
]
},
{
"text": "Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.",
"page_numbers": [
2
]
},
{
"text": "Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days.",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. This condition meets MEAT criteria based on documentation in the Assessment section (listed in Discharge Diagnosis under PMH) and Treatment section (patient is on Atenolol and Furosemide, medications commonly used for hypertension)."
},
{
"icd_10_cm_code": "I51.7",
"icd_10_cm_code_description": "Cardiomegaly",
"Monitoring": [
{
"text": "Moderate cardiomegaly stable.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "CXR [**6-13**]: Tiny right apical pneumothorax and small layering bilateral pleural effusion are unchanged. Moderate cardiomegaly stable.",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "Moderate cardiomegaly",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I51.7 is assigned for Cardiomegaly, documented as moderate cardiomegaly. This condition meets MEAT criteria based on documentation in the Monitoring section (status stable) and Evaluation section (CXR findings)."
}
]
}
} |
Extract only the clinical evaluation methods used for each condition, such as imaging, physical examination, or biopsy. | Admission Date: [**2151-6-7**] Discharge Date: [**2151-6-14**]
Date of Birth: [**2073-10-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on Exertion with abnormal stress test
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 3(LIMA->LAD, SVG->LCX, OM1)
[**2151-6-7**]
History of Present Illness:
This 77F has a history of HTN had increased DOE and had a +ETT.
She underwent cardiac cath on [**2151-6-2**] at [**Hospital1 18**] which revealed:
LVEF of 80%, 60%LM [**Last Name (un) 2435**]., 70% mid LAD, 80% LCX, 80%OM1, 60% RCA.
She is now admitted for elective CABG.
Past Medical History:
Hypertension
Diverticulosis
Cervical cancer
R breast cancer-s/p R mastectomy [**2137**]
Skin cancer s/p removal
Social History:
Lives alone
Cigs: none
ETOH: occasional
Family History:
+CAD
Physical Exam:
Elderly WF in NAD
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+= bilat. without bruits.
Lungs: Clear to A+P
CV: RRR without R/G/M, nl. S1, S2
Abd: +BS, soft, nontender without masses or hepatosplenomegaly.
Ext.: no C/C/E, pulses 2+= bilat.
Neuro: nonfocal
Pertinent Results:
Echo [**6-7**]: PRE-CPB: Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Trivial mitral regurgitation
is seen. There is a small pericardial effusion. POST-CPB No
changes from pre-CPB
CXR [**6-13**]: Tiny right apical pneumothorax and small layering
bilateral pleural effusion are unchanged. Moderate cardiomegaly
stable. Lateral view shows subcutaneous emphysema in the right
anterior thoracoabdominal wall is unchanged. Left lower lobe
atelectasis has improved. Moderate cardiomegaly is stable.
[**2151-6-7**] 11:44AM BLOOD WBC-5.7 RBC-1.43*# Hgb-4.4*# Hct-12.7*#
MCV-89 MCH-30.4 MCHC-34.3 RDW-13.1 Plt Ct-73*#
[**2151-6-7**] 12:54PM BLOOD WBC-13.2* RBC-3.90* Hgb-11.7* Hct-33.3*
MCV-85 MCH-29.9 MCHC-35.0 RDW-13.1 Plt Ct-145*
[**2151-6-12**] 05:20AM BLOOD WBC-9.5 RBC-2.94* Hgb-8.9* Hct-25.8*
MCV-88 MCH-30.2 MCHC-34.4 RDW-13.5 Plt Ct-269
[**2151-6-7**] 12:54PM BLOOD PT-14.8* PTT-37.3* INR(PT)-1.3*
[**2151-6-7**] 12:54PM BLOOD UreaN-16 Creat-0.7 Cl-113* HCO3-22
[**2151-6-12**] 05:20AM BLOOD Glucose-115* UreaN-16 Creat-0.8 Na-140
K-4.7 Cl-101 HCO3-31 AnGap-13
Brief Hospital Course:
The patient was a same day admit and on [**6-7**] and she underwent a
Coronary Artery Bypass Graft x 3(LIMA->LAD, SVG->LCX, OM1). She
tolerated the procedure well and was transferred to the CSRU for
invasive monitoring in stable condition on Propofol and Neo. She
was weaned from sedation, awoke neurologically intact and was
extubated on the postop night. On post-op day one she was
transferred to the floor. Beta blockers and diuretics were
initiated. Diuretics were adjusted towards pre-op weight. Her
chest tubes were removed on post-op day two and epicardial
pacing wires on post-op day three. Following chest tube removal,
a small right-sided apical pneumothorax was seen. On post-op day
four a right-side chest tube was placed with serial chest x-rays
throughout rest of hospital course. Besides from the small
pneumothorax, she made a good recovery. Her chest tube was
removed on post-op day six and the post-pull chest x-ray
revealed no pneumothorax. Physical therapy followed patient
during entire post-op course for strength and mobility. She
appeared to be doing well and was discharged on post-op day
seven.
Medications on Admission:
ASA 325 mg PO daily
Atenolol 25 mg PO daily
Zocor 40 mg PO daily
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days.
8. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Graft x 3
PMH: Hypertension, Diverticulosis, Cervical Cancer, R Breast
Cancer s/p Mastectomy, Skin Cancer s/p removal
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use lotions, creams, or powders on wounds. Do not take
bath.
Call our office for sternal drainage, temp>101.5.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5763**] Follow-up
appointment should be in 1 week
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) 5764**],[**First Name3 (LF) **] E. [**Telephone/Fax (1) 4105**] Follow-up
appointment should be in 2 weeks
Completed by:[**2151-6-14**] | {
"clinical_findings": {
"I119": [
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "PMH: Hypertension",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "Atenolol 25 mg PO daily",
"page_numbers": [
1
]
},
{
"text": "Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.",
"page_numbers": [
2
]
},
{
"text": "Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days.",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. This condition meets MEAT criteria based on documentation in the Assessment section (listed in Discharge Diagnosis under PMH) and Treatment section (patient is on Atenolol and Furosemide, medications commonly used for hypertension)."
},
{
"icd_10_cm_code": "I51.7",
"icd_10_cm_code_description": "Cardiomegaly",
"Monitoring": [
{
"text": "Moderate cardiomegaly stable.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "CXR [**6-13**]: Tiny right apical pneumothorax and small layering bilateral pleural effusion are unchanged. Moderate cardiomegaly stable.",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "Moderate cardiomegaly",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I51.7 is assigned for Cardiomegaly, documented as moderate cardiomegaly. This condition meets MEAT criteria based on documentation in the Monitoring section (status stable) and Evaluation section (CXR findings)."
}
]
}
} |
Extract only the clinical assessment findings for each condition, including diagnostic conclusions and staging. | Admission Date: [**2151-6-7**] Discharge Date: [**2151-6-14**]
Date of Birth: [**2073-10-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on Exertion with abnormal stress test
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 3(LIMA->LAD, SVG->LCX, OM1)
[**2151-6-7**]
History of Present Illness:
This 77F has a history of HTN had increased DOE and had a +ETT.
She underwent cardiac cath on [**2151-6-2**] at [**Hospital1 18**] which revealed:
LVEF of 80%, 60%LM [**Last Name (un) 2435**]., 70% mid LAD, 80% LCX, 80%OM1, 60% RCA.
She is now admitted for elective CABG.
Past Medical History:
Hypertension
Diverticulosis
Cervical cancer
R breast cancer-s/p R mastectomy [**2137**]
Skin cancer s/p removal
Social History:
Lives alone
Cigs: none
ETOH: occasional
Family History:
+CAD
Physical Exam:
Elderly WF in NAD
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+= bilat. without bruits.
Lungs: Clear to A+P
CV: RRR without R/G/M, nl. S1, S2
Abd: +BS, soft, nontender without masses or hepatosplenomegaly.
Ext.: no C/C/E, pulses 2+= bilat.
Neuro: nonfocal
Pertinent Results:
Echo [**6-7**]: PRE-CPB: Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Trivial mitral regurgitation
is seen. There is a small pericardial effusion. POST-CPB No
changes from pre-CPB
CXR [**6-13**]: Tiny right apical pneumothorax and small layering
bilateral pleural effusion are unchanged. Moderate cardiomegaly
stable. Lateral view shows subcutaneous emphysema in the right
anterior thoracoabdominal wall is unchanged. Left lower lobe
atelectasis has improved. Moderate cardiomegaly is stable.
[**2151-6-7**] 11:44AM BLOOD WBC-5.7 RBC-1.43*# Hgb-4.4*# Hct-12.7*#
MCV-89 MCH-30.4 MCHC-34.3 RDW-13.1 Plt Ct-73*#
[**2151-6-7**] 12:54PM BLOOD WBC-13.2* RBC-3.90* Hgb-11.7* Hct-33.3*
MCV-85 MCH-29.9 MCHC-35.0 RDW-13.1 Plt Ct-145*
[**2151-6-12**] 05:20AM BLOOD WBC-9.5 RBC-2.94* Hgb-8.9* Hct-25.8*
MCV-88 MCH-30.2 MCHC-34.4 RDW-13.5 Plt Ct-269
[**2151-6-7**] 12:54PM BLOOD PT-14.8* PTT-37.3* INR(PT)-1.3*
[**2151-6-7**] 12:54PM BLOOD UreaN-16 Creat-0.7 Cl-113* HCO3-22
[**2151-6-12**] 05:20AM BLOOD Glucose-115* UreaN-16 Creat-0.8 Na-140
K-4.7 Cl-101 HCO3-31 AnGap-13
Brief Hospital Course:
The patient was a same day admit and on [**6-7**] and she underwent a
Coronary Artery Bypass Graft x 3(LIMA->LAD, SVG->LCX, OM1). She
tolerated the procedure well and was transferred to the CSRU for
invasive monitoring in stable condition on Propofol and Neo. She
was weaned from sedation, awoke neurologically intact and was
extubated on the postop night. On post-op day one she was
transferred to the floor. Beta blockers and diuretics were
initiated. Diuretics were adjusted towards pre-op weight. Her
chest tubes were removed on post-op day two and epicardial
pacing wires on post-op day three. Following chest tube removal,
a small right-sided apical pneumothorax was seen. On post-op day
four a right-side chest tube was placed with serial chest x-rays
throughout rest of hospital course. Besides from the small
pneumothorax, she made a good recovery. Her chest tube was
removed on post-op day six and the post-pull chest x-ray
revealed no pneumothorax. Physical therapy followed patient
during entire post-op course for strength and mobility. She
appeared to be doing well and was discharged on post-op day
seven.
Medications on Admission:
ASA 325 mg PO daily
Atenolol 25 mg PO daily
Zocor 40 mg PO daily
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days.
8. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Graft x 3
PMH: Hypertension, Diverticulosis, Cervical Cancer, R Breast
Cancer s/p Mastectomy, Skin Cancer s/p removal
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use lotions, creams, or powders on wounds. Do not take
bath.
Call our office for sternal drainage, temp>101.5.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5763**] Follow-up
appointment should be in 1 week
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) 5764**],[**First Name3 (LF) **] E. [**Telephone/Fax (1) 4105**] Follow-up
appointment should be in 2 weeks
Completed by:[**2151-6-14**] | {
"clinical_findings": {
"I119": [
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "PMH: Hypertension",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "Atenolol 25 mg PO daily",
"page_numbers": [
1
]
},
{
"text": "Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.",
"page_numbers": [
2
]
},
{
"text": "Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days.",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. This condition meets MEAT criteria based on documentation in the Assessment section (listed in Discharge Diagnosis under PMH) and Treatment section (patient is on Atenolol and Furosemide, medications commonly used for hypertension)."
},
{
"icd_10_cm_code": "I51.7",
"icd_10_cm_code_description": "Cardiomegaly",
"Monitoring": [
{
"text": "Moderate cardiomegaly stable.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "CXR [**6-13**]: Tiny right apical pneumothorax and small layering bilateral pleural effusion are unchanged. Moderate cardiomegaly stable.",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "Moderate cardiomegaly",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I51.7 is assigned for Cardiomegaly, documented as moderate cardiomegaly. This condition meets MEAT criteria based on documentation in the Monitoring section (status stable) and Evaluation section (CXR findings)."
}
]
}
} |
Extract only the treatment or intervention given for each condition, including surgeries, procedures, and medications. | Admission Date: [**2151-6-7**] Discharge Date: [**2151-6-14**]
Date of Birth: [**2073-10-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on Exertion with abnormal stress test
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 3(LIMA->LAD, SVG->LCX, OM1)
[**2151-6-7**]
History of Present Illness:
This 77F has a history of HTN had increased DOE and had a +ETT.
She underwent cardiac cath on [**2151-6-2**] at [**Hospital1 18**] which revealed:
LVEF of 80%, 60%LM [**Last Name (un) 2435**]., 70% mid LAD, 80% LCX, 80%OM1, 60% RCA.
She is now admitted for elective CABG.
Past Medical History:
Hypertension
Diverticulosis
Cervical cancer
R breast cancer-s/p R mastectomy [**2137**]
Skin cancer s/p removal
Social History:
Lives alone
Cigs: none
ETOH: occasional
Family History:
+CAD
Physical Exam:
Elderly WF in NAD
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+= bilat. without bruits.
Lungs: Clear to A+P
CV: RRR without R/G/M, nl. S1, S2
Abd: +BS, soft, nontender without masses or hepatosplenomegaly.
Ext.: no C/C/E, pulses 2+= bilat.
Neuro: nonfocal
Pertinent Results:
Echo [**6-7**]: PRE-CPB: Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Trivial mitral regurgitation
is seen. There is a small pericardial effusion. POST-CPB No
changes from pre-CPB
CXR [**6-13**]: Tiny right apical pneumothorax and small layering
bilateral pleural effusion are unchanged. Moderate cardiomegaly
stable. Lateral view shows subcutaneous emphysema in the right
anterior thoracoabdominal wall is unchanged. Left lower lobe
atelectasis has improved. Moderate cardiomegaly is stable.
[**2151-6-7**] 11:44AM BLOOD WBC-5.7 RBC-1.43*# Hgb-4.4*# Hct-12.7*#
MCV-89 MCH-30.4 MCHC-34.3 RDW-13.1 Plt Ct-73*#
[**2151-6-7**] 12:54PM BLOOD WBC-13.2* RBC-3.90* Hgb-11.7* Hct-33.3*
MCV-85 MCH-29.9 MCHC-35.0 RDW-13.1 Plt Ct-145*
[**2151-6-12**] 05:20AM BLOOD WBC-9.5 RBC-2.94* Hgb-8.9* Hct-25.8*
MCV-88 MCH-30.2 MCHC-34.4 RDW-13.5 Plt Ct-269
[**2151-6-7**] 12:54PM BLOOD PT-14.8* PTT-37.3* INR(PT)-1.3*
[**2151-6-7**] 12:54PM BLOOD UreaN-16 Creat-0.7 Cl-113* HCO3-22
[**2151-6-12**] 05:20AM BLOOD Glucose-115* UreaN-16 Creat-0.8 Na-140
K-4.7 Cl-101 HCO3-31 AnGap-13
Brief Hospital Course:
The patient was a same day admit and on [**6-7**] and she underwent a
Coronary Artery Bypass Graft x 3(LIMA->LAD, SVG->LCX, OM1). She
tolerated the procedure well and was transferred to the CSRU for
invasive monitoring in stable condition on Propofol and Neo. She
was weaned from sedation, awoke neurologically intact and was
extubated on the postop night. On post-op day one she was
transferred to the floor. Beta blockers and diuretics were
initiated. Diuretics were adjusted towards pre-op weight. Her
chest tubes were removed on post-op day two and epicardial
pacing wires on post-op day three. Following chest tube removal,
a small right-sided apical pneumothorax was seen. On post-op day
four a right-side chest tube was placed with serial chest x-rays
throughout rest of hospital course. Besides from the small
pneumothorax, she made a good recovery. Her chest tube was
removed on post-op day six and the post-pull chest x-ray
revealed no pneumothorax. Physical therapy followed patient
during entire post-op course for strength and mobility. She
appeared to be doing well and was discharged on post-op day
seven.
Medications on Admission:
ASA 325 mg PO daily
Atenolol 25 mg PO daily
Zocor 40 mg PO daily
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days.
8. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Graft x 3
PMH: Hypertension, Diverticulosis, Cervical Cancer, R Breast
Cancer s/p Mastectomy, Skin Cancer s/p removal
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use lotions, creams, or powders on wounds. Do not take
bath.
Call our office for sternal drainage, temp>101.5.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5763**] Follow-up
appointment should be in 1 week
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) 5764**],[**First Name3 (LF) **] E. [**Telephone/Fax (1) 4105**] Follow-up
appointment should be in 2 weeks
Completed by:[**2151-6-14**] | {
"clinical_findings": {
"I119": [
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "PMH: Hypertension",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "Atenolol 25 mg PO daily",
"page_numbers": [
1
]
},
{
"text": "Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.",
"page_numbers": [
2
]
},
{
"text": "Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days.",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. This condition meets MEAT criteria based on documentation in the Assessment section (listed in Discharge Diagnosis under PMH) and Treatment section (patient is on Atenolol and Furosemide, medications commonly used for hypertension)."
},
{
"icd_10_cm_code": "I51.7",
"icd_10_cm_code_description": "Cardiomegaly",
"Monitoring": [
{
"text": "Moderate cardiomegaly stable.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "CXR [**6-13**]: Tiny right apical pneumothorax and small layering bilateral pleural effusion are unchanged. Moderate cardiomegaly stable.",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "Moderate cardiomegaly",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I51.7 is assigned for Cardiomegaly, documented as moderate cardiomegaly. This condition meets MEAT criteria based on documentation in the Monitoring section (status stable) and Evaluation section (CXR findings)."
}
]
}
} |
Extract only the evidence from the discharge summary that supports the existence of each condition. | Admission Date: [**2151-6-7**] Discharge Date: [**2151-6-14**]
Date of Birth: [**2073-10-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on Exertion with abnormal stress test
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 3(LIMA->LAD, SVG->LCX, OM1)
[**2151-6-7**]
History of Present Illness:
This 77F has a history of HTN had increased DOE and had a +ETT.
She underwent cardiac cath on [**2151-6-2**] at [**Hospital1 18**] which revealed:
LVEF of 80%, 60%LM [**Last Name (un) 2435**]., 70% mid LAD, 80% LCX, 80%OM1, 60% RCA.
She is now admitted for elective CABG.
Past Medical History:
Hypertension
Diverticulosis
Cervical cancer
R breast cancer-s/p R mastectomy [**2137**]
Skin cancer s/p removal
Social History:
Lives alone
Cigs: none
ETOH: occasional
Family History:
+CAD
Physical Exam:
Elderly WF in NAD
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+= bilat. without bruits.
Lungs: Clear to A+P
CV: RRR without R/G/M, nl. S1, S2
Abd: +BS, soft, nontender without masses or hepatosplenomegaly.
Ext.: no C/C/E, pulses 2+= bilat.
Neuro: nonfocal
Pertinent Results:
Echo [**6-7**]: PRE-CPB: Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Trivial mitral regurgitation
is seen. There is a small pericardial effusion. POST-CPB No
changes from pre-CPB
CXR [**6-13**]: Tiny right apical pneumothorax and small layering
bilateral pleural effusion are unchanged. Moderate cardiomegaly
stable. Lateral view shows subcutaneous emphysema in the right
anterior thoracoabdominal wall is unchanged. Left lower lobe
atelectasis has improved. Moderate cardiomegaly is stable.
[**2151-6-7**] 11:44AM BLOOD WBC-5.7 RBC-1.43*# Hgb-4.4*# Hct-12.7*#
MCV-89 MCH-30.4 MCHC-34.3 RDW-13.1 Plt Ct-73*#
[**2151-6-7**] 12:54PM BLOOD WBC-13.2* RBC-3.90* Hgb-11.7* Hct-33.3*
MCV-85 MCH-29.9 MCHC-35.0 RDW-13.1 Plt Ct-145*
[**2151-6-12**] 05:20AM BLOOD WBC-9.5 RBC-2.94* Hgb-8.9* Hct-25.8*
MCV-88 MCH-30.2 MCHC-34.4 RDW-13.5 Plt Ct-269
[**2151-6-7**] 12:54PM BLOOD PT-14.8* PTT-37.3* INR(PT)-1.3*
[**2151-6-7**] 12:54PM BLOOD UreaN-16 Creat-0.7 Cl-113* HCO3-22
[**2151-6-12**] 05:20AM BLOOD Glucose-115* UreaN-16 Creat-0.8 Na-140
K-4.7 Cl-101 HCO3-31 AnGap-13
Brief Hospital Course:
The patient was a same day admit and on [**6-7**] and she underwent a
Coronary Artery Bypass Graft x 3(LIMA->LAD, SVG->LCX, OM1). She
tolerated the procedure well and was transferred to the CSRU for
invasive monitoring in stable condition on Propofol and Neo. She
was weaned from sedation, awoke neurologically intact and was
extubated on the postop night. On post-op day one she was
transferred to the floor. Beta blockers and diuretics were
initiated. Diuretics were adjusted towards pre-op weight. Her
chest tubes were removed on post-op day two and epicardial
pacing wires on post-op day three. Following chest tube removal,
a small right-sided apical pneumothorax was seen. On post-op day
four a right-side chest tube was placed with serial chest x-rays
throughout rest of hospital course. Besides from the small
pneumothorax, she made a good recovery. Her chest tube was
removed on post-op day six and the post-pull chest x-ray
revealed no pneumothorax. Physical therapy followed patient
during entire post-op course for strength and mobility. She
appeared to be doing well and was discharged on post-op day
seven.
Medications on Admission:
ASA 325 mg PO daily
Atenolol 25 mg PO daily
Zocor 40 mg PO daily
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days.
8. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Graft x 3
PMH: Hypertension, Diverticulosis, Cervical Cancer, R Breast
Cancer s/p Mastectomy, Skin Cancer s/p removal
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use lotions, creams, or powders on wounds. Do not take
bath.
Call our office for sternal drainage, temp>101.5.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5763**] Follow-up
appointment should be in 1 week
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) 5764**],[**First Name3 (LF) **] E. [**Telephone/Fax (1) 4105**] Follow-up
appointment should be in 2 weeks
Completed by:[**2151-6-14**] | {
"clinical_findings": {
"I119": [
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "PMH: Hypertension",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "Atenolol 25 mg PO daily",
"page_numbers": [
1
]
},
{
"text": "Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.",
"page_numbers": [
2
]
},
{
"text": "Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days.",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. This condition meets MEAT criteria based on documentation in the Assessment section (listed in Discharge Diagnosis under PMH) and Treatment section (patient is on Atenolol and Furosemide, medications commonly used for hypertension)."
},
{
"icd_10_cm_code": "I51.7",
"icd_10_cm_code_description": "Cardiomegaly",
"Monitoring": [
{
"text": "Moderate cardiomegaly stable.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "CXR [**6-13**]: Tiny right apical pneumothorax and small layering bilateral pleural effusion are unchanged. Moderate cardiomegaly stable.",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "Moderate cardiomegaly",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I51.7 is assigned for Cardiomegaly, documented as moderate cardiomegaly. This condition meets MEAT criteria based on documentation in the Monitoring section (status stable) and Evaluation section (CXR findings)."
}
]
}
} |
Extract only the text-based justification for assigning the ICD-10-CM code to each condition. | Admission Date: [**2151-6-7**] Discharge Date: [**2151-6-14**]
Date of Birth: [**2073-10-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on Exertion with abnormal stress test
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 3(LIMA->LAD, SVG->LCX, OM1)
[**2151-6-7**]
History of Present Illness:
This 77F has a history of HTN had increased DOE and had a +ETT.
She underwent cardiac cath on [**2151-6-2**] at [**Hospital1 18**] which revealed:
LVEF of 80%, 60%LM [**Last Name (un) 2435**]., 70% mid LAD, 80% LCX, 80%OM1, 60% RCA.
She is now admitted for elective CABG.
Past Medical History:
Hypertension
Diverticulosis
Cervical cancer
R breast cancer-s/p R mastectomy [**2137**]
Skin cancer s/p removal
Social History:
Lives alone
Cigs: none
ETOH: occasional
Family History:
+CAD
Physical Exam:
Elderly WF in NAD
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+= bilat. without bruits.
Lungs: Clear to A+P
CV: RRR without R/G/M, nl. S1, S2
Abd: +BS, soft, nontender without masses or hepatosplenomegaly.
Ext.: no C/C/E, pulses 2+= bilat.
Neuro: nonfocal
Pertinent Results:
Echo [**6-7**]: PRE-CPB: Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Trivial mitral regurgitation
is seen. There is a small pericardial effusion. POST-CPB No
changes from pre-CPB
CXR [**6-13**]: Tiny right apical pneumothorax and small layering
bilateral pleural effusion are unchanged. Moderate cardiomegaly
stable. Lateral view shows subcutaneous emphysema in the right
anterior thoracoabdominal wall is unchanged. Left lower lobe
atelectasis has improved. Moderate cardiomegaly is stable.
[**2151-6-7**] 11:44AM BLOOD WBC-5.7 RBC-1.43*# Hgb-4.4*# Hct-12.7*#
MCV-89 MCH-30.4 MCHC-34.3 RDW-13.1 Plt Ct-73*#
[**2151-6-7**] 12:54PM BLOOD WBC-13.2* RBC-3.90* Hgb-11.7* Hct-33.3*
MCV-85 MCH-29.9 MCHC-35.0 RDW-13.1 Plt Ct-145*
[**2151-6-12**] 05:20AM BLOOD WBC-9.5 RBC-2.94* Hgb-8.9* Hct-25.8*
MCV-88 MCH-30.2 MCHC-34.4 RDW-13.5 Plt Ct-269
[**2151-6-7**] 12:54PM BLOOD PT-14.8* PTT-37.3* INR(PT)-1.3*
[**2151-6-7**] 12:54PM BLOOD UreaN-16 Creat-0.7 Cl-113* HCO3-22
[**2151-6-12**] 05:20AM BLOOD Glucose-115* UreaN-16 Creat-0.8 Na-140
K-4.7 Cl-101 HCO3-31 AnGap-13
Brief Hospital Course:
The patient was a same day admit and on [**6-7**] and she underwent a
Coronary Artery Bypass Graft x 3(LIMA->LAD, SVG->LCX, OM1). She
tolerated the procedure well and was transferred to the CSRU for
invasive monitoring in stable condition on Propofol and Neo. She
was weaned from sedation, awoke neurologically intact and was
extubated on the postop night. On post-op day one she was
transferred to the floor. Beta blockers and diuretics were
initiated. Diuretics were adjusted towards pre-op weight. Her
chest tubes were removed on post-op day two and epicardial
pacing wires on post-op day three. Following chest tube removal,
a small right-sided apical pneumothorax was seen. On post-op day
four a right-side chest tube was placed with serial chest x-rays
throughout rest of hospital course. Besides from the small
pneumothorax, she made a good recovery. Her chest tube was
removed on post-op day six and the post-pull chest x-ray
revealed no pneumothorax. Physical therapy followed patient
during entire post-op course for strength and mobility. She
appeared to be doing well and was discharged on post-op day
seven.
Medications on Admission:
ASA 325 mg PO daily
Atenolol 25 mg PO daily
Zocor 40 mg PO daily
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days.
8. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Graft x 3
PMH: Hypertension, Diverticulosis, Cervical Cancer, R Breast
Cancer s/p Mastectomy, Skin Cancer s/p removal
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use lotions, creams, or powders on wounds. Do not take
bath.
Call our office for sternal drainage, temp>101.5.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5763**] Follow-up
appointment should be in 1 week
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) 5764**],[**First Name3 (LF) **] E. [**Telephone/Fax (1) 4105**] Follow-up
appointment should be in 2 weeks
Completed by:[**2151-6-14**] | {
"clinical_findings": {
"I119": [
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "PMH: Hypertension",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "Atenolol 25 mg PO daily",
"page_numbers": [
1
]
},
{
"text": "Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.",
"page_numbers": [
2
]
},
{
"text": "Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days.",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. This condition meets MEAT criteria based on documentation in the Assessment section (listed in Discharge Diagnosis under PMH) and Treatment section (patient is on Atenolol and Furosemide, medications commonly used for hypertension)."
},
{
"icd_10_cm_code": "I51.7",
"icd_10_cm_code_description": "Cardiomegaly",
"Monitoring": [
{
"text": "Moderate cardiomegaly stable.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "CXR [**6-13**]: Tiny right apical pneumothorax and small layering bilateral pleural effusion are unchanged. Moderate cardiomegaly stable.",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "Moderate cardiomegaly",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I51.7 is assigned for Cardiomegaly, documented as moderate cardiomegaly. This condition meets MEAT criteria based on documentation in the Monitoring section (status stable) and Evaluation section (CXR findings)."
}
]
}
} |
Extract the ICD-10-CM code assigned to each clinical condition mentioned in the discharge summary. | Admission Date: [**2195-6-29**] Discharge Date: [**2195-7-6**]
Date of Birth: [**2120-5-13**] Sex: F
Service:
ADDENDUM: 1. Neurological: The patient had an MRI and EEG
to evaluate neurologic status, status post anoxic brain
injury. The EEG showed diffuse encephalopathy and the MRI
showed no severe edema. The patient's neurologic status
improved during her hospital course. The patient
spontaneously opened her eyes, was able to slightly move her
extremities and interact with the family.
2. Renal: The patient continued on hemodialysis throughout
her hospitalization course.
3. Fever/infectious disease: The patient has a history of
recurrent line and wound infections. The patient's sputum
grew Serratia and Pseudomonas sensitive to meropenem and
tobramycin respectively.
4. GI: The patient has a J-tube and she was continued on
tube feeds throughout her hospitalization.
5. Hematology: The patient's hematocrit remained stable.
6. Access: A PICC line was placed. Her arterial line and
central line were removed. The retains her Quinton.
7. Wound: The patient was monitored by plastic surgery. Her
wound dressing was changed in house on [**2195-7-4**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36
D: [**2195-7-6**] 08:46
T: [**2195-7-6**] 09:07
JOB#: [**Job Number 1086**]
| {
"clinical_findings": {
"G931": [
{
"icd_10_cm_code": "G93.1",
"icd_10_cm_code_description": "Anoxic brain damage, not elsewhere classified",
"Monitoring": [
{
"text": "The patient's neurologic status improved during her hospital course. The patient spontaneously opened her eyes, was able to slightly move her extremities and interact with the family.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "The patient had an MRI and EEG to evaluate neurologic status, status post anoxic brain injury.",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "anoxic brain injury",
"page_numbers": [
1
]
}
],
"justification": "The entity 'anoxic brain injury' is a historical diagnosis. MEAT criteria are met through Evaluation (MRI and EEG performed to evaluate neurologic status post injury) and Monitoring (neurologic status improved). Code G93.1 is assigned for anoxic brain damage, not elsewhere classified, representing the sequelae of the injury."
}
],
"Z992": [
{
"icd_10_cm_code": "Z99.2",
"icd_10_cm_code_description": "Dependence on renal dialysis",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "The patient continued on hemodialysis throughout her hospitalization course.",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "hemodialysis",
"page_numbers": [
1
]
}
],
"justification": "The entity 'hemodialysis' is a treatment indicating dependence on renal dialysis. MEAT criteria are met through Treatment (patient continued on hemodialysis). Code Z99.2 is assigned for dependence on renal dialysis."
}
],
"Z930": [
{
"icd_10_cm_code": "Z93.0",
"icd_10_cm_code_description": "Gastrostomy status",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "The patient has a J-tube",
"page_numbers": [
1
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "J-tube",
"page_numbers": [
1
]
}
],
"justification": "The entity 'J-tube' indicates the presence of a gastrostomy tube. MEAT criteria are met through Assessment/Status (patient has a J-tube). Code Z93.0 is assigned for gastrostomy status."
}
]
}
} |
Extract the ICD-10-CM code description for each clinical condition mentioned in the discharge summary. | Admission Date: [**2195-6-29**] Discharge Date: [**2195-7-6**]
Date of Birth: [**2120-5-13**] Sex: F
Service:
ADDENDUM: 1. Neurological: The patient had an MRI and EEG
to evaluate neurologic status, status post anoxic brain
injury. The EEG showed diffuse encephalopathy and the MRI
showed no severe edema. The patient's neurologic status
improved during her hospital course. The patient
spontaneously opened her eyes, was able to slightly move her
extremities and interact with the family.
2. Renal: The patient continued on hemodialysis throughout
her hospitalization course.
3. Fever/infectious disease: The patient has a history of
recurrent line and wound infections. The patient's sputum
grew Serratia and Pseudomonas sensitive to meropenem and
tobramycin respectively.
4. GI: The patient has a J-tube and she was continued on
tube feeds throughout her hospitalization.
5. Hematology: The patient's hematocrit remained stable.
6. Access: A PICC line was placed. Her arterial line and
central line were removed. The retains her Quinton.
7. Wound: The patient was monitored by plastic surgery. Her
wound dressing was changed in house on [**2195-7-4**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36
D: [**2195-7-6**] 08:46
T: [**2195-7-6**] 09:07
JOB#: [**Job Number 1086**]
| {
"clinical_findings": {
"G931": [
{
"icd_10_cm_code": "G93.1",
"icd_10_cm_code_description": "Anoxic brain damage, not elsewhere classified",
"Monitoring": [
{
"text": "The patient's neurologic status improved during her hospital course. The patient spontaneously opened her eyes, was able to slightly move her extremities and interact with the family.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "The patient had an MRI and EEG to evaluate neurologic status, status post anoxic brain injury.",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "anoxic brain injury",
"page_numbers": [
1
]
}
],
"justification": "The entity 'anoxic brain injury' is a historical diagnosis. MEAT criteria are met through Evaluation (MRI and EEG performed to evaluate neurologic status post injury) and Monitoring (neurologic status improved). Code G93.1 is assigned for anoxic brain damage, not elsewhere classified, representing the sequelae of the injury."
}
],
"Z992": [
{
"icd_10_cm_code": "Z99.2",
"icd_10_cm_code_description": "Dependence on renal dialysis",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "The patient continued on hemodialysis throughout her hospitalization course.",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "hemodialysis",
"page_numbers": [
1
]
}
],
"justification": "The entity 'hemodialysis' is a treatment indicating dependence on renal dialysis. MEAT criteria are met through Treatment (patient continued on hemodialysis). Code Z99.2 is assigned for dependence on renal dialysis."
}
],
"Z930": [
{
"icd_10_cm_code": "Z93.0",
"icd_10_cm_code_description": "Gastrostomy status",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "The patient has a J-tube",
"page_numbers": [
1
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "J-tube",
"page_numbers": [
1
]
}
],
"justification": "The entity 'J-tube' indicates the presence of a gastrostomy tube. MEAT criteria are met through Assessment/Status (patient has a J-tube). Code Z93.0 is assigned for gastrostomy status."
}
]
}
} |
Extract only the monitoring information related to each clinical condition, such as vital signs, labs, or telemetry data. | Admission Date: [**2195-6-29**] Discharge Date: [**2195-7-6**]
Date of Birth: [**2120-5-13**] Sex: F
Service:
ADDENDUM: 1. Neurological: The patient had an MRI and EEG
to evaluate neurologic status, status post anoxic brain
injury. The EEG showed diffuse encephalopathy and the MRI
showed no severe edema. The patient's neurologic status
improved during her hospital course. The patient
spontaneously opened her eyes, was able to slightly move her
extremities and interact with the family.
2. Renal: The patient continued on hemodialysis throughout
her hospitalization course.
3. Fever/infectious disease: The patient has a history of
recurrent line and wound infections. The patient's sputum
grew Serratia and Pseudomonas sensitive to meropenem and
tobramycin respectively.
4. GI: The patient has a J-tube and she was continued on
tube feeds throughout her hospitalization.
5. Hematology: The patient's hematocrit remained stable.
6. Access: A PICC line was placed. Her arterial line and
central line were removed. The retains her Quinton.
7. Wound: The patient was monitored by plastic surgery. Her
wound dressing was changed in house on [**2195-7-4**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36
D: [**2195-7-6**] 08:46
T: [**2195-7-6**] 09:07
JOB#: [**Job Number 1086**]
| {
"clinical_findings": {
"G931": [
{
"icd_10_cm_code": "G93.1",
"icd_10_cm_code_description": "Anoxic brain damage, not elsewhere classified",
"Monitoring": [
{
"text": "The patient's neurologic status improved during her hospital course. The patient spontaneously opened her eyes, was able to slightly move her extremities and interact with the family.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "The patient had an MRI and EEG to evaluate neurologic status, status post anoxic brain injury.",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "anoxic brain injury",
"page_numbers": [
1
]
}
],
"justification": "The entity 'anoxic brain injury' is a historical diagnosis. MEAT criteria are met through Evaluation (MRI and EEG performed to evaluate neurologic status post injury) and Monitoring (neurologic status improved). Code G93.1 is assigned for anoxic brain damage, not elsewhere classified, representing the sequelae of the injury."
}
],
"Z992": [
{
"icd_10_cm_code": "Z99.2",
"icd_10_cm_code_description": "Dependence on renal dialysis",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "The patient continued on hemodialysis throughout her hospitalization course.",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "hemodialysis",
"page_numbers": [
1
]
}
],
"justification": "The entity 'hemodialysis' is a treatment indicating dependence on renal dialysis. MEAT criteria are met through Treatment (patient continued on hemodialysis). Code Z99.2 is assigned for dependence on renal dialysis."
}
],
"Z930": [
{
"icd_10_cm_code": "Z93.0",
"icd_10_cm_code_description": "Gastrostomy status",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "The patient has a J-tube",
"page_numbers": [
1
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "J-tube",
"page_numbers": [
1
]
}
],
"justification": "The entity 'J-tube' indicates the presence of a gastrostomy tube. MEAT criteria are met through Assessment/Status (patient has a J-tube). Code Z93.0 is assigned for gastrostomy status."
}
]
}
} |
Extract only the clinical evaluation methods used for each condition, such as imaging, physical examination, or biopsy. | Admission Date: [**2195-6-29**] Discharge Date: [**2195-7-6**]
Date of Birth: [**2120-5-13**] Sex: F
Service:
ADDENDUM: 1. Neurological: The patient had an MRI and EEG
to evaluate neurologic status, status post anoxic brain
injury. The EEG showed diffuse encephalopathy and the MRI
showed no severe edema. The patient's neurologic status
improved during her hospital course. The patient
spontaneously opened her eyes, was able to slightly move her
extremities and interact with the family.
2. Renal: The patient continued on hemodialysis throughout
her hospitalization course.
3. Fever/infectious disease: The patient has a history of
recurrent line and wound infections. The patient's sputum
grew Serratia and Pseudomonas sensitive to meropenem and
tobramycin respectively.
4. GI: The patient has a J-tube and she was continued on
tube feeds throughout her hospitalization.
5. Hematology: The patient's hematocrit remained stable.
6. Access: A PICC line was placed. Her arterial line and
central line were removed. The retains her Quinton.
7. Wound: The patient was monitored by plastic surgery. Her
wound dressing was changed in house on [**2195-7-4**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36
D: [**2195-7-6**] 08:46
T: [**2195-7-6**] 09:07
JOB#: [**Job Number 1086**]
| {
"clinical_findings": {
"G931": [
{
"icd_10_cm_code": "G93.1",
"icd_10_cm_code_description": "Anoxic brain damage, not elsewhere classified",
"Monitoring": [
{
"text": "The patient's neurologic status improved during her hospital course. The patient spontaneously opened her eyes, was able to slightly move her extremities and interact with the family.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "The patient had an MRI and EEG to evaluate neurologic status, status post anoxic brain injury.",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "anoxic brain injury",
"page_numbers": [
1
]
}
],
"justification": "The entity 'anoxic brain injury' is a historical diagnosis. MEAT criteria are met through Evaluation (MRI and EEG performed to evaluate neurologic status post injury) and Monitoring (neurologic status improved). Code G93.1 is assigned for anoxic brain damage, not elsewhere classified, representing the sequelae of the injury."
}
],
"Z992": [
{
"icd_10_cm_code": "Z99.2",
"icd_10_cm_code_description": "Dependence on renal dialysis",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "The patient continued on hemodialysis throughout her hospitalization course.",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "hemodialysis",
"page_numbers": [
1
]
}
],
"justification": "The entity 'hemodialysis' is a treatment indicating dependence on renal dialysis. MEAT criteria are met through Treatment (patient continued on hemodialysis). Code Z99.2 is assigned for dependence on renal dialysis."
}
],
"Z930": [
{
"icd_10_cm_code": "Z93.0",
"icd_10_cm_code_description": "Gastrostomy status",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "The patient has a J-tube",
"page_numbers": [
1
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "J-tube",
"page_numbers": [
1
]
}
],
"justification": "The entity 'J-tube' indicates the presence of a gastrostomy tube. MEAT criteria are met through Assessment/Status (patient has a J-tube). Code Z93.0 is assigned for gastrostomy status."
}
]
}
} |
Extract only the clinical assessment findings for each condition, including diagnostic conclusions and staging. | Admission Date: [**2195-6-29**] Discharge Date: [**2195-7-6**]
Date of Birth: [**2120-5-13**] Sex: F
Service:
ADDENDUM: 1. Neurological: The patient had an MRI and EEG
to evaluate neurologic status, status post anoxic brain
injury. The EEG showed diffuse encephalopathy and the MRI
showed no severe edema. The patient's neurologic status
improved during her hospital course. The patient
spontaneously opened her eyes, was able to slightly move her
extremities and interact with the family.
2. Renal: The patient continued on hemodialysis throughout
her hospitalization course.
3. Fever/infectious disease: The patient has a history of
recurrent line and wound infections. The patient's sputum
grew Serratia and Pseudomonas sensitive to meropenem and
tobramycin respectively.
4. GI: The patient has a J-tube and she was continued on
tube feeds throughout her hospitalization.
5. Hematology: The patient's hematocrit remained stable.
6. Access: A PICC line was placed. Her arterial line and
central line were removed. The retains her Quinton.
7. Wound: The patient was monitored by plastic surgery. Her
wound dressing was changed in house on [**2195-7-4**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36
D: [**2195-7-6**] 08:46
T: [**2195-7-6**] 09:07
JOB#: [**Job Number 1086**]
| {
"clinical_findings": {
"G931": [
{
"icd_10_cm_code": "G93.1",
"icd_10_cm_code_description": "Anoxic brain damage, not elsewhere classified",
"Monitoring": [
{
"text": "The patient's neurologic status improved during her hospital course. The patient spontaneously opened her eyes, was able to slightly move her extremities and interact with the family.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "The patient had an MRI and EEG to evaluate neurologic status, status post anoxic brain injury.",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "anoxic brain injury",
"page_numbers": [
1
]
}
],
"justification": "The entity 'anoxic brain injury' is a historical diagnosis. MEAT criteria are met through Evaluation (MRI and EEG performed to evaluate neurologic status post injury) and Monitoring (neurologic status improved). Code G93.1 is assigned for anoxic brain damage, not elsewhere classified, representing the sequelae of the injury."
}
],
"Z992": [
{
"icd_10_cm_code": "Z99.2",
"icd_10_cm_code_description": "Dependence on renal dialysis",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "The patient continued on hemodialysis throughout her hospitalization course.",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "hemodialysis",
"page_numbers": [
1
]
}
],
"justification": "The entity 'hemodialysis' is a treatment indicating dependence on renal dialysis. MEAT criteria are met through Treatment (patient continued on hemodialysis). Code Z99.2 is assigned for dependence on renal dialysis."
}
],
"Z930": [
{
"icd_10_cm_code": "Z93.0",
"icd_10_cm_code_description": "Gastrostomy status",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "The patient has a J-tube",
"page_numbers": [
1
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "J-tube",
"page_numbers": [
1
]
}
],
"justification": "The entity 'J-tube' indicates the presence of a gastrostomy tube. MEAT criteria are met through Assessment/Status (patient has a J-tube). Code Z93.0 is assigned for gastrostomy status."
}
]
}
} |
Extract only the treatment or intervention given for each condition, including surgeries, procedures, and medications. | Admission Date: [**2195-6-29**] Discharge Date: [**2195-7-6**]
Date of Birth: [**2120-5-13**] Sex: F
Service:
ADDENDUM: 1. Neurological: The patient had an MRI and EEG
to evaluate neurologic status, status post anoxic brain
injury. The EEG showed diffuse encephalopathy and the MRI
showed no severe edema. The patient's neurologic status
improved during her hospital course. The patient
spontaneously opened her eyes, was able to slightly move her
extremities and interact with the family.
2. Renal: The patient continued on hemodialysis throughout
her hospitalization course.
3. Fever/infectious disease: The patient has a history of
recurrent line and wound infections. The patient's sputum
grew Serratia and Pseudomonas sensitive to meropenem and
tobramycin respectively.
4. GI: The patient has a J-tube and she was continued on
tube feeds throughout her hospitalization.
5. Hematology: The patient's hematocrit remained stable.
6. Access: A PICC line was placed. Her arterial line and
central line were removed. The retains her Quinton.
7. Wound: The patient was monitored by plastic surgery. Her
wound dressing was changed in house on [**2195-7-4**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36
D: [**2195-7-6**] 08:46
T: [**2195-7-6**] 09:07
JOB#: [**Job Number 1086**]
| {
"clinical_findings": {
"G931": [
{
"icd_10_cm_code": "G93.1",
"icd_10_cm_code_description": "Anoxic brain damage, not elsewhere classified",
"Monitoring": [
{
"text": "The patient's neurologic status improved during her hospital course. The patient spontaneously opened her eyes, was able to slightly move her extremities and interact with the family.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "The patient had an MRI and EEG to evaluate neurologic status, status post anoxic brain injury.",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "anoxic brain injury",
"page_numbers": [
1
]
}
],
"justification": "The entity 'anoxic brain injury' is a historical diagnosis. MEAT criteria are met through Evaluation (MRI and EEG performed to evaluate neurologic status post injury) and Monitoring (neurologic status improved). Code G93.1 is assigned for anoxic brain damage, not elsewhere classified, representing the sequelae of the injury."
}
],
"Z992": [
{
"icd_10_cm_code": "Z99.2",
"icd_10_cm_code_description": "Dependence on renal dialysis",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "The patient continued on hemodialysis throughout her hospitalization course.",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "hemodialysis",
"page_numbers": [
1
]
}
],
"justification": "The entity 'hemodialysis' is a treatment indicating dependence on renal dialysis. MEAT criteria are met through Treatment (patient continued on hemodialysis). Code Z99.2 is assigned for dependence on renal dialysis."
}
],
"Z930": [
{
"icd_10_cm_code": "Z93.0",
"icd_10_cm_code_description": "Gastrostomy status",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "The patient has a J-tube",
"page_numbers": [
1
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "J-tube",
"page_numbers": [
1
]
}
],
"justification": "The entity 'J-tube' indicates the presence of a gastrostomy tube. MEAT criteria are met through Assessment/Status (patient has a J-tube). Code Z93.0 is assigned for gastrostomy status."
}
]
}
} |
Extract only the evidence from the discharge summary that supports the existence of each condition. | Admission Date: [**2195-6-29**] Discharge Date: [**2195-7-6**]
Date of Birth: [**2120-5-13**] Sex: F
Service:
ADDENDUM: 1. Neurological: The patient had an MRI and EEG
to evaluate neurologic status, status post anoxic brain
injury. The EEG showed diffuse encephalopathy and the MRI
showed no severe edema. The patient's neurologic status
improved during her hospital course. The patient
spontaneously opened her eyes, was able to slightly move her
extremities and interact with the family.
2. Renal: The patient continued on hemodialysis throughout
her hospitalization course.
3. Fever/infectious disease: The patient has a history of
recurrent line and wound infections. The patient's sputum
grew Serratia and Pseudomonas sensitive to meropenem and
tobramycin respectively.
4. GI: The patient has a J-tube and she was continued on
tube feeds throughout her hospitalization.
5. Hematology: The patient's hematocrit remained stable.
6. Access: A PICC line was placed. Her arterial line and
central line were removed. The retains her Quinton.
7. Wound: The patient was monitored by plastic surgery. Her
wound dressing was changed in house on [**2195-7-4**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36
D: [**2195-7-6**] 08:46
T: [**2195-7-6**] 09:07
JOB#: [**Job Number 1086**]
| {
"clinical_findings": {
"G931": [
{
"icd_10_cm_code": "G93.1",
"icd_10_cm_code_description": "Anoxic brain damage, not elsewhere classified",
"Monitoring": [
{
"text": "The patient's neurologic status improved during her hospital course. The patient spontaneously opened her eyes, was able to slightly move her extremities and interact with the family.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "The patient had an MRI and EEG to evaluate neurologic status, status post anoxic brain injury.",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "anoxic brain injury",
"page_numbers": [
1
]
}
],
"justification": "The entity 'anoxic brain injury' is a historical diagnosis. MEAT criteria are met through Evaluation (MRI and EEG performed to evaluate neurologic status post injury) and Monitoring (neurologic status improved). Code G93.1 is assigned for anoxic brain damage, not elsewhere classified, representing the sequelae of the injury."
}
],
"Z992": [
{
"icd_10_cm_code": "Z99.2",
"icd_10_cm_code_description": "Dependence on renal dialysis",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "The patient continued on hemodialysis throughout her hospitalization course.",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "hemodialysis",
"page_numbers": [
1
]
}
],
"justification": "The entity 'hemodialysis' is a treatment indicating dependence on renal dialysis. MEAT criteria are met through Treatment (patient continued on hemodialysis). Code Z99.2 is assigned for dependence on renal dialysis."
}
],
"Z930": [
{
"icd_10_cm_code": "Z93.0",
"icd_10_cm_code_description": "Gastrostomy status",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "The patient has a J-tube",
"page_numbers": [
1
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "J-tube",
"page_numbers": [
1
]
}
],
"justification": "The entity 'J-tube' indicates the presence of a gastrostomy tube. MEAT criteria are met through Assessment/Status (patient has a J-tube). Code Z93.0 is assigned for gastrostomy status."
}
]
}
} |
Extract only the text-based justification for assigning the ICD-10-CM code to each condition. | Admission Date: [**2195-6-29**] Discharge Date: [**2195-7-6**]
Date of Birth: [**2120-5-13**] Sex: F
Service:
ADDENDUM: 1. Neurological: The patient had an MRI and EEG
to evaluate neurologic status, status post anoxic brain
injury. The EEG showed diffuse encephalopathy and the MRI
showed no severe edema. The patient's neurologic status
improved during her hospital course. The patient
spontaneously opened her eyes, was able to slightly move her
extremities and interact with the family.
2. Renal: The patient continued on hemodialysis throughout
her hospitalization course.
3. Fever/infectious disease: The patient has a history of
recurrent line and wound infections. The patient's sputum
grew Serratia and Pseudomonas sensitive to meropenem and
tobramycin respectively.
4. GI: The patient has a J-tube and she was continued on
tube feeds throughout her hospitalization.
5. Hematology: The patient's hematocrit remained stable.
6. Access: A PICC line was placed. Her arterial line and
central line were removed. The retains her Quinton.
7. Wound: The patient was monitored by plastic surgery. Her
wound dressing was changed in house on [**2195-7-4**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36
D: [**2195-7-6**] 08:46
T: [**2195-7-6**] 09:07
JOB#: [**Job Number 1086**]
| {
"clinical_findings": {
"G931": [
{
"icd_10_cm_code": "G93.1",
"icd_10_cm_code_description": "Anoxic brain damage, not elsewhere classified",
"Monitoring": [
{
"text": "The patient's neurologic status improved during her hospital course. The patient spontaneously opened her eyes, was able to slightly move her extremities and interact with the family.",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "The patient had an MRI and EEG to evaluate neurologic status, status post anoxic brain injury.",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "anoxic brain injury",
"page_numbers": [
1
]
}
],
"justification": "The entity 'anoxic brain injury' is a historical diagnosis. MEAT criteria are met through Evaluation (MRI and EEG performed to evaluate neurologic status post injury) and Monitoring (neurologic status improved). Code G93.1 is assigned for anoxic brain damage, not elsewhere classified, representing the sequelae of the injury."
}
],
"Z992": [
{
"icd_10_cm_code": "Z99.2",
"icd_10_cm_code_description": "Dependence on renal dialysis",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "The patient continued on hemodialysis throughout her hospitalization course.",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "hemodialysis",
"page_numbers": [
1
]
}
],
"justification": "The entity 'hemodialysis' is a treatment indicating dependence on renal dialysis. MEAT criteria are met through Treatment (patient continued on hemodialysis). Code Z99.2 is assigned for dependence on renal dialysis."
}
],
"Z930": [
{
"icd_10_cm_code": "Z93.0",
"icd_10_cm_code_description": "Gastrostomy status",
"Monitoring": [],
"Evaluation": [],
"Assessment": [
{
"text": "The patient has a J-tube",
"page_numbers": [
1
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "J-tube",
"page_numbers": [
1
]
}
],
"justification": "The entity 'J-tube' indicates the presence of a gastrostomy tube. MEAT criteria are met through Assessment/Status (patient has a J-tube). Code Z93.0 is assigned for gastrostomy status."
}
]
}
} |
Extract the ICD-10-CM code assigned to each clinical condition mentioned in the discharge summary. | Admission Date: [**2184-3-3**] Discharge Date: [**2184-3-8**]
Date of Birth: [**2143-4-11**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Progesterone in Oil
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Hypoxemic respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 8980**] is a 40 year old pregnant woman at 6 weeks EGA with
a past medical history significant for asthma admitted on [**3-3**]
for fever, cough, and dyspnea felt to be due to CAP now
transferred to the MICU for hypoxemic respiratory distress. The
patient reports that symptoms started 3 days ago with fever to
100.7 (ear) and non-productive cough, with progressively
worsening dyspnea on minimal exertion such that on the day of
admission she had difficulty walking to her bathroom. She does
have a history of well controlled asthma, although states that
her current symptoms are not consistent with prior asthma flare
although dypsnea did improve with albuterol MDI. She does
endorse rhinorrhea and fatigue, but denies any sore throat,
myalgias, LBP, sinus congestion, or wheezing. Her husband had a
cough several days ago, but denies any other sick contacts or
recent travel. She initially presented to an OSH ED, where she
had a CXR demonstrating bilateral lower lung field opacities
(R>L) felt to be CAP and was treated with CTX and azithromycin,
and was transferred to [**Hospital1 18**] for further management.
.
Her [**Hospital1 18**] course has been notable for a persistent tachcyardia,
tachypnea, and an increasing oxygen requirement now up to a 15L
face mask from 4L on admission. ABG prior to MICU transfer
7.48/28/72 on 50% FM. Given persistent tachycardia, tachypnea,
and increasing oxygen requirement, she was transferred to the
MICU for further management.
.
Currently, the patient states that her breathing is improved
after a neb treatment. She denies any CP, palpitations, ST, HA,
LBP, muscle aches, or wheezing.
Past Medical History:
1. Asthma. Only requires albuterol with URI's. Under good
control
on flovent 110mcg 2 puffs [**Hospital1 **]. No nocturnal awakenings, ICU
admissions, inbutations, or ED visits.
2. B12 deficiency. Had low B12 in 180's in [**2175**] and has been on
folgard since then with normal B12 levels. This was just stopped
when she was changed to prenatal vitamin, was told that it has
B12 in it.
3. Severely atypical nevus removed from her back. Sees Dr.
[**Last Name (STitle) 8981**] yearly, saw her last over the summer.
4. Pregnancy - 6 wks EGA with IVF treatments.
Social History:
Married, no children, undergoing fertility tx and is currently 6
weeks pregnant. Has 8 yr old stepson. Works in HR. Tobacco -
None. EtOH - social. Denies IV, illicit or herbal drug use.
Family History:
Mother - MI age 70, non-melanoma skin
CA, DM. Father - prostate CA, AAA, DM. Maternal aunt/uncle -
melanoma. 5 of 8 maternal aunts/uncles with CAD in 60-70's. 4 of
paternal aunts/uncles w/ CAD in 30-50's. MGF - DM. MGM - CAD
50-60's. PGM - CAD 50-60's. No family h/o clotting disorders
Physical Exam:
ADMISSION:
VS: 99.8 105 130/93 37 96% on 50% venturi
Gen: Labored breathing
HEENT: MM dry, OP clear, neck supple without LAD
CV: Tachy S1+S2
Pulm: Bronchial breath sounds at the bases bilaterally with
dullness to percussion. Scattered expiratory wheezes
bilaterally.
Abd: S/NT/ND +bs
Ext: No c/c/e.
Neuro: AOx3, CN II-XII intact.
DISCHARGE:
VS: afebrile, 140s/80s, 70-80, 98% on RA
GA: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: CTAB
Abd: soft, NT, +BS. no g/r.
Extremities: wwp, no edema. DPs, PTs 2+.
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
Pertinent Results:
RELEVANT AND REPRESENTATIVE LABS:
CBC and coags:
-[**2184-3-3**] 05:40PM BLOOD WBC-27.1*# RBC-4.37 Hgb-14.0 Hct-39.4
MCV-90 MCH-32.0 MCHC-35.5* RDW-12.6 Plt Ct-462*
-[**2184-3-3**] 05:40PM BLOOD Neuts-77.9* Lymphs-7.6* Monos-2.8
Eos-11.6* Baso-0.2
-[**2184-3-4**] 06:24AM BLOOD Neuts-72.9* Lymphs-8.1* Monos-2.6
Eos-15.9* Baso-0.3
-[**2184-3-5**] 03:35AM BLOOD WBC-20.4* RBC-3.94* Hgb-12.5 Hct-35.5*
MCV-90 MCH-31.7 MCHC-35.1* RDW-12.5 Plt Ct-405
-[**2184-3-5**] 03:35AM BLOOD Neuts-84* Bands-1 Lymphs-5* Monos-6
Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-2*
-[**2184-3-7**] 07:20AM BLOOD WBC-14.6* RBC-3.76* Hgb-11.6* Hct-33.9*
MCV-90 MCH-30.7 MCHC-34.1 RDW-12.6 Plt Ct-381
-[**2184-3-8**] 07:30AM BLOOD WBC-13.8* RBC-3.66* Hgb-11.7* Hct-32.7*
MCV-89 MCH-32.1* MCHC-35.9* RDW-12.5 Plt Ct-352
-[**2184-3-6**] 04:47AM BLOOD PT-13.1 PTT-23.4 INR(PT)-1.1
.
Chem:
-[**2184-3-3**] 05:40PM BLOOD Glucose-90 UreaN-8 Creat-0.6 Na-138
K-4.0 Cl-103 HCO3-21*
-[**2184-3-5**] 03:35AM BLOOD Glucose-140* UreaN-9 Creat-0.6 Na-138
K-3.7 Cl-106 HCO3-21*
-[**2184-3-7**] 07:20AM BLOOD Glucose-129* UreaN-14 Creat-0.5 Na-136
K-4.1 Cl-103 HCO3-24
-[**2184-3-8**] 07:30AM BLOOD Glucose-75 UreaN-13 Creat-0.6 Na-136
K-3.3 Cl-103 HCO3-24
.
LFTs
-[**2184-3-4**] 06:24AM BLOOD ALT-15 AST-16 LD(LDH)-238 AlkPhos-57
TotBili-0.3
.
Misc:
-[**2184-3-6**] 04:47AM BLOOD calTIBC-230* Ferritn-185* TRF-177*
-[**2184-3-4**] 02:35PM BLOOD ANCA-NEGATIVE B
-[**2184-3-3**] 05:40PM BLOOD HCG-7597
-[**2184-3-3**] 05:53PM BLOOD Lactate-1.4
.
.
IMAGING:
.
TVUS [**3-4**]:
Single live intrauterine gestation corresponding to a
gestational
age of 6 weeks 4 days.
.
CXR [**3-4**]:
Moderate-to-severe pulmonary edema, without evidence of pleural
effusions. Borderline size of the cardiac silhouette. No
interval appearance of new parenchymal opacities.
.
SPIROMETRY 10:30 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 2.81 3.44 82
FEV1 2.55 2.67 95
MMF 4.09 3.13 131
FEV1/FVC 91 78 117
Brief Hospital Course:
Mrs. [**Known lastname 8980**] is a 40 year old pregnant woman at 6 weeks EGA by
IVF with a past medical history significant for asthma admitted
on [**3-3**] for fever, cough, and dyspnea felt to be due to CAP, but
found to have eosinophilic pneumonitis.
# Eosinophilic pneumonitis: Patient's A-a gradient was >180 with
potential etiologies including V/Q mismatch, diffusion
abnormality, or shunt. Given absolute eosinophilic count of
>3000, fever, and acute shortness of breath, the diagnosis of
acute eosinophilic pneumonia was presumptively made. She was
treated with solumedrol 125 Q6H with improvement in symptoms and
rapid weaning of supplemental oxygen to room air. She was also
covered for pneumonia initially with vancomycin and
levofloxacin, but the regimen was narrowed to a 5 day course of
azithromycin, which she completed while hospitalized. She was
also initially treated with oseltamavir, which was discontinued
after Influenza DFA returned negative. Patient was transitioned
to prednisone 60 mg daily, and she will continue this dose until
follow-up with Dr. [**First Name8 (NamePattern2) 8982**] [**Last Name (NamePattern1) 7273**] as an outpatient. Her
eosinophilic pneumonitis was felt to be secondary to IM
progesterone in sesame oil suspension, and progesterone was
changed to intravaginal preparation. She will require PCP
prophylaxis if steroid course continues for longer than 1 month,
and this will be determined as an outpatient.
# Pregnancy: Intravaginal fetal u/s performed during MICU course
demonstrating viable fetus. OB consulted on the patient, and
[**Last Name (un) **] was also consulted for blood glucose control (see below).
She will continue intravaginal progesterone as above, and
follow-up with OB/Gyn.
# Hyperglycemia: elevated FSBG in the setting of steroid use.
Patient was started on sliding scale insulin [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs for
goal fingerstick <130 at one hour post-prandial. She will
continue insulin at home and f/u with the Diabetes in Pregnancy
Center at [**Last Name (un) **].
# Asthma: Continued on nebs during admission.
# Code: full
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs qid prn
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs
twice a day
PRENATAL VIT-IRON FUMARATE-FA [PRENATAL VITAMIN] - (Prescribed
by Other Provider) - Dosage uncertain
PROGESTERONE 50 mg/mL 1 mL QHS at 8:30 pm
Discharge Medications:
1. Prenatal 10-400 mg-mcg Capsule Sig: One (1) Capsule PO once a
day.
2. progesterone micronized 8 % Gel Sig: One (1) Appl Vaginal QHS
(once a day (at bedtime)) for 4 weeks.
[**Last Name (un) **]:*QS gel* Refills:*0*
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath, wheeze.
4. Supplies
"Humalog Kwik-pen" 1 box of 5 pens
5. Supplies
Humalog "pen needle" 31x3/16 needle, 200 needles
6. One Touch Delica Lancets Misc Sig: One (1) lancet
Miscellaneous four times a day: fasting and 1hour post-meals.
[**Last Name (un) **]:*200 lancets* Refills:*0*
7. One Touch Test Strip Sig: One (1) strip Miscellaneous
four times a day: fasting and 1hour post-meal.
[**Last Name (un) **]:*200 strips* Refills:*0*
8. prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day:
Take until you see pulmonary doctors.
[**Last Name (Titles) **]:*75 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Eosinophilic pneumonitis
Hyperglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital for shortness of breath, likely
caused by eosinophilic pneumonitis (pneumonia associated with an
increase in a white blood cell called eosinophils). This
improved with steroids. Please continue taking prednisone 60 mg
daily until you see Dr. [**Last Name (STitle) 7273**] at your followup appointment.
You were also found to have elevated blood sugars after being
started on prednisone, which is a common side effect. Please
continue taking insulin with meals as directed. You should
follow up with an endocrinologist at the [**Hospital **] clinic as
indicated below.
Changes to your medications:
-START taking humalog insulin as directed by [**Last Name (un) **]: 6units
before breakfast, 6units before lunch, 7units before dinner
-START taking prednisone 60 mg daily until you see Dr. [**Last Name (STitle) 7273**]
[**Name (STitle) 8983**] taking progesterone IM shots, and START taking
progesterone intravaginally daily
Followup Instructions:
Dr. [**Last Name (STitle) 8984**] (maternal fetal medicine specialist, OB/Gyn)
[**Location (un) 8985**] [**Location (un) 2274**] Tuesday [**3-9**] at 2pm. You can have an ultrasound
done on either Tuesday or Wednesday (see below).
Name: [**Name6 (MD) 6507**] [**Last Name (NamePattern4) 8986**], MD
Specialty: Fertility
When: Wednesday [**3-10**] at 1:30pm
Location: [**Hospital1 641**]
Address: [**Location (un) 4363**], [**Location (un) 86**], MA
Phone: [**Telephone/Fax (1) 8987**]
Department: INTERNAL MEDICINE
When: MONDAY [**2184-3-15**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8988**], MD [**Telephone/Fax (1) 4775**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2184-3-24**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
Specialty: Pulmonary
When: WEDNESDAY [**2184-3-24**] at 1:30 PM
With: DR [**Last Name (STitle) **]/DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: OB/GYN, [**Hospital 8989**] CLINIC (Diabetes in [**Hospital **]
Clinic)
When: FRIDAY [**2184-3-26**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 8990**] [**Last Name (NamePattern4) 8991**], MD [**Telephone/Fax (1) 8992**]
Specialty: Endocrinology
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**Please call [**Doctor Last Name 8993**] at [**Telephone/Fax (1) 8994**] once you are discharged. She
is the scheduler for the pregnancy clinic here at the hospital
and she would like to speak to you to get more information.**
**You can also call [**Telephone/Fax (1) 3681**] to set up an appointment to see
a nutritionist.**
| {
"clinical_findings": {
"J45909": [
{
"icd_10_cm_code": "J45.909",
"icd_10_cm_code_description": "Unspecified asthma, uncomplicated, without status asthmaticus",
"Monitoring": [
{
"text": "well controlled asthma",
"page_numbers": [
1
]
},
{
"text": "Continued on nebs during admission",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "Scattered expiratory wheezes\nbilaterally",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [
{
"text": "ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler",
"page_numbers": [
1
]
},
{
"text": "FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol",
"page_numbers": [
1
]
},
{
"text": "albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "well controlled asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "Asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "Asthma",
"page_numbers": [
1
]
}
],
"justification": "Asthma is a documented diagnosis in the patient's history and hospital course. MEAT criteria are met through documentation of the condition being 'well controlled' and 'Continued on nebs during admission' (Monitoring), 'Scattered expiratory wheezes bilaterally' on physical exam (Evaluation), and treatment with Albuterol and Fluticasone inhalers (Treatment). J45.909 is the appropriate code for unspecified uncomplicated asthma."
}
]
}
} |
Extract the ICD-10-CM code description for each clinical condition mentioned in the discharge summary. | Admission Date: [**2184-3-3**] Discharge Date: [**2184-3-8**]
Date of Birth: [**2143-4-11**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Progesterone in Oil
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Hypoxemic respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 8980**] is a 40 year old pregnant woman at 6 weeks EGA with
a past medical history significant for asthma admitted on [**3-3**]
for fever, cough, and dyspnea felt to be due to CAP now
transferred to the MICU for hypoxemic respiratory distress. The
patient reports that symptoms started 3 days ago with fever to
100.7 (ear) and non-productive cough, with progressively
worsening dyspnea on minimal exertion such that on the day of
admission she had difficulty walking to her bathroom. She does
have a history of well controlled asthma, although states that
her current symptoms are not consistent with prior asthma flare
although dypsnea did improve with albuterol MDI. She does
endorse rhinorrhea and fatigue, but denies any sore throat,
myalgias, LBP, sinus congestion, or wheezing. Her husband had a
cough several days ago, but denies any other sick contacts or
recent travel. She initially presented to an OSH ED, where she
had a CXR demonstrating bilateral lower lung field opacities
(R>L) felt to be CAP and was treated with CTX and azithromycin,
and was transferred to [**Hospital1 18**] for further management.
.
Her [**Hospital1 18**] course has been notable for a persistent tachcyardia,
tachypnea, and an increasing oxygen requirement now up to a 15L
face mask from 4L on admission. ABG prior to MICU transfer
7.48/28/72 on 50% FM. Given persistent tachycardia, tachypnea,
and increasing oxygen requirement, she was transferred to the
MICU for further management.
.
Currently, the patient states that her breathing is improved
after a neb treatment. She denies any CP, palpitations, ST, HA,
LBP, muscle aches, or wheezing.
Past Medical History:
1. Asthma. Only requires albuterol with URI's. Under good
control
on flovent 110mcg 2 puffs [**Hospital1 **]. No nocturnal awakenings, ICU
admissions, inbutations, or ED visits.
2. B12 deficiency. Had low B12 in 180's in [**2175**] and has been on
folgard since then with normal B12 levels. This was just stopped
when she was changed to prenatal vitamin, was told that it has
B12 in it.
3. Severely atypical nevus removed from her back. Sees Dr.
[**Last Name (STitle) 8981**] yearly, saw her last over the summer.
4. Pregnancy - 6 wks EGA with IVF treatments.
Social History:
Married, no children, undergoing fertility tx and is currently 6
weeks pregnant. Has 8 yr old stepson. Works in HR. Tobacco -
None. EtOH - social. Denies IV, illicit or herbal drug use.
Family History:
Mother - MI age 70, non-melanoma skin
CA, DM. Father - prostate CA, AAA, DM. Maternal aunt/uncle -
melanoma. 5 of 8 maternal aunts/uncles with CAD in 60-70's. 4 of
paternal aunts/uncles w/ CAD in 30-50's. MGF - DM. MGM - CAD
50-60's. PGM - CAD 50-60's. No family h/o clotting disorders
Physical Exam:
ADMISSION:
VS: 99.8 105 130/93 37 96% on 50% venturi
Gen: Labored breathing
HEENT: MM dry, OP clear, neck supple without LAD
CV: Tachy S1+S2
Pulm: Bronchial breath sounds at the bases bilaterally with
dullness to percussion. Scattered expiratory wheezes
bilaterally.
Abd: S/NT/ND +bs
Ext: No c/c/e.
Neuro: AOx3, CN II-XII intact.
DISCHARGE:
VS: afebrile, 140s/80s, 70-80, 98% on RA
GA: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: CTAB
Abd: soft, NT, +BS. no g/r.
Extremities: wwp, no edema. DPs, PTs 2+.
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
Pertinent Results:
RELEVANT AND REPRESENTATIVE LABS:
CBC and coags:
-[**2184-3-3**] 05:40PM BLOOD WBC-27.1*# RBC-4.37 Hgb-14.0 Hct-39.4
MCV-90 MCH-32.0 MCHC-35.5* RDW-12.6 Plt Ct-462*
-[**2184-3-3**] 05:40PM BLOOD Neuts-77.9* Lymphs-7.6* Monos-2.8
Eos-11.6* Baso-0.2
-[**2184-3-4**] 06:24AM BLOOD Neuts-72.9* Lymphs-8.1* Monos-2.6
Eos-15.9* Baso-0.3
-[**2184-3-5**] 03:35AM BLOOD WBC-20.4* RBC-3.94* Hgb-12.5 Hct-35.5*
MCV-90 MCH-31.7 MCHC-35.1* RDW-12.5 Plt Ct-405
-[**2184-3-5**] 03:35AM BLOOD Neuts-84* Bands-1 Lymphs-5* Monos-6
Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-2*
-[**2184-3-7**] 07:20AM BLOOD WBC-14.6* RBC-3.76* Hgb-11.6* Hct-33.9*
MCV-90 MCH-30.7 MCHC-34.1 RDW-12.6 Plt Ct-381
-[**2184-3-8**] 07:30AM BLOOD WBC-13.8* RBC-3.66* Hgb-11.7* Hct-32.7*
MCV-89 MCH-32.1* MCHC-35.9* RDW-12.5 Plt Ct-352
-[**2184-3-6**] 04:47AM BLOOD PT-13.1 PTT-23.4 INR(PT)-1.1
.
Chem:
-[**2184-3-3**] 05:40PM BLOOD Glucose-90 UreaN-8 Creat-0.6 Na-138
K-4.0 Cl-103 HCO3-21*
-[**2184-3-5**] 03:35AM BLOOD Glucose-140* UreaN-9 Creat-0.6 Na-138
K-3.7 Cl-106 HCO3-21*
-[**2184-3-7**] 07:20AM BLOOD Glucose-129* UreaN-14 Creat-0.5 Na-136
K-4.1 Cl-103 HCO3-24
-[**2184-3-8**] 07:30AM BLOOD Glucose-75 UreaN-13 Creat-0.6 Na-136
K-3.3 Cl-103 HCO3-24
.
LFTs
-[**2184-3-4**] 06:24AM BLOOD ALT-15 AST-16 LD(LDH)-238 AlkPhos-57
TotBili-0.3
.
Misc:
-[**2184-3-6**] 04:47AM BLOOD calTIBC-230* Ferritn-185* TRF-177*
-[**2184-3-4**] 02:35PM BLOOD ANCA-NEGATIVE B
-[**2184-3-3**] 05:40PM BLOOD HCG-7597
-[**2184-3-3**] 05:53PM BLOOD Lactate-1.4
.
.
IMAGING:
.
TVUS [**3-4**]:
Single live intrauterine gestation corresponding to a
gestational
age of 6 weeks 4 days.
.
CXR [**3-4**]:
Moderate-to-severe pulmonary edema, without evidence of pleural
effusions. Borderline size of the cardiac silhouette. No
interval appearance of new parenchymal opacities.
.
SPIROMETRY 10:30 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 2.81 3.44 82
FEV1 2.55 2.67 95
MMF 4.09 3.13 131
FEV1/FVC 91 78 117
Brief Hospital Course:
Mrs. [**Known lastname 8980**] is a 40 year old pregnant woman at 6 weeks EGA by
IVF with a past medical history significant for asthma admitted
on [**3-3**] for fever, cough, and dyspnea felt to be due to CAP, but
found to have eosinophilic pneumonitis.
# Eosinophilic pneumonitis: Patient's A-a gradient was >180 with
potential etiologies including V/Q mismatch, diffusion
abnormality, or shunt. Given absolute eosinophilic count of
>3000, fever, and acute shortness of breath, the diagnosis of
acute eosinophilic pneumonia was presumptively made. She was
treated with solumedrol 125 Q6H with improvement in symptoms and
rapid weaning of supplemental oxygen to room air. She was also
covered for pneumonia initially with vancomycin and
levofloxacin, but the regimen was narrowed to a 5 day course of
azithromycin, which she completed while hospitalized. She was
also initially treated with oseltamavir, which was discontinued
after Influenza DFA returned negative. Patient was transitioned
to prednisone 60 mg daily, and she will continue this dose until
follow-up with Dr. [**First Name8 (NamePattern2) 8982**] [**Last Name (NamePattern1) 7273**] as an outpatient. Her
eosinophilic pneumonitis was felt to be secondary to IM
progesterone in sesame oil suspension, and progesterone was
changed to intravaginal preparation. She will require PCP
prophylaxis if steroid course continues for longer than 1 month,
and this will be determined as an outpatient.
# Pregnancy: Intravaginal fetal u/s performed during MICU course
demonstrating viable fetus. OB consulted on the patient, and
[**Last Name (un) **] was also consulted for blood glucose control (see below).
She will continue intravaginal progesterone as above, and
follow-up with OB/Gyn.
# Hyperglycemia: elevated FSBG in the setting of steroid use.
Patient was started on sliding scale insulin [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs for
goal fingerstick <130 at one hour post-prandial. She will
continue insulin at home and f/u with the Diabetes in Pregnancy
Center at [**Last Name (un) **].
# Asthma: Continued on nebs during admission.
# Code: full
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs qid prn
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs
twice a day
PRENATAL VIT-IRON FUMARATE-FA [PRENATAL VITAMIN] - (Prescribed
by Other Provider) - Dosage uncertain
PROGESTERONE 50 mg/mL 1 mL QHS at 8:30 pm
Discharge Medications:
1. Prenatal 10-400 mg-mcg Capsule Sig: One (1) Capsule PO once a
day.
2. progesterone micronized 8 % Gel Sig: One (1) Appl Vaginal QHS
(once a day (at bedtime)) for 4 weeks.
[**Last Name (un) **]:*QS gel* Refills:*0*
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath, wheeze.
4. Supplies
"Humalog Kwik-pen" 1 box of 5 pens
5. Supplies
Humalog "pen needle" 31x3/16 needle, 200 needles
6. One Touch Delica Lancets Misc Sig: One (1) lancet
Miscellaneous four times a day: fasting and 1hour post-meals.
[**Last Name (un) **]:*200 lancets* Refills:*0*
7. One Touch Test Strip Sig: One (1) strip Miscellaneous
four times a day: fasting and 1hour post-meal.
[**Last Name (un) **]:*200 strips* Refills:*0*
8. prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day:
Take until you see pulmonary doctors.
[**Last Name (Titles) **]:*75 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Eosinophilic pneumonitis
Hyperglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital for shortness of breath, likely
caused by eosinophilic pneumonitis (pneumonia associated with an
increase in a white blood cell called eosinophils). This
improved with steroids. Please continue taking prednisone 60 mg
daily until you see Dr. [**Last Name (STitle) 7273**] at your followup appointment.
You were also found to have elevated blood sugars after being
started on prednisone, which is a common side effect. Please
continue taking insulin with meals as directed. You should
follow up with an endocrinologist at the [**Hospital **] clinic as
indicated below.
Changes to your medications:
-START taking humalog insulin as directed by [**Last Name (un) **]: 6units
before breakfast, 6units before lunch, 7units before dinner
-START taking prednisone 60 mg daily until you see Dr. [**Last Name (STitle) 7273**]
[**Name (STitle) 8983**] taking progesterone IM shots, and START taking
progesterone intravaginally daily
Followup Instructions:
Dr. [**Last Name (STitle) 8984**] (maternal fetal medicine specialist, OB/Gyn)
[**Location (un) 8985**] [**Location (un) 2274**] Tuesday [**3-9**] at 2pm. You can have an ultrasound
done on either Tuesday or Wednesday (see below).
Name: [**Name6 (MD) 6507**] [**Last Name (NamePattern4) 8986**], MD
Specialty: Fertility
When: Wednesday [**3-10**] at 1:30pm
Location: [**Hospital1 641**]
Address: [**Location (un) 4363**], [**Location (un) 86**], MA
Phone: [**Telephone/Fax (1) 8987**]
Department: INTERNAL MEDICINE
When: MONDAY [**2184-3-15**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8988**], MD [**Telephone/Fax (1) 4775**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2184-3-24**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
Specialty: Pulmonary
When: WEDNESDAY [**2184-3-24**] at 1:30 PM
With: DR [**Last Name (STitle) **]/DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: OB/GYN, [**Hospital 8989**] CLINIC (Diabetes in [**Hospital **]
Clinic)
When: FRIDAY [**2184-3-26**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 8990**] [**Last Name (NamePattern4) 8991**], MD [**Telephone/Fax (1) 8992**]
Specialty: Endocrinology
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**Please call [**Doctor Last Name 8993**] at [**Telephone/Fax (1) 8994**] once you are discharged. She
is the scheduler for the pregnancy clinic here at the hospital
and she would like to speak to you to get more information.**
**You can also call [**Telephone/Fax (1) 3681**] to set up an appointment to see
a nutritionist.**
| {
"clinical_findings": {
"J45909": [
{
"icd_10_cm_code": "J45.909",
"icd_10_cm_code_description": "Unspecified asthma, uncomplicated, without status asthmaticus",
"Monitoring": [
{
"text": "well controlled asthma",
"page_numbers": [
1
]
},
{
"text": "Continued on nebs during admission",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "Scattered expiratory wheezes\nbilaterally",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [
{
"text": "ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler",
"page_numbers": [
1
]
},
{
"text": "FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol",
"page_numbers": [
1
]
},
{
"text": "albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "well controlled asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "Asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "Asthma",
"page_numbers": [
1
]
}
],
"justification": "Asthma is a documented diagnosis in the patient's history and hospital course. MEAT criteria are met through documentation of the condition being 'well controlled' and 'Continued on nebs during admission' (Monitoring), 'Scattered expiratory wheezes bilaterally' on physical exam (Evaluation), and treatment with Albuterol and Fluticasone inhalers (Treatment). J45.909 is the appropriate code for unspecified uncomplicated asthma."
}
]
}
} |
Extract only the monitoring information related to each clinical condition, such as vital signs, labs, or telemetry data. | Admission Date: [**2184-3-3**] Discharge Date: [**2184-3-8**]
Date of Birth: [**2143-4-11**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Progesterone in Oil
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Hypoxemic respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 8980**] is a 40 year old pregnant woman at 6 weeks EGA with
a past medical history significant for asthma admitted on [**3-3**]
for fever, cough, and dyspnea felt to be due to CAP now
transferred to the MICU for hypoxemic respiratory distress. The
patient reports that symptoms started 3 days ago with fever to
100.7 (ear) and non-productive cough, with progressively
worsening dyspnea on minimal exertion such that on the day of
admission she had difficulty walking to her bathroom. She does
have a history of well controlled asthma, although states that
her current symptoms are not consistent with prior asthma flare
although dypsnea did improve with albuterol MDI. She does
endorse rhinorrhea and fatigue, but denies any sore throat,
myalgias, LBP, sinus congestion, or wheezing. Her husband had a
cough several days ago, but denies any other sick contacts or
recent travel. She initially presented to an OSH ED, where she
had a CXR demonstrating bilateral lower lung field opacities
(R>L) felt to be CAP and was treated with CTX and azithromycin,
and was transferred to [**Hospital1 18**] for further management.
.
Her [**Hospital1 18**] course has been notable for a persistent tachcyardia,
tachypnea, and an increasing oxygen requirement now up to a 15L
face mask from 4L on admission. ABG prior to MICU transfer
7.48/28/72 on 50% FM. Given persistent tachycardia, tachypnea,
and increasing oxygen requirement, she was transferred to the
MICU for further management.
.
Currently, the patient states that her breathing is improved
after a neb treatment. She denies any CP, palpitations, ST, HA,
LBP, muscle aches, or wheezing.
Past Medical History:
1. Asthma. Only requires albuterol with URI's. Under good
control
on flovent 110mcg 2 puffs [**Hospital1 **]. No nocturnal awakenings, ICU
admissions, inbutations, or ED visits.
2. B12 deficiency. Had low B12 in 180's in [**2175**] and has been on
folgard since then with normal B12 levels. This was just stopped
when she was changed to prenatal vitamin, was told that it has
B12 in it.
3. Severely atypical nevus removed from her back. Sees Dr.
[**Last Name (STitle) 8981**] yearly, saw her last over the summer.
4. Pregnancy - 6 wks EGA with IVF treatments.
Social History:
Married, no children, undergoing fertility tx and is currently 6
weeks pregnant. Has 8 yr old stepson. Works in HR. Tobacco -
None. EtOH - social. Denies IV, illicit or herbal drug use.
Family History:
Mother - MI age 70, non-melanoma skin
CA, DM. Father - prostate CA, AAA, DM. Maternal aunt/uncle -
melanoma. 5 of 8 maternal aunts/uncles with CAD in 60-70's. 4 of
paternal aunts/uncles w/ CAD in 30-50's. MGF - DM. MGM - CAD
50-60's. PGM - CAD 50-60's. No family h/o clotting disorders
Physical Exam:
ADMISSION:
VS: 99.8 105 130/93 37 96% on 50% venturi
Gen: Labored breathing
HEENT: MM dry, OP clear, neck supple without LAD
CV: Tachy S1+S2
Pulm: Bronchial breath sounds at the bases bilaterally with
dullness to percussion. Scattered expiratory wheezes
bilaterally.
Abd: S/NT/ND +bs
Ext: No c/c/e.
Neuro: AOx3, CN II-XII intact.
DISCHARGE:
VS: afebrile, 140s/80s, 70-80, 98% on RA
GA: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: CTAB
Abd: soft, NT, +BS. no g/r.
Extremities: wwp, no edema. DPs, PTs 2+.
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
Pertinent Results:
RELEVANT AND REPRESENTATIVE LABS:
CBC and coags:
-[**2184-3-3**] 05:40PM BLOOD WBC-27.1*# RBC-4.37 Hgb-14.0 Hct-39.4
MCV-90 MCH-32.0 MCHC-35.5* RDW-12.6 Plt Ct-462*
-[**2184-3-3**] 05:40PM BLOOD Neuts-77.9* Lymphs-7.6* Monos-2.8
Eos-11.6* Baso-0.2
-[**2184-3-4**] 06:24AM BLOOD Neuts-72.9* Lymphs-8.1* Monos-2.6
Eos-15.9* Baso-0.3
-[**2184-3-5**] 03:35AM BLOOD WBC-20.4* RBC-3.94* Hgb-12.5 Hct-35.5*
MCV-90 MCH-31.7 MCHC-35.1* RDW-12.5 Plt Ct-405
-[**2184-3-5**] 03:35AM BLOOD Neuts-84* Bands-1 Lymphs-5* Monos-6
Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-2*
-[**2184-3-7**] 07:20AM BLOOD WBC-14.6* RBC-3.76* Hgb-11.6* Hct-33.9*
MCV-90 MCH-30.7 MCHC-34.1 RDW-12.6 Plt Ct-381
-[**2184-3-8**] 07:30AM BLOOD WBC-13.8* RBC-3.66* Hgb-11.7* Hct-32.7*
MCV-89 MCH-32.1* MCHC-35.9* RDW-12.5 Plt Ct-352
-[**2184-3-6**] 04:47AM BLOOD PT-13.1 PTT-23.4 INR(PT)-1.1
.
Chem:
-[**2184-3-3**] 05:40PM BLOOD Glucose-90 UreaN-8 Creat-0.6 Na-138
K-4.0 Cl-103 HCO3-21*
-[**2184-3-5**] 03:35AM BLOOD Glucose-140* UreaN-9 Creat-0.6 Na-138
K-3.7 Cl-106 HCO3-21*
-[**2184-3-7**] 07:20AM BLOOD Glucose-129* UreaN-14 Creat-0.5 Na-136
K-4.1 Cl-103 HCO3-24
-[**2184-3-8**] 07:30AM BLOOD Glucose-75 UreaN-13 Creat-0.6 Na-136
K-3.3 Cl-103 HCO3-24
.
LFTs
-[**2184-3-4**] 06:24AM BLOOD ALT-15 AST-16 LD(LDH)-238 AlkPhos-57
TotBili-0.3
.
Misc:
-[**2184-3-6**] 04:47AM BLOOD calTIBC-230* Ferritn-185* TRF-177*
-[**2184-3-4**] 02:35PM BLOOD ANCA-NEGATIVE B
-[**2184-3-3**] 05:40PM BLOOD HCG-7597
-[**2184-3-3**] 05:53PM BLOOD Lactate-1.4
.
.
IMAGING:
.
TVUS [**3-4**]:
Single live intrauterine gestation corresponding to a
gestational
age of 6 weeks 4 days.
.
CXR [**3-4**]:
Moderate-to-severe pulmonary edema, without evidence of pleural
effusions. Borderline size of the cardiac silhouette. No
interval appearance of new parenchymal opacities.
.
SPIROMETRY 10:30 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 2.81 3.44 82
FEV1 2.55 2.67 95
MMF 4.09 3.13 131
FEV1/FVC 91 78 117
Brief Hospital Course:
Mrs. [**Known lastname 8980**] is a 40 year old pregnant woman at 6 weeks EGA by
IVF with a past medical history significant for asthma admitted
on [**3-3**] for fever, cough, and dyspnea felt to be due to CAP, but
found to have eosinophilic pneumonitis.
# Eosinophilic pneumonitis: Patient's A-a gradient was >180 with
potential etiologies including V/Q mismatch, diffusion
abnormality, or shunt. Given absolute eosinophilic count of
>3000, fever, and acute shortness of breath, the diagnosis of
acute eosinophilic pneumonia was presumptively made. She was
treated with solumedrol 125 Q6H with improvement in symptoms and
rapid weaning of supplemental oxygen to room air. She was also
covered for pneumonia initially with vancomycin and
levofloxacin, but the regimen was narrowed to a 5 day course of
azithromycin, which she completed while hospitalized. She was
also initially treated with oseltamavir, which was discontinued
after Influenza DFA returned negative. Patient was transitioned
to prednisone 60 mg daily, and she will continue this dose until
follow-up with Dr. [**First Name8 (NamePattern2) 8982**] [**Last Name (NamePattern1) 7273**] as an outpatient. Her
eosinophilic pneumonitis was felt to be secondary to IM
progesterone in sesame oil suspension, and progesterone was
changed to intravaginal preparation. She will require PCP
prophylaxis if steroid course continues for longer than 1 month,
and this will be determined as an outpatient.
# Pregnancy: Intravaginal fetal u/s performed during MICU course
demonstrating viable fetus. OB consulted on the patient, and
[**Last Name (un) **] was also consulted for blood glucose control (see below).
She will continue intravaginal progesterone as above, and
follow-up with OB/Gyn.
# Hyperglycemia: elevated FSBG in the setting of steroid use.
Patient was started on sliding scale insulin [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs for
goal fingerstick <130 at one hour post-prandial. She will
continue insulin at home and f/u with the Diabetes in Pregnancy
Center at [**Last Name (un) **].
# Asthma: Continued on nebs during admission.
# Code: full
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs qid prn
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs
twice a day
PRENATAL VIT-IRON FUMARATE-FA [PRENATAL VITAMIN] - (Prescribed
by Other Provider) - Dosage uncertain
PROGESTERONE 50 mg/mL 1 mL QHS at 8:30 pm
Discharge Medications:
1. Prenatal 10-400 mg-mcg Capsule Sig: One (1) Capsule PO once a
day.
2. progesterone micronized 8 % Gel Sig: One (1) Appl Vaginal QHS
(once a day (at bedtime)) for 4 weeks.
[**Last Name (un) **]:*QS gel* Refills:*0*
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath, wheeze.
4. Supplies
"Humalog Kwik-pen" 1 box of 5 pens
5. Supplies
Humalog "pen needle" 31x3/16 needle, 200 needles
6. One Touch Delica Lancets Misc Sig: One (1) lancet
Miscellaneous four times a day: fasting and 1hour post-meals.
[**Last Name (un) **]:*200 lancets* Refills:*0*
7. One Touch Test Strip Sig: One (1) strip Miscellaneous
four times a day: fasting and 1hour post-meal.
[**Last Name (un) **]:*200 strips* Refills:*0*
8. prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day:
Take until you see pulmonary doctors.
[**Last Name (Titles) **]:*75 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Eosinophilic pneumonitis
Hyperglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital for shortness of breath, likely
caused by eosinophilic pneumonitis (pneumonia associated with an
increase in a white blood cell called eosinophils). This
improved with steroids. Please continue taking prednisone 60 mg
daily until you see Dr. [**Last Name (STitle) 7273**] at your followup appointment.
You were also found to have elevated blood sugars after being
started on prednisone, which is a common side effect. Please
continue taking insulin with meals as directed. You should
follow up with an endocrinologist at the [**Hospital **] clinic as
indicated below.
Changes to your medications:
-START taking humalog insulin as directed by [**Last Name (un) **]: 6units
before breakfast, 6units before lunch, 7units before dinner
-START taking prednisone 60 mg daily until you see Dr. [**Last Name (STitle) 7273**]
[**Name (STitle) 8983**] taking progesterone IM shots, and START taking
progesterone intravaginally daily
Followup Instructions:
Dr. [**Last Name (STitle) 8984**] (maternal fetal medicine specialist, OB/Gyn)
[**Location (un) 8985**] [**Location (un) 2274**] Tuesday [**3-9**] at 2pm. You can have an ultrasound
done on either Tuesday or Wednesday (see below).
Name: [**Name6 (MD) 6507**] [**Last Name (NamePattern4) 8986**], MD
Specialty: Fertility
When: Wednesday [**3-10**] at 1:30pm
Location: [**Hospital1 641**]
Address: [**Location (un) 4363**], [**Location (un) 86**], MA
Phone: [**Telephone/Fax (1) 8987**]
Department: INTERNAL MEDICINE
When: MONDAY [**2184-3-15**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8988**], MD [**Telephone/Fax (1) 4775**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2184-3-24**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
Specialty: Pulmonary
When: WEDNESDAY [**2184-3-24**] at 1:30 PM
With: DR [**Last Name (STitle) **]/DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: OB/GYN, [**Hospital 8989**] CLINIC (Diabetes in [**Hospital **]
Clinic)
When: FRIDAY [**2184-3-26**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 8990**] [**Last Name (NamePattern4) 8991**], MD [**Telephone/Fax (1) 8992**]
Specialty: Endocrinology
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**Please call [**Doctor Last Name 8993**] at [**Telephone/Fax (1) 8994**] once you are discharged. She
is the scheduler for the pregnancy clinic here at the hospital
and she would like to speak to you to get more information.**
**You can also call [**Telephone/Fax (1) 3681**] to set up an appointment to see
a nutritionist.**
| {
"clinical_findings": {
"J45909": [
{
"icd_10_cm_code": "J45.909",
"icd_10_cm_code_description": "Unspecified asthma, uncomplicated, without status asthmaticus",
"Monitoring": [
{
"text": "well controlled asthma",
"page_numbers": [
1
]
},
{
"text": "Continued on nebs during admission",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "Scattered expiratory wheezes\nbilaterally",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [
{
"text": "ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler",
"page_numbers": [
1
]
},
{
"text": "FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol",
"page_numbers": [
1
]
},
{
"text": "albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "well controlled asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "Asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "Asthma",
"page_numbers": [
1
]
}
],
"justification": "Asthma is a documented diagnosis in the patient's history and hospital course. MEAT criteria are met through documentation of the condition being 'well controlled' and 'Continued on nebs during admission' (Monitoring), 'Scattered expiratory wheezes bilaterally' on physical exam (Evaluation), and treatment with Albuterol and Fluticasone inhalers (Treatment). J45.909 is the appropriate code for unspecified uncomplicated asthma."
}
]
}
} |
Extract only the clinical evaluation methods used for each condition, such as imaging, physical examination, or biopsy. | Admission Date: [**2184-3-3**] Discharge Date: [**2184-3-8**]
Date of Birth: [**2143-4-11**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Progesterone in Oil
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Hypoxemic respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 8980**] is a 40 year old pregnant woman at 6 weeks EGA with
a past medical history significant for asthma admitted on [**3-3**]
for fever, cough, and dyspnea felt to be due to CAP now
transferred to the MICU for hypoxemic respiratory distress. The
patient reports that symptoms started 3 days ago with fever to
100.7 (ear) and non-productive cough, with progressively
worsening dyspnea on minimal exertion such that on the day of
admission she had difficulty walking to her bathroom. She does
have a history of well controlled asthma, although states that
her current symptoms are not consistent with prior asthma flare
although dypsnea did improve with albuterol MDI. She does
endorse rhinorrhea and fatigue, but denies any sore throat,
myalgias, LBP, sinus congestion, or wheezing. Her husband had a
cough several days ago, but denies any other sick contacts or
recent travel. She initially presented to an OSH ED, where she
had a CXR demonstrating bilateral lower lung field opacities
(R>L) felt to be CAP and was treated with CTX and azithromycin,
and was transferred to [**Hospital1 18**] for further management.
.
Her [**Hospital1 18**] course has been notable for a persistent tachcyardia,
tachypnea, and an increasing oxygen requirement now up to a 15L
face mask from 4L on admission. ABG prior to MICU transfer
7.48/28/72 on 50% FM. Given persistent tachycardia, tachypnea,
and increasing oxygen requirement, she was transferred to the
MICU for further management.
.
Currently, the patient states that her breathing is improved
after a neb treatment. She denies any CP, palpitations, ST, HA,
LBP, muscle aches, or wheezing.
Past Medical History:
1. Asthma. Only requires albuterol with URI's. Under good
control
on flovent 110mcg 2 puffs [**Hospital1 **]. No nocturnal awakenings, ICU
admissions, inbutations, or ED visits.
2. B12 deficiency. Had low B12 in 180's in [**2175**] and has been on
folgard since then with normal B12 levels. This was just stopped
when she was changed to prenatal vitamin, was told that it has
B12 in it.
3. Severely atypical nevus removed from her back. Sees Dr.
[**Last Name (STitle) 8981**] yearly, saw her last over the summer.
4. Pregnancy - 6 wks EGA with IVF treatments.
Social History:
Married, no children, undergoing fertility tx and is currently 6
weeks pregnant. Has 8 yr old stepson. Works in HR. Tobacco -
None. EtOH - social. Denies IV, illicit or herbal drug use.
Family History:
Mother - MI age 70, non-melanoma skin
CA, DM. Father - prostate CA, AAA, DM. Maternal aunt/uncle -
melanoma. 5 of 8 maternal aunts/uncles with CAD in 60-70's. 4 of
paternal aunts/uncles w/ CAD in 30-50's. MGF - DM. MGM - CAD
50-60's. PGM - CAD 50-60's. No family h/o clotting disorders
Physical Exam:
ADMISSION:
VS: 99.8 105 130/93 37 96% on 50% venturi
Gen: Labored breathing
HEENT: MM dry, OP clear, neck supple without LAD
CV: Tachy S1+S2
Pulm: Bronchial breath sounds at the bases bilaterally with
dullness to percussion. Scattered expiratory wheezes
bilaterally.
Abd: S/NT/ND +bs
Ext: No c/c/e.
Neuro: AOx3, CN II-XII intact.
DISCHARGE:
VS: afebrile, 140s/80s, 70-80, 98% on RA
GA: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: CTAB
Abd: soft, NT, +BS. no g/r.
Extremities: wwp, no edema. DPs, PTs 2+.
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
Pertinent Results:
RELEVANT AND REPRESENTATIVE LABS:
CBC and coags:
-[**2184-3-3**] 05:40PM BLOOD WBC-27.1*# RBC-4.37 Hgb-14.0 Hct-39.4
MCV-90 MCH-32.0 MCHC-35.5* RDW-12.6 Plt Ct-462*
-[**2184-3-3**] 05:40PM BLOOD Neuts-77.9* Lymphs-7.6* Monos-2.8
Eos-11.6* Baso-0.2
-[**2184-3-4**] 06:24AM BLOOD Neuts-72.9* Lymphs-8.1* Monos-2.6
Eos-15.9* Baso-0.3
-[**2184-3-5**] 03:35AM BLOOD WBC-20.4* RBC-3.94* Hgb-12.5 Hct-35.5*
MCV-90 MCH-31.7 MCHC-35.1* RDW-12.5 Plt Ct-405
-[**2184-3-5**] 03:35AM BLOOD Neuts-84* Bands-1 Lymphs-5* Monos-6
Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-2*
-[**2184-3-7**] 07:20AM BLOOD WBC-14.6* RBC-3.76* Hgb-11.6* Hct-33.9*
MCV-90 MCH-30.7 MCHC-34.1 RDW-12.6 Plt Ct-381
-[**2184-3-8**] 07:30AM BLOOD WBC-13.8* RBC-3.66* Hgb-11.7* Hct-32.7*
MCV-89 MCH-32.1* MCHC-35.9* RDW-12.5 Plt Ct-352
-[**2184-3-6**] 04:47AM BLOOD PT-13.1 PTT-23.4 INR(PT)-1.1
.
Chem:
-[**2184-3-3**] 05:40PM BLOOD Glucose-90 UreaN-8 Creat-0.6 Na-138
K-4.0 Cl-103 HCO3-21*
-[**2184-3-5**] 03:35AM BLOOD Glucose-140* UreaN-9 Creat-0.6 Na-138
K-3.7 Cl-106 HCO3-21*
-[**2184-3-7**] 07:20AM BLOOD Glucose-129* UreaN-14 Creat-0.5 Na-136
K-4.1 Cl-103 HCO3-24
-[**2184-3-8**] 07:30AM BLOOD Glucose-75 UreaN-13 Creat-0.6 Na-136
K-3.3 Cl-103 HCO3-24
.
LFTs
-[**2184-3-4**] 06:24AM BLOOD ALT-15 AST-16 LD(LDH)-238 AlkPhos-57
TotBili-0.3
.
Misc:
-[**2184-3-6**] 04:47AM BLOOD calTIBC-230* Ferritn-185* TRF-177*
-[**2184-3-4**] 02:35PM BLOOD ANCA-NEGATIVE B
-[**2184-3-3**] 05:40PM BLOOD HCG-7597
-[**2184-3-3**] 05:53PM BLOOD Lactate-1.4
.
.
IMAGING:
.
TVUS [**3-4**]:
Single live intrauterine gestation corresponding to a
gestational
age of 6 weeks 4 days.
.
CXR [**3-4**]:
Moderate-to-severe pulmonary edema, without evidence of pleural
effusions. Borderline size of the cardiac silhouette. No
interval appearance of new parenchymal opacities.
.
SPIROMETRY 10:30 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 2.81 3.44 82
FEV1 2.55 2.67 95
MMF 4.09 3.13 131
FEV1/FVC 91 78 117
Brief Hospital Course:
Mrs. [**Known lastname 8980**] is a 40 year old pregnant woman at 6 weeks EGA by
IVF with a past medical history significant for asthma admitted
on [**3-3**] for fever, cough, and dyspnea felt to be due to CAP, but
found to have eosinophilic pneumonitis.
# Eosinophilic pneumonitis: Patient's A-a gradient was >180 with
potential etiologies including V/Q mismatch, diffusion
abnormality, or shunt. Given absolute eosinophilic count of
>3000, fever, and acute shortness of breath, the diagnosis of
acute eosinophilic pneumonia was presumptively made. She was
treated with solumedrol 125 Q6H with improvement in symptoms and
rapid weaning of supplemental oxygen to room air. She was also
covered for pneumonia initially with vancomycin and
levofloxacin, but the regimen was narrowed to a 5 day course of
azithromycin, which she completed while hospitalized. She was
also initially treated with oseltamavir, which was discontinued
after Influenza DFA returned negative. Patient was transitioned
to prednisone 60 mg daily, and she will continue this dose until
follow-up with Dr. [**First Name8 (NamePattern2) 8982**] [**Last Name (NamePattern1) 7273**] as an outpatient. Her
eosinophilic pneumonitis was felt to be secondary to IM
progesterone in sesame oil suspension, and progesterone was
changed to intravaginal preparation. She will require PCP
prophylaxis if steroid course continues for longer than 1 month,
and this will be determined as an outpatient.
# Pregnancy: Intravaginal fetal u/s performed during MICU course
demonstrating viable fetus. OB consulted on the patient, and
[**Last Name (un) **] was also consulted for blood glucose control (see below).
She will continue intravaginal progesterone as above, and
follow-up with OB/Gyn.
# Hyperglycemia: elevated FSBG in the setting of steroid use.
Patient was started on sliding scale insulin [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs for
goal fingerstick <130 at one hour post-prandial. She will
continue insulin at home and f/u with the Diabetes in Pregnancy
Center at [**Last Name (un) **].
# Asthma: Continued on nebs during admission.
# Code: full
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs qid prn
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs
twice a day
PRENATAL VIT-IRON FUMARATE-FA [PRENATAL VITAMIN] - (Prescribed
by Other Provider) - Dosage uncertain
PROGESTERONE 50 mg/mL 1 mL QHS at 8:30 pm
Discharge Medications:
1. Prenatal 10-400 mg-mcg Capsule Sig: One (1) Capsule PO once a
day.
2. progesterone micronized 8 % Gel Sig: One (1) Appl Vaginal QHS
(once a day (at bedtime)) for 4 weeks.
[**Last Name (un) **]:*QS gel* Refills:*0*
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath, wheeze.
4. Supplies
"Humalog Kwik-pen" 1 box of 5 pens
5. Supplies
Humalog "pen needle" 31x3/16 needle, 200 needles
6. One Touch Delica Lancets Misc Sig: One (1) lancet
Miscellaneous four times a day: fasting and 1hour post-meals.
[**Last Name (un) **]:*200 lancets* Refills:*0*
7. One Touch Test Strip Sig: One (1) strip Miscellaneous
four times a day: fasting and 1hour post-meal.
[**Last Name (un) **]:*200 strips* Refills:*0*
8. prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day:
Take until you see pulmonary doctors.
[**Last Name (Titles) **]:*75 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Eosinophilic pneumonitis
Hyperglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital for shortness of breath, likely
caused by eosinophilic pneumonitis (pneumonia associated with an
increase in a white blood cell called eosinophils). This
improved with steroids. Please continue taking prednisone 60 mg
daily until you see Dr. [**Last Name (STitle) 7273**] at your followup appointment.
You were also found to have elevated blood sugars after being
started on prednisone, which is a common side effect. Please
continue taking insulin with meals as directed. You should
follow up with an endocrinologist at the [**Hospital **] clinic as
indicated below.
Changes to your medications:
-START taking humalog insulin as directed by [**Last Name (un) **]: 6units
before breakfast, 6units before lunch, 7units before dinner
-START taking prednisone 60 mg daily until you see Dr. [**Last Name (STitle) 7273**]
[**Name (STitle) 8983**] taking progesterone IM shots, and START taking
progesterone intravaginally daily
Followup Instructions:
Dr. [**Last Name (STitle) 8984**] (maternal fetal medicine specialist, OB/Gyn)
[**Location (un) 8985**] [**Location (un) 2274**] Tuesday [**3-9**] at 2pm. You can have an ultrasound
done on either Tuesday or Wednesday (see below).
Name: [**Name6 (MD) 6507**] [**Last Name (NamePattern4) 8986**], MD
Specialty: Fertility
When: Wednesday [**3-10**] at 1:30pm
Location: [**Hospital1 641**]
Address: [**Location (un) 4363**], [**Location (un) 86**], MA
Phone: [**Telephone/Fax (1) 8987**]
Department: INTERNAL MEDICINE
When: MONDAY [**2184-3-15**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8988**], MD [**Telephone/Fax (1) 4775**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2184-3-24**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
Specialty: Pulmonary
When: WEDNESDAY [**2184-3-24**] at 1:30 PM
With: DR [**Last Name (STitle) **]/DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: OB/GYN, [**Hospital 8989**] CLINIC (Diabetes in [**Hospital **]
Clinic)
When: FRIDAY [**2184-3-26**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 8990**] [**Last Name (NamePattern4) 8991**], MD [**Telephone/Fax (1) 8992**]
Specialty: Endocrinology
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**Please call [**Doctor Last Name 8993**] at [**Telephone/Fax (1) 8994**] once you are discharged. She
is the scheduler for the pregnancy clinic here at the hospital
and she would like to speak to you to get more information.**
**You can also call [**Telephone/Fax (1) 3681**] to set up an appointment to see
a nutritionist.**
| {
"clinical_findings": {
"J45909": [
{
"icd_10_cm_code": "J45.909",
"icd_10_cm_code_description": "Unspecified asthma, uncomplicated, without status asthmaticus",
"Monitoring": [
{
"text": "well controlled asthma",
"page_numbers": [
1
]
},
{
"text": "Continued on nebs during admission",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "Scattered expiratory wheezes\nbilaterally",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [
{
"text": "ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler",
"page_numbers": [
1
]
},
{
"text": "FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol",
"page_numbers": [
1
]
},
{
"text": "albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "well controlled asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "Asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "Asthma",
"page_numbers": [
1
]
}
],
"justification": "Asthma is a documented diagnosis in the patient's history and hospital course. MEAT criteria are met through documentation of the condition being 'well controlled' and 'Continued on nebs during admission' (Monitoring), 'Scattered expiratory wheezes bilaterally' on physical exam (Evaluation), and treatment with Albuterol and Fluticasone inhalers (Treatment). J45.909 is the appropriate code for unspecified uncomplicated asthma."
}
]
}
} |
Extract only the clinical assessment findings for each condition, including diagnostic conclusions and staging. | Admission Date: [**2184-3-3**] Discharge Date: [**2184-3-8**]
Date of Birth: [**2143-4-11**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Progesterone in Oil
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Hypoxemic respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 8980**] is a 40 year old pregnant woman at 6 weeks EGA with
a past medical history significant for asthma admitted on [**3-3**]
for fever, cough, and dyspnea felt to be due to CAP now
transferred to the MICU for hypoxemic respiratory distress. The
patient reports that symptoms started 3 days ago with fever to
100.7 (ear) and non-productive cough, with progressively
worsening dyspnea on minimal exertion such that on the day of
admission she had difficulty walking to her bathroom. She does
have a history of well controlled asthma, although states that
her current symptoms are not consistent with prior asthma flare
although dypsnea did improve with albuterol MDI. She does
endorse rhinorrhea and fatigue, but denies any sore throat,
myalgias, LBP, sinus congestion, or wheezing. Her husband had a
cough several days ago, but denies any other sick contacts or
recent travel. She initially presented to an OSH ED, where she
had a CXR demonstrating bilateral lower lung field opacities
(R>L) felt to be CAP and was treated with CTX and azithromycin,
and was transferred to [**Hospital1 18**] for further management.
.
Her [**Hospital1 18**] course has been notable for a persistent tachcyardia,
tachypnea, and an increasing oxygen requirement now up to a 15L
face mask from 4L on admission. ABG prior to MICU transfer
7.48/28/72 on 50% FM. Given persistent tachycardia, tachypnea,
and increasing oxygen requirement, she was transferred to the
MICU for further management.
.
Currently, the patient states that her breathing is improved
after a neb treatment. She denies any CP, palpitations, ST, HA,
LBP, muscle aches, or wheezing.
Past Medical History:
1. Asthma. Only requires albuterol with URI's. Under good
control
on flovent 110mcg 2 puffs [**Hospital1 **]. No nocturnal awakenings, ICU
admissions, inbutations, or ED visits.
2. B12 deficiency. Had low B12 in 180's in [**2175**] and has been on
folgard since then with normal B12 levels. This was just stopped
when she was changed to prenatal vitamin, was told that it has
B12 in it.
3. Severely atypical nevus removed from her back. Sees Dr.
[**Last Name (STitle) 8981**] yearly, saw her last over the summer.
4. Pregnancy - 6 wks EGA with IVF treatments.
Social History:
Married, no children, undergoing fertility tx and is currently 6
weeks pregnant. Has 8 yr old stepson. Works in HR. Tobacco -
None. EtOH - social. Denies IV, illicit or herbal drug use.
Family History:
Mother - MI age 70, non-melanoma skin
CA, DM. Father - prostate CA, AAA, DM. Maternal aunt/uncle -
melanoma. 5 of 8 maternal aunts/uncles with CAD in 60-70's. 4 of
paternal aunts/uncles w/ CAD in 30-50's. MGF - DM. MGM - CAD
50-60's. PGM - CAD 50-60's. No family h/o clotting disorders
Physical Exam:
ADMISSION:
VS: 99.8 105 130/93 37 96% on 50% venturi
Gen: Labored breathing
HEENT: MM dry, OP clear, neck supple without LAD
CV: Tachy S1+S2
Pulm: Bronchial breath sounds at the bases bilaterally with
dullness to percussion. Scattered expiratory wheezes
bilaterally.
Abd: S/NT/ND +bs
Ext: No c/c/e.
Neuro: AOx3, CN II-XII intact.
DISCHARGE:
VS: afebrile, 140s/80s, 70-80, 98% on RA
GA: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: CTAB
Abd: soft, NT, +BS. no g/r.
Extremities: wwp, no edema. DPs, PTs 2+.
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
Pertinent Results:
RELEVANT AND REPRESENTATIVE LABS:
CBC and coags:
-[**2184-3-3**] 05:40PM BLOOD WBC-27.1*# RBC-4.37 Hgb-14.0 Hct-39.4
MCV-90 MCH-32.0 MCHC-35.5* RDW-12.6 Plt Ct-462*
-[**2184-3-3**] 05:40PM BLOOD Neuts-77.9* Lymphs-7.6* Monos-2.8
Eos-11.6* Baso-0.2
-[**2184-3-4**] 06:24AM BLOOD Neuts-72.9* Lymphs-8.1* Monos-2.6
Eos-15.9* Baso-0.3
-[**2184-3-5**] 03:35AM BLOOD WBC-20.4* RBC-3.94* Hgb-12.5 Hct-35.5*
MCV-90 MCH-31.7 MCHC-35.1* RDW-12.5 Plt Ct-405
-[**2184-3-5**] 03:35AM BLOOD Neuts-84* Bands-1 Lymphs-5* Monos-6
Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-2*
-[**2184-3-7**] 07:20AM BLOOD WBC-14.6* RBC-3.76* Hgb-11.6* Hct-33.9*
MCV-90 MCH-30.7 MCHC-34.1 RDW-12.6 Plt Ct-381
-[**2184-3-8**] 07:30AM BLOOD WBC-13.8* RBC-3.66* Hgb-11.7* Hct-32.7*
MCV-89 MCH-32.1* MCHC-35.9* RDW-12.5 Plt Ct-352
-[**2184-3-6**] 04:47AM BLOOD PT-13.1 PTT-23.4 INR(PT)-1.1
.
Chem:
-[**2184-3-3**] 05:40PM BLOOD Glucose-90 UreaN-8 Creat-0.6 Na-138
K-4.0 Cl-103 HCO3-21*
-[**2184-3-5**] 03:35AM BLOOD Glucose-140* UreaN-9 Creat-0.6 Na-138
K-3.7 Cl-106 HCO3-21*
-[**2184-3-7**] 07:20AM BLOOD Glucose-129* UreaN-14 Creat-0.5 Na-136
K-4.1 Cl-103 HCO3-24
-[**2184-3-8**] 07:30AM BLOOD Glucose-75 UreaN-13 Creat-0.6 Na-136
K-3.3 Cl-103 HCO3-24
.
LFTs
-[**2184-3-4**] 06:24AM BLOOD ALT-15 AST-16 LD(LDH)-238 AlkPhos-57
TotBili-0.3
.
Misc:
-[**2184-3-6**] 04:47AM BLOOD calTIBC-230* Ferritn-185* TRF-177*
-[**2184-3-4**] 02:35PM BLOOD ANCA-NEGATIVE B
-[**2184-3-3**] 05:40PM BLOOD HCG-7597
-[**2184-3-3**] 05:53PM BLOOD Lactate-1.4
.
.
IMAGING:
.
TVUS [**3-4**]:
Single live intrauterine gestation corresponding to a
gestational
age of 6 weeks 4 days.
.
CXR [**3-4**]:
Moderate-to-severe pulmonary edema, without evidence of pleural
effusions. Borderline size of the cardiac silhouette. No
interval appearance of new parenchymal opacities.
.
SPIROMETRY 10:30 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 2.81 3.44 82
FEV1 2.55 2.67 95
MMF 4.09 3.13 131
FEV1/FVC 91 78 117
Brief Hospital Course:
Mrs. [**Known lastname 8980**] is a 40 year old pregnant woman at 6 weeks EGA by
IVF with a past medical history significant for asthma admitted
on [**3-3**] for fever, cough, and dyspnea felt to be due to CAP, but
found to have eosinophilic pneumonitis.
# Eosinophilic pneumonitis: Patient's A-a gradient was >180 with
potential etiologies including V/Q mismatch, diffusion
abnormality, or shunt. Given absolute eosinophilic count of
>3000, fever, and acute shortness of breath, the diagnosis of
acute eosinophilic pneumonia was presumptively made. She was
treated with solumedrol 125 Q6H with improvement in symptoms and
rapid weaning of supplemental oxygen to room air. She was also
covered for pneumonia initially with vancomycin and
levofloxacin, but the regimen was narrowed to a 5 day course of
azithromycin, which she completed while hospitalized. She was
also initially treated with oseltamavir, which was discontinued
after Influenza DFA returned negative. Patient was transitioned
to prednisone 60 mg daily, and she will continue this dose until
follow-up with Dr. [**First Name8 (NamePattern2) 8982**] [**Last Name (NamePattern1) 7273**] as an outpatient. Her
eosinophilic pneumonitis was felt to be secondary to IM
progesterone in sesame oil suspension, and progesterone was
changed to intravaginal preparation. She will require PCP
prophylaxis if steroid course continues for longer than 1 month,
and this will be determined as an outpatient.
# Pregnancy: Intravaginal fetal u/s performed during MICU course
demonstrating viable fetus. OB consulted on the patient, and
[**Last Name (un) **] was also consulted for blood glucose control (see below).
She will continue intravaginal progesterone as above, and
follow-up with OB/Gyn.
# Hyperglycemia: elevated FSBG in the setting of steroid use.
Patient was started on sliding scale insulin [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs for
goal fingerstick <130 at one hour post-prandial. She will
continue insulin at home and f/u with the Diabetes in Pregnancy
Center at [**Last Name (un) **].
# Asthma: Continued on nebs during admission.
# Code: full
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs qid prn
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs
twice a day
PRENATAL VIT-IRON FUMARATE-FA [PRENATAL VITAMIN] - (Prescribed
by Other Provider) - Dosage uncertain
PROGESTERONE 50 mg/mL 1 mL QHS at 8:30 pm
Discharge Medications:
1. Prenatal 10-400 mg-mcg Capsule Sig: One (1) Capsule PO once a
day.
2. progesterone micronized 8 % Gel Sig: One (1) Appl Vaginal QHS
(once a day (at bedtime)) for 4 weeks.
[**Last Name (un) **]:*QS gel* Refills:*0*
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath, wheeze.
4. Supplies
"Humalog Kwik-pen" 1 box of 5 pens
5. Supplies
Humalog "pen needle" 31x3/16 needle, 200 needles
6. One Touch Delica Lancets Misc Sig: One (1) lancet
Miscellaneous four times a day: fasting and 1hour post-meals.
[**Last Name (un) **]:*200 lancets* Refills:*0*
7. One Touch Test Strip Sig: One (1) strip Miscellaneous
four times a day: fasting and 1hour post-meal.
[**Last Name (un) **]:*200 strips* Refills:*0*
8. prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day:
Take until you see pulmonary doctors.
[**Last Name (Titles) **]:*75 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Eosinophilic pneumonitis
Hyperglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital for shortness of breath, likely
caused by eosinophilic pneumonitis (pneumonia associated with an
increase in a white blood cell called eosinophils). This
improved with steroids. Please continue taking prednisone 60 mg
daily until you see Dr. [**Last Name (STitle) 7273**] at your followup appointment.
You were also found to have elevated blood sugars after being
started on prednisone, which is a common side effect. Please
continue taking insulin with meals as directed. You should
follow up with an endocrinologist at the [**Hospital **] clinic as
indicated below.
Changes to your medications:
-START taking humalog insulin as directed by [**Last Name (un) **]: 6units
before breakfast, 6units before lunch, 7units before dinner
-START taking prednisone 60 mg daily until you see Dr. [**Last Name (STitle) 7273**]
[**Name (STitle) 8983**] taking progesterone IM shots, and START taking
progesterone intravaginally daily
Followup Instructions:
Dr. [**Last Name (STitle) 8984**] (maternal fetal medicine specialist, OB/Gyn)
[**Location (un) 8985**] [**Location (un) 2274**] Tuesday [**3-9**] at 2pm. You can have an ultrasound
done on either Tuesday or Wednesday (see below).
Name: [**Name6 (MD) 6507**] [**Last Name (NamePattern4) 8986**], MD
Specialty: Fertility
When: Wednesday [**3-10**] at 1:30pm
Location: [**Hospital1 641**]
Address: [**Location (un) 4363**], [**Location (un) 86**], MA
Phone: [**Telephone/Fax (1) 8987**]
Department: INTERNAL MEDICINE
When: MONDAY [**2184-3-15**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8988**], MD [**Telephone/Fax (1) 4775**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2184-3-24**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
Specialty: Pulmonary
When: WEDNESDAY [**2184-3-24**] at 1:30 PM
With: DR [**Last Name (STitle) **]/DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: OB/GYN, [**Hospital 8989**] CLINIC (Diabetes in [**Hospital **]
Clinic)
When: FRIDAY [**2184-3-26**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 8990**] [**Last Name (NamePattern4) 8991**], MD [**Telephone/Fax (1) 8992**]
Specialty: Endocrinology
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**Please call [**Doctor Last Name 8993**] at [**Telephone/Fax (1) 8994**] once you are discharged. She
is the scheduler for the pregnancy clinic here at the hospital
and she would like to speak to you to get more information.**
**You can also call [**Telephone/Fax (1) 3681**] to set up an appointment to see
a nutritionist.**
| {
"clinical_findings": {
"J45909": [
{
"icd_10_cm_code": "J45.909",
"icd_10_cm_code_description": "Unspecified asthma, uncomplicated, without status asthmaticus",
"Monitoring": [
{
"text": "well controlled asthma",
"page_numbers": [
1
]
},
{
"text": "Continued on nebs during admission",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "Scattered expiratory wheezes\nbilaterally",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [
{
"text": "ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler",
"page_numbers": [
1
]
},
{
"text": "FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol",
"page_numbers": [
1
]
},
{
"text": "albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "well controlled asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "Asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "Asthma",
"page_numbers": [
1
]
}
],
"justification": "Asthma is a documented diagnosis in the patient's history and hospital course. MEAT criteria are met through documentation of the condition being 'well controlled' and 'Continued on nebs during admission' (Monitoring), 'Scattered expiratory wheezes bilaterally' on physical exam (Evaluation), and treatment with Albuterol and Fluticasone inhalers (Treatment). J45.909 is the appropriate code for unspecified uncomplicated asthma."
}
]
}
} |
Extract only the treatment or intervention given for each condition, including surgeries, procedures, and medications. | Admission Date: [**2184-3-3**] Discharge Date: [**2184-3-8**]
Date of Birth: [**2143-4-11**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Progesterone in Oil
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Hypoxemic respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 8980**] is a 40 year old pregnant woman at 6 weeks EGA with
a past medical history significant for asthma admitted on [**3-3**]
for fever, cough, and dyspnea felt to be due to CAP now
transferred to the MICU for hypoxemic respiratory distress. The
patient reports that symptoms started 3 days ago with fever to
100.7 (ear) and non-productive cough, with progressively
worsening dyspnea on minimal exertion such that on the day of
admission she had difficulty walking to her bathroom. She does
have a history of well controlled asthma, although states that
her current symptoms are not consistent with prior asthma flare
although dypsnea did improve with albuterol MDI. She does
endorse rhinorrhea and fatigue, but denies any sore throat,
myalgias, LBP, sinus congestion, or wheezing. Her husband had a
cough several days ago, but denies any other sick contacts or
recent travel. She initially presented to an OSH ED, where she
had a CXR demonstrating bilateral lower lung field opacities
(R>L) felt to be CAP and was treated with CTX and azithromycin,
and was transferred to [**Hospital1 18**] for further management.
.
Her [**Hospital1 18**] course has been notable for a persistent tachcyardia,
tachypnea, and an increasing oxygen requirement now up to a 15L
face mask from 4L on admission. ABG prior to MICU transfer
7.48/28/72 on 50% FM. Given persistent tachycardia, tachypnea,
and increasing oxygen requirement, she was transferred to the
MICU for further management.
.
Currently, the patient states that her breathing is improved
after a neb treatment. She denies any CP, palpitations, ST, HA,
LBP, muscle aches, or wheezing.
Past Medical History:
1. Asthma. Only requires albuterol with URI's. Under good
control
on flovent 110mcg 2 puffs [**Hospital1 **]. No nocturnal awakenings, ICU
admissions, inbutations, or ED visits.
2. B12 deficiency. Had low B12 in 180's in [**2175**] and has been on
folgard since then with normal B12 levels. This was just stopped
when she was changed to prenatal vitamin, was told that it has
B12 in it.
3. Severely atypical nevus removed from her back. Sees Dr.
[**Last Name (STitle) 8981**] yearly, saw her last over the summer.
4. Pregnancy - 6 wks EGA with IVF treatments.
Social History:
Married, no children, undergoing fertility tx and is currently 6
weeks pregnant. Has 8 yr old stepson. Works in HR. Tobacco -
None. EtOH - social. Denies IV, illicit or herbal drug use.
Family History:
Mother - MI age 70, non-melanoma skin
CA, DM. Father - prostate CA, AAA, DM. Maternal aunt/uncle -
melanoma. 5 of 8 maternal aunts/uncles with CAD in 60-70's. 4 of
paternal aunts/uncles w/ CAD in 30-50's. MGF - DM. MGM - CAD
50-60's. PGM - CAD 50-60's. No family h/o clotting disorders
Physical Exam:
ADMISSION:
VS: 99.8 105 130/93 37 96% on 50% venturi
Gen: Labored breathing
HEENT: MM dry, OP clear, neck supple without LAD
CV: Tachy S1+S2
Pulm: Bronchial breath sounds at the bases bilaterally with
dullness to percussion. Scattered expiratory wheezes
bilaterally.
Abd: S/NT/ND +bs
Ext: No c/c/e.
Neuro: AOx3, CN II-XII intact.
DISCHARGE:
VS: afebrile, 140s/80s, 70-80, 98% on RA
GA: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: CTAB
Abd: soft, NT, +BS. no g/r.
Extremities: wwp, no edema. DPs, PTs 2+.
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
Pertinent Results:
RELEVANT AND REPRESENTATIVE LABS:
CBC and coags:
-[**2184-3-3**] 05:40PM BLOOD WBC-27.1*# RBC-4.37 Hgb-14.0 Hct-39.4
MCV-90 MCH-32.0 MCHC-35.5* RDW-12.6 Plt Ct-462*
-[**2184-3-3**] 05:40PM BLOOD Neuts-77.9* Lymphs-7.6* Monos-2.8
Eos-11.6* Baso-0.2
-[**2184-3-4**] 06:24AM BLOOD Neuts-72.9* Lymphs-8.1* Monos-2.6
Eos-15.9* Baso-0.3
-[**2184-3-5**] 03:35AM BLOOD WBC-20.4* RBC-3.94* Hgb-12.5 Hct-35.5*
MCV-90 MCH-31.7 MCHC-35.1* RDW-12.5 Plt Ct-405
-[**2184-3-5**] 03:35AM BLOOD Neuts-84* Bands-1 Lymphs-5* Monos-6
Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-2*
-[**2184-3-7**] 07:20AM BLOOD WBC-14.6* RBC-3.76* Hgb-11.6* Hct-33.9*
MCV-90 MCH-30.7 MCHC-34.1 RDW-12.6 Plt Ct-381
-[**2184-3-8**] 07:30AM BLOOD WBC-13.8* RBC-3.66* Hgb-11.7* Hct-32.7*
MCV-89 MCH-32.1* MCHC-35.9* RDW-12.5 Plt Ct-352
-[**2184-3-6**] 04:47AM BLOOD PT-13.1 PTT-23.4 INR(PT)-1.1
.
Chem:
-[**2184-3-3**] 05:40PM BLOOD Glucose-90 UreaN-8 Creat-0.6 Na-138
K-4.0 Cl-103 HCO3-21*
-[**2184-3-5**] 03:35AM BLOOD Glucose-140* UreaN-9 Creat-0.6 Na-138
K-3.7 Cl-106 HCO3-21*
-[**2184-3-7**] 07:20AM BLOOD Glucose-129* UreaN-14 Creat-0.5 Na-136
K-4.1 Cl-103 HCO3-24
-[**2184-3-8**] 07:30AM BLOOD Glucose-75 UreaN-13 Creat-0.6 Na-136
K-3.3 Cl-103 HCO3-24
.
LFTs
-[**2184-3-4**] 06:24AM BLOOD ALT-15 AST-16 LD(LDH)-238 AlkPhos-57
TotBili-0.3
.
Misc:
-[**2184-3-6**] 04:47AM BLOOD calTIBC-230* Ferritn-185* TRF-177*
-[**2184-3-4**] 02:35PM BLOOD ANCA-NEGATIVE B
-[**2184-3-3**] 05:40PM BLOOD HCG-7597
-[**2184-3-3**] 05:53PM BLOOD Lactate-1.4
.
.
IMAGING:
.
TVUS [**3-4**]:
Single live intrauterine gestation corresponding to a
gestational
age of 6 weeks 4 days.
.
CXR [**3-4**]:
Moderate-to-severe pulmonary edema, without evidence of pleural
effusions. Borderline size of the cardiac silhouette. No
interval appearance of new parenchymal opacities.
.
SPIROMETRY 10:30 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 2.81 3.44 82
FEV1 2.55 2.67 95
MMF 4.09 3.13 131
FEV1/FVC 91 78 117
Brief Hospital Course:
Mrs. [**Known lastname 8980**] is a 40 year old pregnant woman at 6 weeks EGA by
IVF with a past medical history significant for asthma admitted
on [**3-3**] for fever, cough, and dyspnea felt to be due to CAP, but
found to have eosinophilic pneumonitis.
# Eosinophilic pneumonitis: Patient's A-a gradient was >180 with
potential etiologies including V/Q mismatch, diffusion
abnormality, or shunt. Given absolute eosinophilic count of
>3000, fever, and acute shortness of breath, the diagnosis of
acute eosinophilic pneumonia was presumptively made. She was
treated with solumedrol 125 Q6H with improvement in symptoms and
rapid weaning of supplemental oxygen to room air. She was also
covered for pneumonia initially with vancomycin and
levofloxacin, but the regimen was narrowed to a 5 day course of
azithromycin, which she completed while hospitalized. She was
also initially treated with oseltamavir, which was discontinued
after Influenza DFA returned negative. Patient was transitioned
to prednisone 60 mg daily, and she will continue this dose until
follow-up with Dr. [**First Name8 (NamePattern2) 8982**] [**Last Name (NamePattern1) 7273**] as an outpatient. Her
eosinophilic pneumonitis was felt to be secondary to IM
progesterone in sesame oil suspension, and progesterone was
changed to intravaginal preparation. She will require PCP
prophylaxis if steroid course continues for longer than 1 month,
and this will be determined as an outpatient.
# Pregnancy: Intravaginal fetal u/s performed during MICU course
demonstrating viable fetus. OB consulted on the patient, and
[**Last Name (un) **] was also consulted for blood glucose control (see below).
She will continue intravaginal progesterone as above, and
follow-up with OB/Gyn.
# Hyperglycemia: elevated FSBG in the setting of steroid use.
Patient was started on sliding scale insulin [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs for
goal fingerstick <130 at one hour post-prandial. She will
continue insulin at home and f/u with the Diabetes in Pregnancy
Center at [**Last Name (un) **].
# Asthma: Continued on nebs during admission.
# Code: full
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs qid prn
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs
twice a day
PRENATAL VIT-IRON FUMARATE-FA [PRENATAL VITAMIN] - (Prescribed
by Other Provider) - Dosage uncertain
PROGESTERONE 50 mg/mL 1 mL QHS at 8:30 pm
Discharge Medications:
1. Prenatal 10-400 mg-mcg Capsule Sig: One (1) Capsule PO once a
day.
2. progesterone micronized 8 % Gel Sig: One (1) Appl Vaginal QHS
(once a day (at bedtime)) for 4 weeks.
[**Last Name (un) **]:*QS gel* Refills:*0*
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath, wheeze.
4. Supplies
"Humalog Kwik-pen" 1 box of 5 pens
5. Supplies
Humalog "pen needle" 31x3/16 needle, 200 needles
6. One Touch Delica Lancets Misc Sig: One (1) lancet
Miscellaneous four times a day: fasting and 1hour post-meals.
[**Last Name (un) **]:*200 lancets* Refills:*0*
7. One Touch Test Strip Sig: One (1) strip Miscellaneous
four times a day: fasting and 1hour post-meal.
[**Last Name (un) **]:*200 strips* Refills:*0*
8. prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day:
Take until you see pulmonary doctors.
[**Last Name (Titles) **]:*75 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Eosinophilic pneumonitis
Hyperglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital for shortness of breath, likely
caused by eosinophilic pneumonitis (pneumonia associated with an
increase in a white blood cell called eosinophils). This
improved with steroids. Please continue taking prednisone 60 mg
daily until you see Dr. [**Last Name (STitle) 7273**] at your followup appointment.
You were also found to have elevated blood sugars after being
started on prednisone, which is a common side effect. Please
continue taking insulin with meals as directed. You should
follow up with an endocrinologist at the [**Hospital **] clinic as
indicated below.
Changes to your medications:
-START taking humalog insulin as directed by [**Last Name (un) **]: 6units
before breakfast, 6units before lunch, 7units before dinner
-START taking prednisone 60 mg daily until you see Dr. [**Last Name (STitle) 7273**]
[**Name (STitle) 8983**] taking progesterone IM shots, and START taking
progesterone intravaginally daily
Followup Instructions:
Dr. [**Last Name (STitle) 8984**] (maternal fetal medicine specialist, OB/Gyn)
[**Location (un) 8985**] [**Location (un) 2274**] Tuesday [**3-9**] at 2pm. You can have an ultrasound
done on either Tuesday or Wednesday (see below).
Name: [**Name6 (MD) 6507**] [**Last Name (NamePattern4) 8986**], MD
Specialty: Fertility
When: Wednesday [**3-10**] at 1:30pm
Location: [**Hospital1 641**]
Address: [**Location (un) 4363**], [**Location (un) 86**], MA
Phone: [**Telephone/Fax (1) 8987**]
Department: INTERNAL MEDICINE
When: MONDAY [**2184-3-15**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8988**], MD [**Telephone/Fax (1) 4775**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2184-3-24**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
Specialty: Pulmonary
When: WEDNESDAY [**2184-3-24**] at 1:30 PM
With: DR [**Last Name (STitle) **]/DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: OB/GYN, [**Hospital 8989**] CLINIC (Diabetes in [**Hospital **]
Clinic)
When: FRIDAY [**2184-3-26**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 8990**] [**Last Name (NamePattern4) 8991**], MD [**Telephone/Fax (1) 8992**]
Specialty: Endocrinology
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**Please call [**Doctor Last Name 8993**] at [**Telephone/Fax (1) 8994**] once you are discharged. She
is the scheduler for the pregnancy clinic here at the hospital
and she would like to speak to you to get more information.**
**You can also call [**Telephone/Fax (1) 3681**] to set up an appointment to see
a nutritionist.**
| {
"clinical_findings": {
"J45909": [
{
"icd_10_cm_code": "J45.909",
"icd_10_cm_code_description": "Unspecified asthma, uncomplicated, without status asthmaticus",
"Monitoring": [
{
"text": "well controlled asthma",
"page_numbers": [
1
]
},
{
"text": "Continued on nebs during admission",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "Scattered expiratory wheezes\nbilaterally",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [
{
"text": "ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler",
"page_numbers": [
1
]
},
{
"text": "FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol",
"page_numbers": [
1
]
},
{
"text": "albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "well controlled asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "Asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "Asthma",
"page_numbers": [
1
]
}
],
"justification": "Asthma is a documented diagnosis in the patient's history and hospital course. MEAT criteria are met through documentation of the condition being 'well controlled' and 'Continued on nebs during admission' (Monitoring), 'Scattered expiratory wheezes bilaterally' on physical exam (Evaluation), and treatment with Albuterol and Fluticasone inhalers (Treatment). J45.909 is the appropriate code for unspecified uncomplicated asthma."
}
]
}
} |
Extract only the evidence from the discharge summary that supports the existence of each condition. | Admission Date: [**2184-3-3**] Discharge Date: [**2184-3-8**]
Date of Birth: [**2143-4-11**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Progesterone in Oil
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Hypoxemic respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 8980**] is a 40 year old pregnant woman at 6 weeks EGA with
a past medical history significant for asthma admitted on [**3-3**]
for fever, cough, and dyspnea felt to be due to CAP now
transferred to the MICU for hypoxemic respiratory distress. The
patient reports that symptoms started 3 days ago with fever to
100.7 (ear) and non-productive cough, with progressively
worsening dyspnea on minimal exertion such that on the day of
admission she had difficulty walking to her bathroom. She does
have a history of well controlled asthma, although states that
her current symptoms are not consistent with prior asthma flare
although dypsnea did improve with albuterol MDI. She does
endorse rhinorrhea and fatigue, but denies any sore throat,
myalgias, LBP, sinus congestion, or wheezing. Her husband had a
cough several days ago, but denies any other sick contacts or
recent travel. She initially presented to an OSH ED, where she
had a CXR demonstrating bilateral lower lung field opacities
(R>L) felt to be CAP and was treated with CTX and azithromycin,
and was transferred to [**Hospital1 18**] for further management.
.
Her [**Hospital1 18**] course has been notable for a persistent tachcyardia,
tachypnea, and an increasing oxygen requirement now up to a 15L
face mask from 4L on admission. ABG prior to MICU transfer
7.48/28/72 on 50% FM. Given persistent tachycardia, tachypnea,
and increasing oxygen requirement, she was transferred to the
MICU for further management.
.
Currently, the patient states that her breathing is improved
after a neb treatment. She denies any CP, palpitations, ST, HA,
LBP, muscle aches, or wheezing.
Past Medical History:
1. Asthma. Only requires albuterol with URI's. Under good
control
on flovent 110mcg 2 puffs [**Hospital1 **]. No nocturnal awakenings, ICU
admissions, inbutations, or ED visits.
2. B12 deficiency. Had low B12 in 180's in [**2175**] and has been on
folgard since then with normal B12 levels. This was just stopped
when she was changed to prenatal vitamin, was told that it has
B12 in it.
3. Severely atypical nevus removed from her back. Sees Dr.
[**Last Name (STitle) 8981**] yearly, saw her last over the summer.
4. Pregnancy - 6 wks EGA with IVF treatments.
Social History:
Married, no children, undergoing fertility tx and is currently 6
weeks pregnant. Has 8 yr old stepson. Works in HR. Tobacco -
None. EtOH - social. Denies IV, illicit or herbal drug use.
Family History:
Mother - MI age 70, non-melanoma skin
CA, DM. Father - prostate CA, AAA, DM. Maternal aunt/uncle -
melanoma. 5 of 8 maternal aunts/uncles with CAD in 60-70's. 4 of
paternal aunts/uncles w/ CAD in 30-50's. MGF - DM. MGM - CAD
50-60's. PGM - CAD 50-60's. No family h/o clotting disorders
Physical Exam:
ADMISSION:
VS: 99.8 105 130/93 37 96% on 50% venturi
Gen: Labored breathing
HEENT: MM dry, OP clear, neck supple without LAD
CV: Tachy S1+S2
Pulm: Bronchial breath sounds at the bases bilaterally with
dullness to percussion. Scattered expiratory wheezes
bilaterally.
Abd: S/NT/ND +bs
Ext: No c/c/e.
Neuro: AOx3, CN II-XII intact.
DISCHARGE:
VS: afebrile, 140s/80s, 70-80, 98% on RA
GA: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: CTAB
Abd: soft, NT, +BS. no g/r.
Extremities: wwp, no edema. DPs, PTs 2+.
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
Pertinent Results:
RELEVANT AND REPRESENTATIVE LABS:
CBC and coags:
-[**2184-3-3**] 05:40PM BLOOD WBC-27.1*# RBC-4.37 Hgb-14.0 Hct-39.4
MCV-90 MCH-32.0 MCHC-35.5* RDW-12.6 Plt Ct-462*
-[**2184-3-3**] 05:40PM BLOOD Neuts-77.9* Lymphs-7.6* Monos-2.8
Eos-11.6* Baso-0.2
-[**2184-3-4**] 06:24AM BLOOD Neuts-72.9* Lymphs-8.1* Monos-2.6
Eos-15.9* Baso-0.3
-[**2184-3-5**] 03:35AM BLOOD WBC-20.4* RBC-3.94* Hgb-12.5 Hct-35.5*
MCV-90 MCH-31.7 MCHC-35.1* RDW-12.5 Plt Ct-405
-[**2184-3-5**] 03:35AM BLOOD Neuts-84* Bands-1 Lymphs-5* Monos-6
Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-2*
-[**2184-3-7**] 07:20AM BLOOD WBC-14.6* RBC-3.76* Hgb-11.6* Hct-33.9*
MCV-90 MCH-30.7 MCHC-34.1 RDW-12.6 Plt Ct-381
-[**2184-3-8**] 07:30AM BLOOD WBC-13.8* RBC-3.66* Hgb-11.7* Hct-32.7*
MCV-89 MCH-32.1* MCHC-35.9* RDW-12.5 Plt Ct-352
-[**2184-3-6**] 04:47AM BLOOD PT-13.1 PTT-23.4 INR(PT)-1.1
.
Chem:
-[**2184-3-3**] 05:40PM BLOOD Glucose-90 UreaN-8 Creat-0.6 Na-138
K-4.0 Cl-103 HCO3-21*
-[**2184-3-5**] 03:35AM BLOOD Glucose-140* UreaN-9 Creat-0.6 Na-138
K-3.7 Cl-106 HCO3-21*
-[**2184-3-7**] 07:20AM BLOOD Glucose-129* UreaN-14 Creat-0.5 Na-136
K-4.1 Cl-103 HCO3-24
-[**2184-3-8**] 07:30AM BLOOD Glucose-75 UreaN-13 Creat-0.6 Na-136
K-3.3 Cl-103 HCO3-24
.
LFTs
-[**2184-3-4**] 06:24AM BLOOD ALT-15 AST-16 LD(LDH)-238 AlkPhos-57
TotBili-0.3
.
Misc:
-[**2184-3-6**] 04:47AM BLOOD calTIBC-230* Ferritn-185* TRF-177*
-[**2184-3-4**] 02:35PM BLOOD ANCA-NEGATIVE B
-[**2184-3-3**] 05:40PM BLOOD HCG-7597
-[**2184-3-3**] 05:53PM BLOOD Lactate-1.4
.
.
IMAGING:
.
TVUS [**3-4**]:
Single live intrauterine gestation corresponding to a
gestational
age of 6 weeks 4 days.
.
CXR [**3-4**]:
Moderate-to-severe pulmonary edema, without evidence of pleural
effusions. Borderline size of the cardiac silhouette. No
interval appearance of new parenchymal opacities.
.
SPIROMETRY 10:30 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 2.81 3.44 82
FEV1 2.55 2.67 95
MMF 4.09 3.13 131
FEV1/FVC 91 78 117
Brief Hospital Course:
Mrs. [**Known lastname 8980**] is a 40 year old pregnant woman at 6 weeks EGA by
IVF with a past medical history significant for asthma admitted
on [**3-3**] for fever, cough, and dyspnea felt to be due to CAP, but
found to have eosinophilic pneumonitis.
# Eosinophilic pneumonitis: Patient's A-a gradient was >180 with
potential etiologies including V/Q mismatch, diffusion
abnormality, or shunt. Given absolute eosinophilic count of
>3000, fever, and acute shortness of breath, the diagnosis of
acute eosinophilic pneumonia was presumptively made. She was
treated with solumedrol 125 Q6H with improvement in symptoms and
rapid weaning of supplemental oxygen to room air. She was also
covered for pneumonia initially with vancomycin and
levofloxacin, but the regimen was narrowed to a 5 day course of
azithromycin, which she completed while hospitalized. She was
also initially treated with oseltamavir, which was discontinued
after Influenza DFA returned negative. Patient was transitioned
to prednisone 60 mg daily, and she will continue this dose until
follow-up with Dr. [**First Name8 (NamePattern2) 8982**] [**Last Name (NamePattern1) 7273**] as an outpatient. Her
eosinophilic pneumonitis was felt to be secondary to IM
progesterone in sesame oil suspension, and progesterone was
changed to intravaginal preparation. She will require PCP
prophylaxis if steroid course continues for longer than 1 month,
and this will be determined as an outpatient.
# Pregnancy: Intravaginal fetal u/s performed during MICU course
demonstrating viable fetus. OB consulted on the patient, and
[**Last Name (un) **] was also consulted for blood glucose control (see below).
She will continue intravaginal progesterone as above, and
follow-up with OB/Gyn.
# Hyperglycemia: elevated FSBG in the setting of steroid use.
Patient was started on sliding scale insulin [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs for
goal fingerstick <130 at one hour post-prandial. She will
continue insulin at home and f/u with the Diabetes in Pregnancy
Center at [**Last Name (un) **].
# Asthma: Continued on nebs during admission.
# Code: full
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs qid prn
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs
twice a day
PRENATAL VIT-IRON FUMARATE-FA [PRENATAL VITAMIN] - (Prescribed
by Other Provider) - Dosage uncertain
PROGESTERONE 50 mg/mL 1 mL QHS at 8:30 pm
Discharge Medications:
1. Prenatal 10-400 mg-mcg Capsule Sig: One (1) Capsule PO once a
day.
2. progesterone micronized 8 % Gel Sig: One (1) Appl Vaginal QHS
(once a day (at bedtime)) for 4 weeks.
[**Last Name (un) **]:*QS gel* Refills:*0*
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath, wheeze.
4. Supplies
"Humalog Kwik-pen" 1 box of 5 pens
5. Supplies
Humalog "pen needle" 31x3/16 needle, 200 needles
6. One Touch Delica Lancets Misc Sig: One (1) lancet
Miscellaneous four times a day: fasting and 1hour post-meals.
[**Last Name (un) **]:*200 lancets* Refills:*0*
7. One Touch Test Strip Sig: One (1) strip Miscellaneous
four times a day: fasting and 1hour post-meal.
[**Last Name (un) **]:*200 strips* Refills:*0*
8. prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day:
Take until you see pulmonary doctors.
[**Last Name (Titles) **]:*75 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Eosinophilic pneumonitis
Hyperglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital for shortness of breath, likely
caused by eosinophilic pneumonitis (pneumonia associated with an
increase in a white blood cell called eosinophils). This
improved with steroids. Please continue taking prednisone 60 mg
daily until you see Dr. [**Last Name (STitle) 7273**] at your followup appointment.
You were also found to have elevated blood sugars after being
started on prednisone, which is a common side effect. Please
continue taking insulin with meals as directed. You should
follow up with an endocrinologist at the [**Hospital **] clinic as
indicated below.
Changes to your medications:
-START taking humalog insulin as directed by [**Last Name (un) **]: 6units
before breakfast, 6units before lunch, 7units before dinner
-START taking prednisone 60 mg daily until you see Dr. [**Last Name (STitle) 7273**]
[**Name (STitle) 8983**] taking progesterone IM shots, and START taking
progesterone intravaginally daily
Followup Instructions:
Dr. [**Last Name (STitle) 8984**] (maternal fetal medicine specialist, OB/Gyn)
[**Location (un) 8985**] [**Location (un) 2274**] Tuesday [**3-9**] at 2pm. You can have an ultrasound
done on either Tuesday or Wednesday (see below).
Name: [**Name6 (MD) 6507**] [**Last Name (NamePattern4) 8986**], MD
Specialty: Fertility
When: Wednesday [**3-10**] at 1:30pm
Location: [**Hospital1 641**]
Address: [**Location (un) 4363**], [**Location (un) 86**], MA
Phone: [**Telephone/Fax (1) 8987**]
Department: INTERNAL MEDICINE
When: MONDAY [**2184-3-15**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8988**], MD [**Telephone/Fax (1) 4775**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2184-3-24**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
Specialty: Pulmonary
When: WEDNESDAY [**2184-3-24**] at 1:30 PM
With: DR [**Last Name (STitle) **]/DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: OB/GYN, [**Hospital 8989**] CLINIC (Diabetes in [**Hospital **]
Clinic)
When: FRIDAY [**2184-3-26**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 8990**] [**Last Name (NamePattern4) 8991**], MD [**Telephone/Fax (1) 8992**]
Specialty: Endocrinology
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**Please call [**Doctor Last Name 8993**] at [**Telephone/Fax (1) 8994**] once you are discharged. She
is the scheduler for the pregnancy clinic here at the hospital
and she would like to speak to you to get more information.**
**You can also call [**Telephone/Fax (1) 3681**] to set up an appointment to see
a nutritionist.**
| {
"clinical_findings": {
"J45909": [
{
"icd_10_cm_code": "J45.909",
"icd_10_cm_code_description": "Unspecified asthma, uncomplicated, without status asthmaticus",
"Monitoring": [
{
"text": "well controlled asthma",
"page_numbers": [
1
]
},
{
"text": "Continued on nebs during admission",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "Scattered expiratory wheezes\nbilaterally",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [
{
"text": "ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler",
"page_numbers": [
1
]
},
{
"text": "FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol",
"page_numbers": [
1
]
},
{
"text": "albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "well controlled asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "Asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "Asthma",
"page_numbers": [
1
]
}
],
"justification": "Asthma is a documented diagnosis in the patient's history and hospital course. MEAT criteria are met through documentation of the condition being 'well controlled' and 'Continued on nebs during admission' (Monitoring), 'Scattered expiratory wheezes bilaterally' on physical exam (Evaluation), and treatment with Albuterol and Fluticasone inhalers (Treatment). J45.909 is the appropriate code for unspecified uncomplicated asthma."
}
]
}
} |
Extract only the text-based justification for assigning the ICD-10-CM code to each condition. | Admission Date: [**2184-3-3**] Discharge Date: [**2184-3-8**]
Date of Birth: [**2143-4-11**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Progesterone in Oil
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Hypoxemic respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 8980**] is a 40 year old pregnant woman at 6 weeks EGA with
a past medical history significant for asthma admitted on [**3-3**]
for fever, cough, and dyspnea felt to be due to CAP now
transferred to the MICU for hypoxemic respiratory distress. The
patient reports that symptoms started 3 days ago with fever to
100.7 (ear) and non-productive cough, with progressively
worsening dyspnea on minimal exertion such that on the day of
admission she had difficulty walking to her bathroom. She does
have a history of well controlled asthma, although states that
her current symptoms are not consistent with prior asthma flare
although dypsnea did improve with albuterol MDI. She does
endorse rhinorrhea and fatigue, but denies any sore throat,
myalgias, LBP, sinus congestion, or wheezing. Her husband had a
cough several days ago, but denies any other sick contacts or
recent travel. She initially presented to an OSH ED, where she
had a CXR demonstrating bilateral lower lung field opacities
(R>L) felt to be CAP and was treated with CTX and azithromycin,
and was transferred to [**Hospital1 18**] for further management.
.
Her [**Hospital1 18**] course has been notable for a persistent tachcyardia,
tachypnea, and an increasing oxygen requirement now up to a 15L
face mask from 4L on admission. ABG prior to MICU transfer
7.48/28/72 on 50% FM. Given persistent tachycardia, tachypnea,
and increasing oxygen requirement, she was transferred to the
MICU for further management.
.
Currently, the patient states that her breathing is improved
after a neb treatment. She denies any CP, palpitations, ST, HA,
LBP, muscle aches, or wheezing.
Past Medical History:
1. Asthma. Only requires albuterol with URI's. Under good
control
on flovent 110mcg 2 puffs [**Hospital1 **]. No nocturnal awakenings, ICU
admissions, inbutations, or ED visits.
2. B12 deficiency. Had low B12 in 180's in [**2175**] and has been on
folgard since then with normal B12 levels. This was just stopped
when she was changed to prenatal vitamin, was told that it has
B12 in it.
3. Severely atypical nevus removed from her back. Sees Dr.
[**Last Name (STitle) 8981**] yearly, saw her last over the summer.
4. Pregnancy - 6 wks EGA with IVF treatments.
Social History:
Married, no children, undergoing fertility tx and is currently 6
weeks pregnant. Has 8 yr old stepson. Works in HR. Tobacco -
None. EtOH - social. Denies IV, illicit or herbal drug use.
Family History:
Mother - MI age 70, non-melanoma skin
CA, DM. Father - prostate CA, AAA, DM. Maternal aunt/uncle -
melanoma. 5 of 8 maternal aunts/uncles with CAD in 60-70's. 4 of
paternal aunts/uncles w/ CAD in 30-50's. MGF - DM. MGM - CAD
50-60's. PGM - CAD 50-60's. No family h/o clotting disorders
Physical Exam:
ADMISSION:
VS: 99.8 105 130/93 37 96% on 50% venturi
Gen: Labored breathing
HEENT: MM dry, OP clear, neck supple without LAD
CV: Tachy S1+S2
Pulm: Bronchial breath sounds at the bases bilaterally with
dullness to percussion. Scattered expiratory wheezes
bilaterally.
Abd: S/NT/ND +bs
Ext: No c/c/e.
Neuro: AOx3, CN II-XII intact.
DISCHARGE:
VS: afebrile, 140s/80s, 70-80, 98% on RA
GA: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: CTAB
Abd: soft, NT, +BS. no g/r.
Extremities: wwp, no edema. DPs, PTs 2+.
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
Pertinent Results:
RELEVANT AND REPRESENTATIVE LABS:
CBC and coags:
-[**2184-3-3**] 05:40PM BLOOD WBC-27.1*# RBC-4.37 Hgb-14.0 Hct-39.4
MCV-90 MCH-32.0 MCHC-35.5* RDW-12.6 Plt Ct-462*
-[**2184-3-3**] 05:40PM BLOOD Neuts-77.9* Lymphs-7.6* Monos-2.8
Eos-11.6* Baso-0.2
-[**2184-3-4**] 06:24AM BLOOD Neuts-72.9* Lymphs-8.1* Monos-2.6
Eos-15.9* Baso-0.3
-[**2184-3-5**] 03:35AM BLOOD WBC-20.4* RBC-3.94* Hgb-12.5 Hct-35.5*
MCV-90 MCH-31.7 MCHC-35.1* RDW-12.5 Plt Ct-405
-[**2184-3-5**] 03:35AM BLOOD Neuts-84* Bands-1 Lymphs-5* Monos-6
Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-2*
-[**2184-3-7**] 07:20AM BLOOD WBC-14.6* RBC-3.76* Hgb-11.6* Hct-33.9*
MCV-90 MCH-30.7 MCHC-34.1 RDW-12.6 Plt Ct-381
-[**2184-3-8**] 07:30AM BLOOD WBC-13.8* RBC-3.66* Hgb-11.7* Hct-32.7*
MCV-89 MCH-32.1* MCHC-35.9* RDW-12.5 Plt Ct-352
-[**2184-3-6**] 04:47AM BLOOD PT-13.1 PTT-23.4 INR(PT)-1.1
.
Chem:
-[**2184-3-3**] 05:40PM BLOOD Glucose-90 UreaN-8 Creat-0.6 Na-138
K-4.0 Cl-103 HCO3-21*
-[**2184-3-5**] 03:35AM BLOOD Glucose-140* UreaN-9 Creat-0.6 Na-138
K-3.7 Cl-106 HCO3-21*
-[**2184-3-7**] 07:20AM BLOOD Glucose-129* UreaN-14 Creat-0.5 Na-136
K-4.1 Cl-103 HCO3-24
-[**2184-3-8**] 07:30AM BLOOD Glucose-75 UreaN-13 Creat-0.6 Na-136
K-3.3 Cl-103 HCO3-24
.
LFTs
-[**2184-3-4**] 06:24AM BLOOD ALT-15 AST-16 LD(LDH)-238 AlkPhos-57
TotBili-0.3
.
Misc:
-[**2184-3-6**] 04:47AM BLOOD calTIBC-230* Ferritn-185* TRF-177*
-[**2184-3-4**] 02:35PM BLOOD ANCA-NEGATIVE B
-[**2184-3-3**] 05:40PM BLOOD HCG-7597
-[**2184-3-3**] 05:53PM BLOOD Lactate-1.4
.
.
IMAGING:
.
TVUS [**3-4**]:
Single live intrauterine gestation corresponding to a
gestational
age of 6 weeks 4 days.
.
CXR [**3-4**]:
Moderate-to-severe pulmonary edema, without evidence of pleural
effusions. Borderline size of the cardiac silhouette. No
interval appearance of new parenchymal opacities.
.
SPIROMETRY 10:30 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 2.81 3.44 82
FEV1 2.55 2.67 95
MMF 4.09 3.13 131
FEV1/FVC 91 78 117
Brief Hospital Course:
Mrs. [**Known lastname 8980**] is a 40 year old pregnant woman at 6 weeks EGA by
IVF with a past medical history significant for asthma admitted
on [**3-3**] for fever, cough, and dyspnea felt to be due to CAP, but
found to have eosinophilic pneumonitis.
# Eosinophilic pneumonitis: Patient's A-a gradient was >180 with
potential etiologies including V/Q mismatch, diffusion
abnormality, or shunt. Given absolute eosinophilic count of
>3000, fever, and acute shortness of breath, the diagnosis of
acute eosinophilic pneumonia was presumptively made. She was
treated with solumedrol 125 Q6H with improvement in symptoms and
rapid weaning of supplemental oxygen to room air. She was also
covered for pneumonia initially with vancomycin and
levofloxacin, but the regimen was narrowed to a 5 day course of
azithromycin, which she completed while hospitalized. She was
also initially treated with oseltamavir, which was discontinued
after Influenza DFA returned negative. Patient was transitioned
to prednisone 60 mg daily, and she will continue this dose until
follow-up with Dr. [**First Name8 (NamePattern2) 8982**] [**Last Name (NamePattern1) 7273**] as an outpatient. Her
eosinophilic pneumonitis was felt to be secondary to IM
progesterone in sesame oil suspension, and progesterone was
changed to intravaginal preparation. She will require PCP
prophylaxis if steroid course continues for longer than 1 month,
and this will be determined as an outpatient.
# Pregnancy: Intravaginal fetal u/s performed during MICU course
demonstrating viable fetus. OB consulted on the patient, and
[**Last Name (un) **] was also consulted for blood glucose control (see below).
She will continue intravaginal progesterone as above, and
follow-up with OB/Gyn.
# Hyperglycemia: elevated FSBG in the setting of steroid use.
Patient was started on sliding scale insulin [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs for
goal fingerstick <130 at one hour post-prandial. She will
continue insulin at home and f/u with the Diabetes in Pregnancy
Center at [**Last Name (un) **].
# Asthma: Continued on nebs during admission.
# Code: full
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs qid prn
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs
twice a day
PRENATAL VIT-IRON FUMARATE-FA [PRENATAL VITAMIN] - (Prescribed
by Other Provider) - Dosage uncertain
PROGESTERONE 50 mg/mL 1 mL QHS at 8:30 pm
Discharge Medications:
1. Prenatal 10-400 mg-mcg Capsule Sig: One (1) Capsule PO once a
day.
2. progesterone micronized 8 % Gel Sig: One (1) Appl Vaginal QHS
(once a day (at bedtime)) for 4 weeks.
[**Last Name (un) **]:*QS gel* Refills:*0*
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath, wheeze.
4. Supplies
"Humalog Kwik-pen" 1 box of 5 pens
5. Supplies
Humalog "pen needle" 31x3/16 needle, 200 needles
6. One Touch Delica Lancets Misc Sig: One (1) lancet
Miscellaneous four times a day: fasting and 1hour post-meals.
[**Last Name (un) **]:*200 lancets* Refills:*0*
7. One Touch Test Strip Sig: One (1) strip Miscellaneous
four times a day: fasting and 1hour post-meal.
[**Last Name (un) **]:*200 strips* Refills:*0*
8. prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day:
Take until you see pulmonary doctors.
[**Last Name (Titles) **]:*75 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Eosinophilic pneumonitis
Hyperglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital for shortness of breath, likely
caused by eosinophilic pneumonitis (pneumonia associated with an
increase in a white blood cell called eosinophils). This
improved with steroids. Please continue taking prednisone 60 mg
daily until you see Dr. [**Last Name (STitle) 7273**] at your followup appointment.
You were also found to have elevated blood sugars after being
started on prednisone, which is a common side effect. Please
continue taking insulin with meals as directed. You should
follow up with an endocrinologist at the [**Hospital **] clinic as
indicated below.
Changes to your medications:
-START taking humalog insulin as directed by [**Last Name (un) **]: 6units
before breakfast, 6units before lunch, 7units before dinner
-START taking prednisone 60 mg daily until you see Dr. [**Last Name (STitle) 7273**]
[**Name (STitle) 8983**] taking progesterone IM shots, and START taking
progesterone intravaginally daily
Followup Instructions:
Dr. [**Last Name (STitle) 8984**] (maternal fetal medicine specialist, OB/Gyn)
[**Location (un) 8985**] [**Location (un) 2274**] Tuesday [**3-9**] at 2pm. You can have an ultrasound
done on either Tuesday or Wednesday (see below).
Name: [**Name6 (MD) 6507**] [**Last Name (NamePattern4) 8986**], MD
Specialty: Fertility
When: Wednesday [**3-10**] at 1:30pm
Location: [**Hospital1 641**]
Address: [**Location (un) 4363**], [**Location (un) 86**], MA
Phone: [**Telephone/Fax (1) 8987**]
Department: INTERNAL MEDICINE
When: MONDAY [**2184-3-15**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8988**], MD [**Telephone/Fax (1) 4775**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2184-3-24**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
Specialty: Pulmonary
When: WEDNESDAY [**2184-3-24**] at 1:30 PM
With: DR [**Last Name (STitle) **]/DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: OB/GYN, [**Hospital 8989**] CLINIC (Diabetes in [**Hospital **]
Clinic)
When: FRIDAY [**2184-3-26**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 8990**] [**Last Name (NamePattern4) 8991**], MD [**Telephone/Fax (1) 8992**]
Specialty: Endocrinology
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**Please call [**Doctor Last Name 8993**] at [**Telephone/Fax (1) 8994**] once you are discharged. She
is the scheduler for the pregnancy clinic here at the hospital
and she would like to speak to you to get more information.**
**You can also call [**Telephone/Fax (1) 3681**] to set up an appointment to see
a nutritionist.**
| {
"clinical_findings": {
"J45909": [
{
"icd_10_cm_code": "J45.909",
"icd_10_cm_code_description": "Unspecified asthma, uncomplicated, without status asthmaticus",
"Monitoring": [
{
"text": "well controlled asthma",
"page_numbers": [
1
]
},
{
"text": "Continued on nebs during admission",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "Scattered expiratory wheezes\nbilaterally",
"page_numbers": [
1
]
}
],
"Assessment": [],
"Treatment": [
{
"text": "ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler",
"page_numbers": [
1
]
},
{
"text": "FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol",
"page_numbers": [
1
]
},
{
"text": "albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "well controlled asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "Asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "asthma",
"page_numbers": [
1
]
},
{
"evidence_text": "Asthma",
"page_numbers": [
1
]
}
],
"justification": "Asthma is a documented diagnosis in the patient's history and hospital course. MEAT criteria are met through documentation of the condition being 'well controlled' and 'Continued on nebs during admission' (Monitoring), 'Scattered expiratory wheezes bilaterally' on physical exam (Evaluation), and treatment with Albuterol and Fluticasone inhalers (Treatment). J45.909 is the appropriate code for unspecified uncomplicated asthma."
}
]
}
} |
Extract the ICD-10-CM code assigned to each clinical condition mentioned in the discharge summary. | Admission Date: [**2144-8-1**] Discharge Date: [**2144-8-6**]
Date of Birth: [**2075-9-18**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 2888**]
Chief Complaint:
CP
Major Surgical or Invasive Procedure:
PCI with angioplasty and DES to Mid-RCA
History of Present Illness:
68-year-old woman haitian Crecole speaking only with history of
type 2 DM, hypertension and hyperlidpedemia who presented to
[**Hospital1 18**] ED with 3 days of chest pain. Patient reports that about
three days ago while she was putting her clothes in the laundry
she had suddedn onset of substernal chest pain with radiation to
her neck, right arm and her abdomen. She attributed this pain
to indigestion. The pain was [**4-16**] and remained constant. Today
at 6:30am patient patient acutely worsened [**9-16**] associated with
nasuea, diaphoresis and shonrtess of breaht.
.
In the ED, initial vitals were 45 96/45 16 100% RA. ECG showed
ST Elevation Myocardial Infarction in inferior leads. She was
given aspirin 325 mg, plavix 600 mg, eptifibatide 180 mcg/kg x 1
and heparin 4000 units IV bolus. She was noted to be bradycardic
and hypotensive and thus given atropine 1mgx2 and started on
dopamine gtt which improved her blood pressure. She was
transfer to Cath lab.
.
In the Cath lab, she was noted to acute mid RCA occlusion which
was treated with angioplasty x 3 (10 mm/12 mm/14 mm) with
residual thrombus which was exported and Promus DES was placed
in mid RCA. His cath lab course was complicated by intermittent
complete heart block requiring temporary pacemaker pre-stenting
though she was conducting 1:1 in NSR after stenting. She was
also noted to have AIVR. Dopamine at 5 mcg/kg/min was turned
off at the end of her cath lab course. A small 1.5cm hematoma
was visible at the RFV access site after the case, and manual
pressure was applied for 10 minutes.
.
In the CCU, she did not report chest pain, discomfort,
palpatations or shortness of breath. She desnies any history of
chest pain.
Past Medical History:
DM2
HTN
TB
peripheral neuropathy
aseptic thrombophlebitis of the left internal jugular in [**2130**].
Social History:
Lives with husband, ha two children who live in [**Country 2045**]. Creole
speaking from [**Country 2045**] 14 years ago. Three children. No history
of tobacco, ETOH or illicit.
Family History:
non-contributory
Physical Exam:
Admission Physical:
GENERAL: Appears well NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL. MMM
NECK: Supple with no JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Wamr and well perfused No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs:
[**2144-8-1**] 11:35AM BLOOD WBC-10.8# RBC-3.35* Hgb-10.3* Hct-30.8*
MCV-92 MCH-30.7 MCHC-33.4 RDW-12.8 Plt Ct-178
[**2144-8-1**] 11:35AM BLOOD PT-12.5 PTT-30.7 INR(PT)-1.2*
[**2144-8-1**] 11:35AM BLOOD Glucose-394* UreaN-22* Creat-1.2* Na-135
K-4.0 Cl-99 HCO3-25 AnGap-15
[**2144-8-1**] 11:35AM BLOOD CK-MB-11* MB Indx-1.2
[**2144-8-1**] 05:15PM BLOOD CK-MB-16* MB Indx-1.9
[**2144-8-2**] 05:28AM BLOOD CK-MB-10 MB Indx-1.8 cTropnT-3.44*
[**2144-8-1**] 11:35AM BLOOD CK(CPK)-891*
[**2144-8-1**] 05:15PM BLOOD CK(CPK)-821*
[**2144-8-2**] 05:28AM BLOOD CK(CPK)-555*
Cardiac Cath
1) Selective coronary angiography of this co-dominant system
demonstrated three-vessel coronary artery disease. The LMCA had
mild
luminal irregularities. The proximal-mid LAD had an 80%
trifurcation
lesion that was tightest at the large diagonal branch takeoff;
there was
a high diagonal branch (functionally a ramus) that had diffuse
proximal
70% stenosis. The LCx was a diffusely-diseased vessel with a
likely
stump-occluded OM2 and severely diseased distal vessel; it
provided a
smaller left PDA. The mid-RCA was 100% occluded without
anterograde
flow into the distal vessel; there was also haziness noted at
the AM
origin. The ostial RCA had a 30-40% stenosis.
2)
3) During the procedure, and given the degeneration of the
conduction
disease to high-grade heart block associated with hypotension, a
temporary pacing wire was inserted through the 5 French venous
sheath
with successful capture at 80 bpm and [**7-17**] mA. After the PCI,
pacing
was discontinued, and the patient remained in sinus rhythm with
1:1
conduction at a rate of 80 bpm with normotensive blood
pressures. The
temporary pacing wire was therefore removed and the dopamine was
discontinued.
4) After the procedure, the 6 French right femoral arteriotomy
site was
AngioSealed with adequate hemostasis. The 5 French right femoral
venous
sheath was left in place in case of worsening conduction disease
overnight. A small 1.5cm hematoma was noted after the
procedure.
FINAL DIAGNOSIS:
1. Inferior wall STEMI with high-grade AV block.
2. Successful emergent primary PCI of occluded mid RCA with
PTCA, export
thrombectomy, and Promus drug eluting stent.
3. Emergent temporary pacing wire placement with active pacing
during
the procedure.
.
TTE: [**2144-8-3**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with severe
hypokinesis of the inferolateral wall. The remaining segments
contract normally (LVEF = 40 %). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. There is no aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild to moderate ([**12-9**]+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD (PDA distribution).
Mild-moderate mitral regurgitation most likely due to papillary
muscle dysfunction. Pulmonary artery hypertension.
.
CLINICAL IMPLICATIONS:
Based on [**2138**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
Discharge Labs:
Brief Hospital Course:
68-year-old woman, Haitian-Creole speaking, with history of type
2 DM, hypertension, and hyperlidpedemia, presented with inferior
STEMI now s/p DES to mid RCA.
.
# STEMI: Patient with multiple cardiovascular risk factors
(uncontrolled diabetes, uncontrolled hypertension and
hyperlidemia) presented with worsening chest pain. ECG was
consistent with ST elevation myocardial infarction in inferior
leads. She was given aspirin 325 mg, plavix 600 mg, eptifibatide
180 mcg/kg x 1 and heparin 4000 units IV bolus. She was noted to
be bradycardic and hypotensive and thus given atropine 1mgx2 and
started on dopamine gtt which improved her blood pressure. She
was transfer to the Cath lab. In the Cath lab, she was noted to
have acute mid RCA occlusion which was treated with angioplasty
x 3 (10 mm/12 mm/14 mm) with residual thrombus, which was
removed, and Promus DES was placed in the mid RCA. Her Cath lab
course was complicated by intermittent complete heart block
requiring temporary pacemaker pre-stenting though she was
conducting 1:1 in NSR after stenting. She was also noted to
have AIVR. Dopamine at 5 mcg/kg/min was turned off at the end
of her Cath lab course. She had an ECHO report that showed mild
regional left ventricular systolic dysfunction with severe
hypokinesis of the inferolateral wall with EF 40%. Mild
symmetric left ventricular hypertrophy with regional systolic
dysfunction c/w CAD (PDA distribution). Mild-moderate mitral
regurgitation most likely due to papillary muscle dysfunction.
Pulmonary artery hypertension.
During her CCU course, patient had one episode of shortness of
breath and increased respiratory rate with bilateral crackles on
exam. She was treated with Lasix which improved her sxs and she
had no further episodes of chest pain or shortness of breath
during her hospital stay. Patient was evaluated by physical
therapy on the day of discharge and determined safe to go home.
Patient will follow up with Dr. [**Last Name (STitle) 10156**] in Cardiology and
with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. She was discharged on the
following medications: Lasix, metoprolol, lisinopril,
atorvastatin, and Plavix.
.
# Arrythmia: Patient had bradycardia with dropped beats and
atrial ectopy likely in the setting of reperfusion post [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 10157**]. She did not have any symptomatic episodes of
bradycardia during her CCU course. She was also started on low
dose metoprolol which she tolerated very well.
.
# Diabetes Type 2: Poorly controlled and complicated by diabetic
nephropathy, retinopathy, and neuropathy. Last A1c was 8.7 in
3/[**2143**]. She was continued on 11units of NPH and insulin sliding
scale. On discharge, she was put on ----.
.
# Anemia: Hematocrit during this admission was around 30.
Prior HCT on OMR from [**2141**] shows HCT of 37.9. Unclear etiology.
No source of obvious bleeding and normal coags. Patient will
follow up with PCP for further management.
.
# Hypertension: Patient blood pressure was well controlled on
low dose metoprolol. Her home chorthalidone, amlodopine, and
lisinopril were initally held due to low bps. She was
discharged on metoprolol, lisinopril and lasix.
.
# Hyperlidemia: Started atorvastain 80mg daily.
.
Transitional Issues:
- needs close follow-up with Cardiology, PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] recommend [**Last Name (un) **] consultation for DM
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Aspirin 81 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Ranitidine 150 mg PO BID
7. NPH 32 Units Breakfast
NPH 22 Units Dinner
Discharge Medications:
1. Aspirin EC 325 mg PO DAILY
RX *aspirin [Enteric Coated Aspirin] 325 mg one tablet(s) by
mouth daily Disp #*30 Tablet Refills:*2
2. Ranitidine 150 mg PO BID
3. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
4. Clopidogrel 75 mg PO DAILY
for the recommended duration
RX *clopidogrel 75 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
5. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg one tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. NPH 32 Units Breakfast
NPH 22 Units Dinner
8. Lisinopril 20 mg PO DAILY
RX *lisinopril 40 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*2
9. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg one tablets by mouth daily Disp #*30 Tablet
Refills:*2
10. Outpatient Lab Work
Please check Chem-7 at [**Hospital6 733**] on [**2144-8-11**] with
results to Dr. [**Last Name (STitle) 6215**] at Phone: [**Telephone/Fax (1) 2010**]
Fax: [**Telephone/Fax (1) 4004**]
ICD-9 428
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Inferolateral ST elevation myocardial infarction
acute systolic congestive heart failure
hypertension
diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 10158**],
It was a pleasure taking care of your during your admission at
[**Hospital1 18**]. You were admitted because you were having chest pain and
you were found to have a heart attack for which you had a stent
placed in your heart. You have also been started on new
medications (aspirin and clopidogrel) to prevent the stenting of
the clot which you should continue to take unless told otherwise
by your cardiologist.
Weigh yourself every day before breakfast. Call Dr. [**Last Name (STitle) **] if
weight increases more than 3 pounds in 1 day or 5 pounds in 3
days.
The visiting nurse will help you with a low salt diet.
.
Please continue to take your medications as directed in your
discharge medication sheet. Please do not stop any medication
especially clopidogrel unless told by your cardiologist. You
risk having a heart attack if you do not take this medicine
every day.
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2144-9-3**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital **] HEALTH CENTER
When: TUESDAY [**2144-8-11**] at 11:50 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
| {
"clinical_findings": {
"E785": [
{
"icd_10_cm_code": "E78.5",
"icd_10_cm_code_description": "Hyperlipidemia, unspecified",
"Monitoring": [
{
"text": "hyperlidpedemia",
"page_numbers": [
1
]
},
{
"text": "hyperlidpedemia",
"page_numbers": [
2
]
},
{
"text": "hyperlidemia",
"page_numbers": [
2
]
},
{
"text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "Started atorvastain 80mg daily",
"page_numbers": [
2
]
},
{
"text": "Atorvastatin 80 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "hyperlidpedemia",
"page_numbers": [
1
]
},
{
"evidence_text": "hyperlidpedemia",
"page_numbers": [
2
]
},
{
"evidence_text": "hyperlidemia",
"page_numbers": [
2
]
},
{
"evidence_text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E78.5 is assigned for Hyperlipidemia, unspecified. The diagnosis is documented multiple times. MEAT criteria are met through monitoring (documented diagnosis), assessment (documented as Hyperlidemia), and treatment (Atorvastatin started)."
}
],
"I2119": [
{
"icd_10_cm_code": "I21.19",
"icd_10_cm_code_description": "ST elevation myocardial infarction involving other inferior wall",
"Monitoring": [
{
"text": "ECG showed\nST Elevation Myocardial Infarction in inferior leads",
"page_numbers": [
1
]
},
{
"text": "ECG was\nconsistent with ST elevation myocardial infarction in inferior\nleads",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "mid-RCA was 100% occluded without\nanterograde\nflow into the distal vessel",
"page_numbers": [
1
]
},
{
"text": "cTropnT-3.44*",
"page_numbers": [
1
]
},
{
"text": "CK-MB-11*",
"page_numbers": [
1
]
},
{
"text": "CK(CPK)-891*",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Inferior wall STEMI",
"page_numbers": [
1
]
},
{
"text": "inferior\nSTEMI",
"page_numbers": [
2
]
},
{
"text": "Inferolateral ST elevation myocardial infarction",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "given aspirin 325 mg, plavix 600 mg, eptifibatide 180 mcg/kg x 1\nand heparin 4000 units IV bolus",
"page_numbers": [
1
]
},
{
"text": "transfer to Cath lab",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty x 3 (10 mm/12 mm/14 mm) with\nresidual thrombus which was exported and Promus DES was placed\nin mid RCA",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty\nx 3 (10 mm/12 mm/14 mm) with residual thrombus, which was\nremoved, and Promus DES was placed in the mid RCA",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "ST Elevation Myocardial Infarction in inferior leads",
"page_numbers": [
1
]
},
{
"evidence_text": "Inferior wall STEMI",
"page_numbers": [
1
]
},
{
"evidence_text": "inferior\nSTEMI",
"page_numbers": [
2
]
},
{
"evidence_text": "ST elevation myocardial infarction in inferior\nleads",
"page_numbers": [
2
]
},
{
"evidence_text": "Inferolateral ST elevation myocardial infarction",
"page_numbers": [
3
]
},
{
"evidence_text": "heart attack",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I21.19 is assigned for ST elevation myocardial infarction involving other inferior wall. The diagnosis is clearly documented multiple times, including in the final and discharge diagnoses. MEAT criteria are met through monitoring (ECG findings), evaluation (cardiac cath findings, elevated cardiac enzymes), assessment (documented diagnosis), and treatment (medications, PCI)."
}
],
"I442": [
{
"icd_10_cm_code": "I44.2",
"icd_10_cm_code_description": "Atrioventricular block, third degree",
"Monitoring": [
{
"text": "intermittent\ncomplete heart block",
"page_numbers": [
1
]
},
{
"text": "intermittent complete heart block",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "degeneration of the\nconduction\ndisease to high-grade heart block",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "high-grade AV block",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "requiring temporary pacemaker",
"page_numbers": [
1
]
},
{
"text": "requiring temporary pacemaker",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "intermittent\ncomplete heart block",
"page_numbers": [
1
]
},
{
"evidence_text": "degeneration of the\nconduction\ndisease to high-grade heart block",
"page_numbers": [
1
]
},
{
"evidence_text": "high-grade AV block",
"page_numbers": [
1
]
},
{
"evidence_text": "intermittent complete heart block",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I44.2 is assigned for Atrioventricular block, third degree, based on documentation of 'intermittent complete heart block' and 'high-grade AV block' requiring temporary pacing. MEAT criteria are met through monitoring (documented status), evaluation (documented degeneration), assessment (documented as high-grade AV block), and treatment (temporary pacemaker)."
}
],
"E1140": [
{
"icd_10_cm_code": "E11.40",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with diabetic neuropathy, unspecified",
"Monitoring": [
{
"text": "neuropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic neuropathy"
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "neuropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic neuropathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "peripheral neuropathy",
"page_numbers": [
1
]
},
{
"evidence_text": "neuropathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.40 is assigned for Type 2 diabetes mellitus with diabetic neuropathy. The entity 'peripheral neuropathy' is documented in PMH and 'neuropathy' is mentioned as a complication of poorly controlled diabetes in the Brief Hospital Course. MEAT criteria are met for the neuropathy component via monitoring and assessment. This is a combination code requiring an additional code for the manifestation (G63.0*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"I2510": [
{
"icd_10_cm_code": "I25.10",
"icd_10_cm_code_description": "Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Monitoring": [],
"Evaluation": [
{
"text": "Selective coronary angiography of this co-dominant system\ndemonstrated three-vessel coronary artery disease",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "treated with angioplasty x 3 (10 mm/12 mm/14 mm) with\nresidual thrombus which was exported and Promus DES was placed\nin mid RCA",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty\nx 3 (10 mm/12 mm/14 mm) with residual thrombus, which was\nremoved, and Promus DES was placed in the mid RCA",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "three-vessel coronary artery disease",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I25.10 is assigned for Atherosclerotic heart disease of native coronary artery without angina pectoris. The entity 'three-vessel coronary artery disease' is documented in the cardiac cath report. MEAT criteria are met through evaluation (angiography findings), assessment (systolic dysfunction c/w CAD), and treatment (PCI of RCA)."
}
],
"I2721": [
{
"icd_10_cm_code": "I27.21",
"icd_10_cm_code_description": "Secondary pulmonary arterial hypertension",
"Monitoring": [
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I27.21 is assigned for Secondary pulmonary arterial hypertension, based on the TTE finding of 'moderate pulmonary artery systolic hypertension'. MEAT criteria are met through monitoring (documented finding), evaluation (TTE report), and assessment (documented in TTE impression and Brief Hospital Course)."
}
],
"E1121": [
{
"icd_10_cm_code": "E11.21",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with diabetic nephropathy",
"Monitoring": [
{
"text": "diabetic\nnephropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Evaluation": [
{
"text": "Creat-1.2*",
"page_numbers": [
1
],
"applies_to": [
"Diabetic nephropathy"
]
},
{
"text": "UreaN-22*",
"page_numbers": [
1
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Assessment": [
{
"text": "diabetic\nnephropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "diabetic\nnephropathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.21 is assigned for Type 2 diabetes mellitus with diabetic nephropathy. The entity 'diabetic nephropathy' is documented as a complication of poorly controlled diabetes. MEAT criteria are met for the nephropathy component via monitoring, evaluation (labs), and assessment. This is a combination code requiring an additional code for the manifestation (N08*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"E1139": [
{
"icd_10_cm_code": "E11.39",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with other diabetic ophthalmic complication",
"Monitoring": [
{
"text": "retinopathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic retinopathy"
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "retinopathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic retinopathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "retinopathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.39 is assigned for Type 2 diabetes mellitus with other diabetic ophthalmic complication. The entity 'retinopathy' is documented as a complication of poorly controlled diabetes. MEAT criteria are met for the retinopathy component via monitoring and assessment. This is a combination code requiring an additional code for the manifestation (H36*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"I5021": [
{
"icd_10_cm_code": "I50.21",
"icd_10_cm_code_description": "Acute systolic (congestive) heart failure",
"Monitoring": [
{
"text": "one episode of shortness of\nbreath and increased respiratory rate with bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "Mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "She was treated with Lasix which improved her sxs",
"page_numbers": [
2
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I50.21 is assigned for Acute systolic (congestive) heart failure. The diagnosis is documented in the Discharge Diagnosis. MEAT criteria are met through monitoring (symptoms like shortness of breath, crackles, TTE findings), evaluation (physical exam, TTE report), assessment (documented diagnosis), and treatment (Lasix/Furosemide)."
}
],
"I110": [
{
"icd_10_cm_code": "I50.21",
"icd_10_cm_code_description": "Acute systolic (congestive) heart failure",
"Monitoring": [
{
"text": "one episode of shortness of\nbreath and increased respiratory rate with bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "Mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "She was treated with Lasix which improved her sxs",
"page_numbers": [
2
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I50.21 is assigned for Acute systolic (congestive) heart failure. The diagnosis is documented in the Discharge Diagnosis. MEAT criteria are met through monitoring (symptoms like shortness of breath, crackles, TTE findings), evaluation (physical exam, TTE report), assessment (documented diagnosis), and treatment (Lasix/Furosemide)."
},
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [
{
"text": "uncontrolled hypertension",
"page_numbers": [
2
]
},
{
"text": "Patient blood pressure was well controlled on\nlow dose metoprolol",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "initial vitals were 45 96/45",
"page_numbers": [
1
]
},
{
"text": "low bps",
"page_numbers": [
2
]
}
],
"Assessment": [
{
"text": "Hypertension",
"page_numbers": [
2
]
},
{
"text": "hypertension",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "Amlodipine 10 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Chlorthalidone 25 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Lisinopril 40 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Metoprolol Succinate XL 50 mg PO DAILY",
"page_numbers": [
3
]
},
{
"text": "Lisinopril 20 mg PO DAILY",
"page_numbers": [
3
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "uncontrolled hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "hypertension",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. The diagnosis is documented multiple times. MEAT criteria are met through monitoring (uncontrolled/controlled status), evaluation (vital signs, low bps), assessment (documented as Hypertension), and treatment (multiple antihypertensive medications)."
},
{
"icd_10_cm_code": "I51.9",
"icd_10_cm_code_description": "Heart disease, unspecified",
"Monitoring": [
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"evidence_text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"evidence_text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
2
]
},
{
"evidence_text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I51.9 is assigned for Heart disease, unspecified, based on the TTE finding of 'mild regional left ventricular systolic dysfunction'. MEAT criteria are met through monitoring (documented finding), evaluation (TTE report including EF), and assessment (documented in TTE impression and Brief Hospital Course)."
}
]
}
} |
Extract the ICD-10-CM code description for each clinical condition mentioned in the discharge summary. | Admission Date: [**2144-8-1**] Discharge Date: [**2144-8-6**]
Date of Birth: [**2075-9-18**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 2888**]
Chief Complaint:
CP
Major Surgical or Invasive Procedure:
PCI with angioplasty and DES to Mid-RCA
History of Present Illness:
68-year-old woman haitian Crecole speaking only with history of
type 2 DM, hypertension and hyperlidpedemia who presented to
[**Hospital1 18**] ED with 3 days of chest pain. Patient reports that about
three days ago while she was putting her clothes in the laundry
she had suddedn onset of substernal chest pain with radiation to
her neck, right arm and her abdomen. She attributed this pain
to indigestion. The pain was [**4-16**] and remained constant. Today
at 6:30am patient patient acutely worsened [**9-16**] associated with
nasuea, diaphoresis and shonrtess of breaht.
.
In the ED, initial vitals were 45 96/45 16 100% RA. ECG showed
ST Elevation Myocardial Infarction in inferior leads. She was
given aspirin 325 mg, plavix 600 mg, eptifibatide 180 mcg/kg x 1
and heparin 4000 units IV bolus. She was noted to be bradycardic
and hypotensive and thus given atropine 1mgx2 and started on
dopamine gtt which improved her blood pressure. She was
transfer to Cath lab.
.
In the Cath lab, she was noted to acute mid RCA occlusion which
was treated with angioplasty x 3 (10 mm/12 mm/14 mm) with
residual thrombus which was exported and Promus DES was placed
in mid RCA. His cath lab course was complicated by intermittent
complete heart block requiring temporary pacemaker pre-stenting
though she was conducting 1:1 in NSR after stenting. She was
also noted to have AIVR. Dopamine at 5 mcg/kg/min was turned
off at the end of her cath lab course. A small 1.5cm hematoma
was visible at the RFV access site after the case, and manual
pressure was applied for 10 minutes.
.
In the CCU, she did not report chest pain, discomfort,
palpatations or shortness of breath. She desnies any history of
chest pain.
Past Medical History:
DM2
HTN
TB
peripheral neuropathy
aseptic thrombophlebitis of the left internal jugular in [**2130**].
Social History:
Lives with husband, ha two children who live in [**Country 2045**]. Creole
speaking from [**Country 2045**] 14 years ago. Three children. No history
of tobacco, ETOH or illicit.
Family History:
non-contributory
Physical Exam:
Admission Physical:
GENERAL: Appears well NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL. MMM
NECK: Supple with no JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Wamr and well perfused No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs:
[**2144-8-1**] 11:35AM BLOOD WBC-10.8# RBC-3.35* Hgb-10.3* Hct-30.8*
MCV-92 MCH-30.7 MCHC-33.4 RDW-12.8 Plt Ct-178
[**2144-8-1**] 11:35AM BLOOD PT-12.5 PTT-30.7 INR(PT)-1.2*
[**2144-8-1**] 11:35AM BLOOD Glucose-394* UreaN-22* Creat-1.2* Na-135
K-4.0 Cl-99 HCO3-25 AnGap-15
[**2144-8-1**] 11:35AM BLOOD CK-MB-11* MB Indx-1.2
[**2144-8-1**] 05:15PM BLOOD CK-MB-16* MB Indx-1.9
[**2144-8-2**] 05:28AM BLOOD CK-MB-10 MB Indx-1.8 cTropnT-3.44*
[**2144-8-1**] 11:35AM BLOOD CK(CPK)-891*
[**2144-8-1**] 05:15PM BLOOD CK(CPK)-821*
[**2144-8-2**] 05:28AM BLOOD CK(CPK)-555*
Cardiac Cath
1) Selective coronary angiography of this co-dominant system
demonstrated three-vessel coronary artery disease. The LMCA had
mild
luminal irregularities. The proximal-mid LAD had an 80%
trifurcation
lesion that was tightest at the large diagonal branch takeoff;
there was
a high diagonal branch (functionally a ramus) that had diffuse
proximal
70% stenosis. The LCx was a diffusely-diseased vessel with a
likely
stump-occluded OM2 and severely diseased distal vessel; it
provided a
smaller left PDA. The mid-RCA was 100% occluded without
anterograde
flow into the distal vessel; there was also haziness noted at
the AM
origin. The ostial RCA had a 30-40% stenosis.
2)
3) During the procedure, and given the degeneration of the
conduction
disease to high-grade heart block associated with hypotension, a
temporary pacing wire was inserted through the 5 French venous
sheath
with successful capture at 80 bpm and [**7-17**] mA. After the PCI,
pacing
was discontinued, and the patient remained in sinus rhythm with
1:1
conduction at a rate of 80 bpm with normotensive blood
pressures. The
temporary pacing wire was therefore removed and the dopamine was
discontinued.
4) After the procedure, the 6 French right femoral arteriotomy
site was
AngioSealed with adequate hemostasis. The 5 French right femoral
venous
sheath was left in place in case of worsening conduction disease
overnight. A small 1.5cm hematoma was noted after the
procedure.
FINAL DIAGNOSIS:
1. Inferior wall STEMI with high-grade AV block.
2. Successful emergent primary PCI of occluded mid RCA with
PTCA, export
thrombectomy, and Promus drug eluting stent.
3. Emergent temporary pacing wire placement with active pacing
during
the procedure.
.
TTE: [**2144-8-3**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with severe
hypokinesis of the inferolateral wall. The remaining segments
contract normally (LVEF = 40 %). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. There is no aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild to moderate ([**12-9**]+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD (PDA distribution).
Mild-moderate mitral regurgitation most likely due to papillary
muscle dysfunction. Pulmonary artery hypertension.
.
CLINICAL IMPLICATIONS:
Based on [**2138**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
Discharge Labs:
Brief Hospital Course:
68-year-old woman, Haitian-Creole speaking, with history of type
2 DM, hypertension, and hyperlidpedemia, presented with inferior
STEMI now s/p DES to mid RCA.
.
# STEMI: Patient with multiple cardiovascular risk factors
(uncontrolled diabetes, uncontrolled hypertension and
hyperlidemia) presented with worsening chest pain. ECG was
consistent with ST elevation myocardial infarction in inferior
leads. She was given aspirin 325 mg, plavix 600 mg, eptifibatide
180 mcg/kg x 1 and heparin 4000 units IV bolus. She was noted to
be bradycardic and hypotensive and thus given atropine 1mgx2 and
started on dopamine gtt which improved her blood pressure. She
was transfer to the Cath lab. In the Cath lab, she was noted to
have acute mid RCA occlusion which was treated with angioplasty
x 3 (10 mm/12 mm/14 mm) with residual thrombus, which was
removed, and Promus DES was placed in the mid RCA. Her Cath lab
course was complicated by intermittent complete heart block
requiring temporary pacemaker pre-stenting though she was
conducting 1:1 in NSR after stenting. She was also noted to
have AIVR. Dopamine at 5 mcg/kg/min was turned off at the end
of her Cath lab course. She had an ECHO report that showed mild
regional left ventricular systolic dysfunction with severe
hypokinesis of the inferolateral wall with EF 40%. Mild
symmetric left ventricular hypertrophy with regional systolic
dysfunction c/w CAD (PDA distribution). Mild-moderate mitral
regurgitation most likely due to papillary muscle dysfunction.
Pulmonary artery hypertension.
During her CCU course, patient had one episode of shortness of
breath and increased respiratory rate with bilateral crackles on
exam. She was treated with Lasix which improved her sxs and she
had no further episodes of chest pain or shortness of breath
during her hospital stay. Patient was evaluated by physical
therapy on the day of discharge and determined safe to go home.
Patient will follow up with Dr. [**Last Name (STitle) 10156**] in Cardiology and
with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. She was discharged on the
following medications: Lasix, metoprolol, lisinopril,
atorvastatin, and Plavix.
.
# Arrythmia: Patient had bradycardia with dropped beats and
atrial ectopy likely in the setting of reperfusion post [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 10157**]. She did not have any symptomatic episodes of
bradycardia during her CCU course. She was also started on low
dose metoprolol which she tolerated very well.
.
# Diabetes Type 2: Poorly controlled and complicated by diabetic
nephropathy, retinopathy, and neuropathy. Last A1c was 8.7 in
3/[**2143**]. She was continued on 11units of NPH and insulin sliding
scale. On discharge, she was put on ----.
.
# Anemia: Hematocrit during this admission was around 30.
Prior HCT on OMR from [**2141**] shows HCT of 37.9. Unclear etiology.
No source of obvious bleeding and normal coags. Patient will
follow up with PCP for further management.
.
# Hypertension: Patient blood pressure was well controlled on
low dose metoprolol. Her home chorthalidone, amlodopine, and
lisinopril were initally held due to low bps. She was
discharged on metoprolol, lisinopril and lasix.
.
# Hyperlidemia: Started atorvastain 80mg daily.
.
Transitional Issues:
- needs close follow-up with Cardiology, PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] recommend [**Last Name (un) **] consultation for DM
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Aspirin 81 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Ranitidine 150 mg PO BID
7. NPH 32 Units Breakfast
NPH 22 Units Dinner
Discharge Medications:
1. Aspirin EC 325 mg PO DAILY
RX *aspirin [Enteric Coated Aspirin] 325 mg one tablet(s) by
mouth daily Disp #*30 Tablet Refills:*2
2. Ranitidine 150 mg PO BID
3. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
4. Clopidogrel 75 mg PO DAILY
for the recommended duration
RX *clopidogrel 75 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
5. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg one tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. NPH 32 Units Breakfast
NPH 22 Units Dinner
8. Lisinopril 20 mg PO DAILY
RX *lisinopril 40 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*2
9. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg one tablets by mouth daily Disp #*30 Tablet
Refills:*2
10. Outpatient Lab Work
Please check Chem-7 at [**Hospital6 733**] on [**2144-8-11**] with
results to Dr. [**Last Name (STitle) 6215**] at Phone: [**Telephone/Fax (1) 2010**]
Fax: [**Telephone/Fax (1) 4004**]
ICD-9 428
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Inferolateral ST elevation myocardial infarction
acute systolic congestive heart failure
hypertension
diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 10158**],
It was a pleasure taking care of your during your admission at
[**Hospital1 18**]. You were admitted because you were having chest pain and
you were found to have a heart attack for which you had a stent
placed in your heart. You have also been started on new
medications (aspirin and clopidogrel) to prevent the stenting of
the clot which you should continue to take unless told otherwise
by your cardiologist.
Weigh yourself every day before breakfast. Call Dr. [**Last Name (STitle) **] if
weight increases more than 3 pounds in 1 day or 5 pounds in 3
days.
The visiting nurse will help you with a low salt diet.
.
Please continue to take your medications as directed in your
discharge medication sheet. Please do not stop any medication
especially clopidogrel unless told by your cardiologist. You
risk having a heart attack if you do not take this medicine
every day.
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2144-9-3**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital **] HEALTH CENTER
When: TUESDAY [**2144-8-11**] at 11:50 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
| {
"clinical_findings": {
"E785": [
{
"icd_10_cm_code": "E78.5",
"icd_10_cm_code_description": "Hyperlipidemia, unspecified",
"Monitoring": [
{
"text": "hyperlidpedemia",
"page_numbers": [
1
]
},
{
"text": "hyperlidpedemia",
"page_numbers": [
2
]
},
{
"text": "hyperlidemia",
"page_numbers": [
2
]
},
{
"text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "Started atorvastain 80mg daily",
"page_numbers": [
2
]
},
{
"text": "Atorvastatin 80 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "hyperlidpedemia",
"page_numbers": [
1
]
},
{
"evidence_text": "hyperlidpedemia",
"page_numbers": [
2
]
},
{
"evidence_text": "hyperlidemia",
"page_numbers": [
2
]
},
{
"evidence_text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E78.5 is assigned for Hyperlipidemia, unspecified. The diagnosis is documented multiple times. MEAT criteria are met through monitoring (documented diagnosis), assessment (documented as Hyperlidemia), and treatment (Atorvastatin started)."
}
],
"I2119": [
{
"icd_10_cm_code": "I21.19",
"icd_10_cm_code_description": "ST elevation myocardial infarction involving other inferior wall",
"Monitoring": [
{
"text": "ECG showed\nST Elevation Myocardial Infarction in inferior leads",
"page_numbers": [
1
]
},
{
"text": "ECG was\nconsistent with ST elevation myocardial infarction in inferior\nleads",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "mid-RCA was 100% occluded without\nanterograde\nflow into the distal vessel",
"page_numbers": [
1
]
},
{
"text": "cTropnT-3.44*",
"page_numbers": [
1
]
},
{
"text": "CK-MB-11*",
"page_numbers": [
1
]
},
{
"text": "CK(CPK)-891*",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Inferior wall STEMI",
"page_numbers": [
1
]
},
{
"text": "inferior\nSTEMI",
"page_numbers": [
2
]
},
{
"text": "Inferolateral ST elevation myocardial infarction",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "given aspirin 325 mg, plavix 600 mg, eptifibatide 180 mcg/kg x 1\nand heparin 4000 units IV bolus",
"page_numbers": [
1
]
},
{
"text": "transfer to Cath lab",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty x 3 (10 mm/12 mm/14 mm) with\nresidual thrombus which was exported and Promus DES was placed\nin mid RCA",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty\nx 3 (10 mm/12 mm/14 mm) with residual thrombus, which was\nremoved, and Promus DES was placed in the mid RCA",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "ST Elevation Myocardial Infarction in inferior leads",
"page_numbers": [
1
]
},
{
"evidence_text": "Inferior wall STEMI",
"page_numbers": [
1
]
},
{
"evidence_text": "inferior\nSTEMI",
"page_numbers": [
2
]
},
{
"evidence_text": "ST elevation myocardial infarction in inferior\nleads",
"page_numbers": [
2
]
},
{
"evidence_text": "Inferolateral ST elevation myocardial infarction",
"page_numbers": [
3
]
},
{
"evidence_text": "heart attack",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I21.19 is assigned for ST elevation myocardial infarction involving other inferior wall. The diagnosis is clearly documented multiple times, including in the final and discharge diagnoses. MEAT criteria are met through monitoring (ECG findings), evaluation (cardiac cath findings, elevated cardiac enzymes), assessment (documented diagnosis), and treatment (medications, PCI)."
}
],
"I442": [
{
"icd_10_cm_code": "I44.2",
"icd_10_cm_code_description": "Atrioventricular block, third degree",
"Monitoring": [
{
"text": "intermittent\ncomplete heart block",
"page_numbers": [
1
]
},
{
"text": "intermittent complete heart block",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "degeneration of the\nconduction\ndisease to high-grade heart block",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "high-grade AV block",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "requiring temporary pacemaker",
"page_numbers": [
1
]
},
{
"text": "requiring temporary pacemaker",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "intermittent\ncomplete heart block",
"page_numbers": [
1
]
},
{
"evidence_text": "degeneration of the\nconduction\ndisease to high-grade heart block",
"page_numbers": [
1
]
},
{
"evidence_text": "high-grade AV block",
"page_numbers": [
1
]
},
{
"evidence_text": "intermittent complete heart block",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I44.2 is assigned for Atrioventricular block, third degree, based on documentation of 'intermittent complete heart block' and 'high-grade AV block' requiring temporary pacing. MEAT criteria are met through monitoring (documented status), evaluation (documented degeneration), assessment (documented as high-grade AV block), and treatment (temporary pacemaker)."
}
],
"E1140": [
{
"icd_10_cm_code": "E11.40",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with diabetic neuropathy, unspecified",
"Monitoring": [
{
"text": "neuropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic neuropathy"
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "neuropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic neuropathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "peripheral neuropathy",
"page_numbers": [
1
]
},
{
"evidence_text": "neuropathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.40 is assigned for Type 2 diabetes mellitus with diabetic neuropathy. The entity 'peripheral neuropathy' is documented in PMH and 'neuropathy' is mentioned as a complication of poorly controlled diabetes in the Brief Hospital Course. MEAT criteria are met for the neuropathy component via monitoring and assessment. This is a combination code requiring an additional code for the manifestation (G63.0*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"I2510": [
{
"icd_10_cm_code": "I25.10",
"icd_10_cm_code_description": "Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Monitoring": [],
"Evaluation": [
{
"text": "Selective coronary angiography of this co-dominant system\ndemonstrated three-vessel coronary artery disease",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "treated with angioplasty x 3 (10 mm/12 mm/14 mm) with\nresidual thrombus which was exported and Promus DES was placed\nin mid RCA",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty\nx 3 (10 mm/12 mm/14 mm) with residual thrombus, which was\nremoved, and Promus DES was placed in the mid RCA",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "three-vessel coronary artery disease",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I25.10 is assigned for Atherosclerotic heart disease of native coronary artery without angina pectoris. The entity 'three-vessel coronary artery disease' is documented in the cardiac cath report. MEAT criteria are met through evaluation (angiography findings), assessment (systolic dysfunction c/w CAD), and treatment (PCI of RCA)."
}
],
"I2721": [
{
"icd_10_cm_code": "I27.21",
"icd_10_cm_code_description": "Secondary pulmonary arterial hypertension",
"Monitoring": [
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I27.21 is assigned for Secondary pulmonary arterial hypertension, based on the TTE finding of 'moderate pulmonary artery systolic hypertension'. MEAT criteria are met through monitoring (documented finding), evaluation (TTE report), and assessment (documented in TTE impression and Brief Hospital Course)."
}
],
"E1121": [
{
"icd_10_cm_code": "E11.21",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with diabetic nephropathy",
"Monitoring": [
{
"text": "diabetic\nnephropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Evaluation": [
{
"text": "Creat-1.2*",
"page_numbers": [
1
],
"applies_to": [
"Diabetic nephropathy"
]
},
{
"text": "UreaN-22*",
"page_numbers": [
1
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Assessment": [
{
"text": "diabetic\nnephropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "diabetic\nnephropathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.21 is assigned for Type 2 diabetes mellitus with diabetic nephropathy. The entity 'diabetic nephropathy' is documented as a complication of poorly controlled diabetes. MEAT criteria are met for the nephropathy component via monitoring, evaluation (labs), and assessment. This is a combination code requiring an additional code for the manifestation (N08*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"E1139": [
{
"icd_10_cm_code": "E11.39",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with other diabetic ophthalmic complication",
"Monitoring": [
{
"text": "retinopathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic retinopathy"
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "retinopathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic retinopathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "retinopathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.39 is assigned for Type 2 diabetes mellitus with other diabetic ophthalmic complication. The entity 'retinopathy' is documented as a complication of poorly controlled diabetes. MEAT criteria are met for the retinopathy component via monitoring and assessment. This is a combination code requiring an additional code for the manifestation (H36*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"I5021": [
{
"icd_10_cm_code": "I50.21",
"icd_10_cm_code_description": "Acute systolic (congestive) heart failure",
"Monitoring": [
{
"text": "one episode of shortness of\nbreath and increased respiratory rate with bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "Mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "She was treated with Lasix which improved her sxs",
"page_numbers": [
2
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I50.21 is assigned for Acute systolic (congestive) heart failure. The diagnosis is documented in the Discharge Diagnosis. MEAT criteria are met through monitoring (symptoms like shortness of breath, crackles, TTE findings), evaluation (physical exam, TTE report), assessment (documented diagnosis), and treatment (Lasix/Furosemide)."
}
],
"I110": [
{
"icd_10_cm_code": "I50.21",
"icd_10_cm_code_description": "Acute systolic (congestive) heart failure",
"Monitoring": [
{
"text": "one episode of shortness of\nbreath and increased respiratory rate with bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "Mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "She was treated with Lasix which improved her sxs",
"page_numbers": [
2
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I50.21 is assigned for Acute systolic (congestive) heart failure. The diagnosis is documented in the Discharge Diagnosis. MEAT criteria are met through monitoring (symptoms like shortness of breath, crackles, TTE findings), evaluation (physical exam, TTE report), assessment (documented diagnosis), and treatment (Lasix/Furosemide)."
},
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [
{
"text": "uncontrolled hypertension",
"page_numbers": [
2
]
},
{
"text": "Patient blood pressure was well controlled on\nlow dose metoprolol",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "initial vitals were 45 96/45",
"page_numbers": [
1
]
},
{
"text": "low bps",
"page_numbers": [
2
]
}
],
"Assessment": [
{
"text": "Hypertension",
"page_numbers": [
2
]
},
{
"text": "hypertension",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "Amlodipine 10 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Chlorthalidone 25 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Lisinopril 40 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Metoprolol Succinate XL 50 mg PO DAILY",
"page_numbers": [
3
]
},
{
"text": "Lisinopril 20 mg PO DAILY",
"page_numbers": [
3
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "uncontrolled hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "hypertension",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. The diagnosis is documented multiple times. MEAT criteria are met through monitoring (uncontrolled/controlled status), evaluation (vital signs, low bps), assessment (documented as Hypertension), and treatment (multiple antihypertensive medications)."
},
{
"icd_10_cm_code": "I51.9",
"icd_10_cm_code_description": "Heart disease, unspecified",
"Monitoring": [
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"evidence_text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"evidence_text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
2
]
},
{
"evidence_text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I51.9 is assigned for Heart disease, unspecified, based on the TTE finding of 'mild regional left ventricular systolic dysfunction'. MEAT criteria are met through monitoring (documented finding), evaluation (TTE report including EF), and assessment (documented in TTE impression and Brief Hospital Course)."
}
]
}
} |
Extract only the monitoring information related to each clinical condition, such as vital signs, labs, or telemetry data. | Admission Date: [**2144-8-1**] Discharge Date: [**2144-8-6**]
Date of Birth: [**2075-9-18**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 2888**]
Chief Complaint:
CP
Major Surgical or Invasive Procedure:
PCI with angioplasty and DES to Mid-RCA
History of Present Illness:
68-year-old woman haitian Crecole speaking only with history of
type 2 DM, hypertension and hyperlidpedemia who presented to
[**Hospital1 18**] ED with 3 days of chest pain. Patient reports that about
three days ago while she was putting her clothes in the laundry
she had suddedn onset of substernal chest pain with radiation to
her neck, right arm and her abdomen. She attributed this pain
to indigestion. The pain was [**4-16**] and remained constant. Today
at 6:30am patient patient acutely worsened [**9-16**] associated with
nasuea, diaphoresis and shonrtess of breaht.
.
In the ED, initial vitals were 45 96/45 16 100% RA. ECG showed
ST Elevation Myocardial Infarction in inferior leads. She was
given aspirin 325 mg, plavix 600 mg, eptifibatide 180 mcg/kg x 1
and heparin 4000 units IV bolus. She was noted to be bradycardic
and hypotensive and thus given atropine 1mgx2 and started on
dopamine gtt which improved her blood pressure. She was
transfer to Cath lab.
.
In the Cath lab, she was noted to acute mid RCA occlusion which
was treated with angioplasty x 3 (10 mm/12 mm/14 mm) with
residual thrombus which was exported and Promus DES was placed
in mid RCA. His cath lab course was complicated by intermittent
complete heart block requiring temporary pacemaker pre-stenting
though she was conducting 1:1 in NSR after stenting. She was
also noted to have AIVR. Dopamine at 5 mcg/kg/min was turned
off at the end of her cath lab course. A small 1.5cm hematoma
was visible at the RFV access site after the case, and manual
pressure was applied for 10 minutes.
.
In the CCU, she did not report chest pain, discomfort,
palpatations or shortness of breath. She desnies any history of
chest pain.
Past Medical History:
DM2
HTN
TB
peripheral neuropathy
aseptic thrombophlebitis of the left internal jugular in [**2130**].
Social History:
Lives with husband, ha two children who live in [**Country 2045**]. Creole
speaking from [**Country 2045**] 14 years ago. Three children. No history
of tobacco, ETOH or illicit.
Family History:
non-contributory
Physical Exam:
Admission Physical:
GENERAL: Appears well NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL. MMM
NECK: Supple with no JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Wamr and well perfused No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs:
[**2144-8-1**] 11:35AM BLOOD WBC-10.8# RBC-3.35* Hgb-10.3* Hct-30.8*
MCV-92 MCH-30.7 MCHC-33.4 RDW-12.8 Plt Ct-178
[**2144-8-1**] 11:35AM BLOOD PT-12.5 PTT-30.7 INR(PT)-1.2*
[**2144-8-1**] 11:35AM BLOOD Glucose-394* UreaN-22* Creat-1.2* Na-135
K-4.0 Cl-99 HCO3-25 AnGap-15
[**2144-8-1**] 11:35AM BLOOD CK-MB-11* MB Indx-1.2
[**2144-8-1**] 05:15PM BLOOD CK-MB-16* MB Indx-1.9
[**2144-8-2**] 05:28AM BLOOD CK-MB-10 MB Indx-1.8 cTropnT-3.44*
[**2144-8-1**] 11:35AM BLOOD CK(CPK)-891*
[**2144-8-1**] 05:15PM BLOOD CK(CPK)-821*
[**2144-8-2**] 05:28AM BLOOD CK(CPK)-555*
Cardiac Cath
1) Selective coronary angiography of this co-dominant system
demonstrated three-vessel coronary artery disease. The LMCA had
mild
luminal irregularities. The proximal-mid LAD had an 80%
trifurcation
lesion that was tightest at the large diagonal branch takeoff;
there was
a high diagonal branch (functionally a ramus) that had diffuse
proximal
70% stenosis. The LCx was a diffusely-diseased vessel with a
likely
stump-occluded OM2 and severely diseased distal vessel; it
provided a
smaller left PDA. The mid-RCA was 100% occluded without
anterograde
flow into the distal vessel; there was also haziness noted at
the AM
origin. The ostial RCA had a 30-40% stenosis.
2)
3) During the procedure, and given the degeneration of the
conduction
disease to high-grade heart block associated with hypotension, a
temporary pacing wire was inserted through the 5 French venous
sheath
with successful capture at 80 bpm and [**7-17**] mA. After the PCI,
pacing
was discontinued, and the patient remained in sinus rhythm with
1:1
conduction at a rate of 80 bpm with normotensive blood
pressures. The
temporary pacing wire was therefore removed and the dopamine was
discontinued.
4) After the procedure, the 6 French right femoral arteriotomy
site was
AngioSealed with adequate hemostasis. The 5 French right femoral
venous
sheath was left in place in case of worsening conduction disease
overnight. A small 1.5cm hematoma was noted after the
procedure.
FINAL DIAGNOSIS:
1. Inferior wall STEMI with high-grade AV block.
2. Successful emergent primary PCI of occluded mid RCA with
PTCA, export
thrombectomy, and Promus drug eluting stent.
3. Emergent temporary pacing wire placement with active pacing
during
the procedure.
.
TTE: [**2144-8-3**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with severe
hypokinesis of the inferolateral wall. The remaining segments
contract normally (LVEF = 40 %). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. There is no aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild to moderate ([**12-9**]+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD (PDA distribution).
Mild-moderate mitral regurgitation most likely due to papillary
muscle dysfunction. Pulmonary artery hypertension.
.
CLINICAL IMPLICATIONS:
Based on [**2138**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
Discharge Labs:
Brief Hospital Course:
68-year-old woman, Haitian-Creole speaking, with history of type
2 DM, hypertension, and hyperlidpedemia, presented with inferior
STEMI now s/p DES to mid RCA.
.
# STEMI: Patient with multiple cardiovascular risk factors
(uncontrolled diabetes, uncontrolled hypertension and
hyperlidemia) presented with worsening chest pain. ECG was
consistent with ST elevation myocardial infarction in inferior
leads. She was given aspirin 325 mg, plavix 600 mg, eptifibatide
180 mcg/kg x 1 and heparin 4000 units IV bolus. She was noted to
be bradycardic and hypotensive and thus given atropine 1mgx2 and
started on dopamine gtt which improved her blood pressure. She
was transfer to the Cath lab. In the Cath lab, she was noted to
have acute mid RCA occlusion which was treated with angioplasty
x 3 (10 mm/12 mm/14 mm) with residual thrombus, which was
removed, and Promus DES was placed in the mid RCA. Her Cath lab
course was complicated by intermittent complete heart block
requiring temporary pacemaker pre-stenting though she was
conducting 1:1 in NSR after stenting. She was also noted to
have AIVR. Dopamine at 5 mcg/kg/min was turned off at the end
of her Cath lab course. She had an ECHO report that showed mild
regional left ventricular systolic dysfunction with severe
hypokinesis of the inferolateral wall with EF 40%. Mild
symmetric left ventricular hypertrophy with regional systolic
dysfunction c/w CAD (PDA distribution). Mild-moderate mitral
regurgitation most likely due to papillary muscle dysfunction.
Pulmonary artery hypertension.
During her CCU course, patient had one episode of shortness of
breath and increased respiratory rate with bilateral crackles on
exam. She was treated with Lasix which improved her sxs and she
had no further episodes of chest pain or shortness of breath
during her hospital stay. Patient was evaluated by physical
therapy on the day of discharge and determined safe to go home.
Patient will follow up with Dr. [**Last Name (STitle) 10156**] in Cardiology and
with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. She was discharged on the
following medications: Lasix, metoprolol, lisinopril,
atorvastatin, and Plavix.
.
# Arrythmia: Patient had bradycardia with dropped beats and
atrial ectopy likely in the setting of reperfusion post [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 10157**]. She did not have any symptomatic episodes of
bradycardia during her CCU course. She was also started on low
dose metoprolol which she tolerated very well.
.
# Diabetes Type 2: Poorly controlled and complicated by diabetic
nephropathy, retinopathy, and neuropathy. Last A1c was 8.7 in
3/[**2143**]. She was continued on 11units of NPH and insulin sliding
scale. On discharge, she was put on ----.
.
# Anemia: Hematocrit during this admission was around 30.
Prior HCT on OMR from [**2141**] shows HCT of 37.9. Unclear etiology.
No source of obvious bleeding and normal coags. Patient will
follow up with PCP for further management.
.
# Hypertension: Patient blood pressure was well controlled on
low dose metoprolol. Her home chorthalidone, amlodopine, and
lisinopril were initally held due to low bps. She was
discharged on metoprolol, lisinopril and lasix.
.
# Hyperlidemia: Started atorvastain 80mg daily.
.
Transitional Issues:
- needs close follow-up with Cardiology, PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] recommend [**Last Name (un) **] consultation for DM
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Aspirin 81 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Ranitidine 150 mg PO BID
7. NPH 32 Units Breakfast
NPH 22 Units Dinner
Discharge Medications:
1. Aspirin EC 325 mg PO DAILY
RX *aspirin [Enteric Coated Aspirin] 325 mg one tablet(s) by
mouth daily Disp #*30 Tablet Refills:*2
2. Ranitidine 150 mg PO BID
3. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
4. Clopidogrel 75 mg PO DAILY
for the recommended duration
RX *clopidogrel 75 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
5. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg one tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. NPH 32 Units Breakfast
NPH 22 Units Dinner
8. Lisinopril 20 mg PO DAILY
RX *lisinopril 40 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*2
9. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg one tablets by mouth daily Disp #*30 Tablet
Refills:*2
10. Outpatient Lab Work
Please check Chem-7 at [**Hospital6 733**] on [**2144-8-11**] with
results to Dr. [**Last Name (STitle) 6215**] at Phone: [**Telephone/Fax (1) 2010**]
Fax: [**Telephone/Fax (1) 4004**]
ICD-9 428
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Inferolateral ST elevation myocardial infarction
acute systolic congestive heart failure
hypertension
diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 10158**],
It was a pleasure taking care of your during your admission at
[**Hospital1 18**]. You were admitted because you were having chest pain and
you were found to have a heart attack for which you had a stent
placed in your heart. You have also been started on new
medications (aspirin and clopidogrel) to prevent the stenting of
the clot which you should continue to take unless told otherwise
by your cardiologist.
Weigh yourself every day before breakfast. Call Dr. [**Last Name (STitle) **] if
weight increases more than 3 pounds in 1 day or 5 pounds in 3
days.
The visiting nurse will help you with a low salt diet.
.
Please continue to take your medications as directed in your
discharge medication sheet. Please do not stop any medication
especially clopidogrel unless told by your cardiologist. You
risk having a heart attack if you do not take this medicine
every day.
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2144-9-3**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital **] HEALTH CENTER
When: TUESDAY [**2144-8-11**] at 11:50 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
| {
"clinical_findings": {
"E785": [
{
"icd_10_cm_code": "E78.5",
"icd_10_cm_code_description": "Hyperlipidemia, unspecified",
"Monitoring": [
{
"text": "hyperlidpedemia",
"page_numbers": [
1
]
},
{
"text": "hyperlidpedemia",
"page_numbers": [
2
]
},
{
"text": "hyperlidemia",
"page_numbers": [
2
]
},
{
"text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "Started atorvastain 80mg daily",
"page_numbers": [
2
]
},
{
"text": "Atorvastatin 80 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "hyperlidpedemia",
"page_numbers": [
1
]
},
{
"evidence_text": "hyperlidpedemia",
"page_numbers": [
2
]
},
{
"evidence_text": "hyperlidemia",
"page_numbers": [
2
]
},
{
"evidence_text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E78.5 is assigned for Hyperlipidemia, unspecified. The diagnosis is documented multiple times. MEAT criteria are met through monitoring (documented diagnosis), assessment (documented as Hyperlidemia), and treatment (Atorvastatin started)."
}
],
"I2119": [
{
"icd_10_cm_code": "I21.19",
"icd_10_cm_code_description": "ST elevation myocardial infarction involving other inferior wall",
"Monitoring": [
{
"text": "ECG showed\nST Elevation Myocardial Infarction in inferior leads",
"page_numbers": [
1
]
},
{
"text": "ECG was\nconsistent with ST elevation myocardial infarction in inferior\nleads",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "mid-RCA was 100% occluded without\nanterograde\nflow into the distal vessel",
"page_numbers": [
1
]
},
{
"text": "cTropnT-3.44*",
"page_numbers": [
1
]
},
{
"text": "CK-MB-11*",
"page_numbers": [
1
]
},
{
"text": "CK(CPK)-891*",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Inferior wall STEMI",
"page_numbers": [
1
]
},
{
"text": "inferior\nSTEMI",
"page_numbers": [
2
]
},
{
"text": "Inferolateral ST elevation myocardial infarction",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "given aspirin 325 mg, plavix 600 mg, eptifibatide 180 mcg/kg x 1\nand heparin 4000 units IV bolus",
"page_numbers": [
1
]
},
{
"text": "transfer to Cath lab",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty x 3 (10 mm/12 mm/14 mm) with\nresidual thrombus which was exported and Promus DES was placed\nin mid RCA",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty\nx 3 (10 mm/12 mm/14 mm) with residual thrombus, which was\nremoved, and Promus DES was placed in the mid RCA",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "ST Elevation Myocardial Infarction in inferior leads",
"page_numbers": [
1
]
},
{
"evidence_text": "Inferior wall STEMI",
"page_numbers": [
1
]
},
{
"evidence_text": "inferior\nSTEMI",
"page_numbers": [
2
]
},
{
"evidence_text": "ST elevation myocardial infarction in inferior\nleads",
"page_numbers": [
2
]
},
{
"evidence_text": "Inferolateral ST elevation myocardial infarction",
"page_numbers": [
3
]
},
{
"evidence_text": "heart attack",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I21.19 is assigned for ST elevation myocardial infarction involving other inferior wall. The diagnosis is clearly documented multiple times, including in the final and discharge diagnoses. MEAT criteria are met through monitoring (ECG findings), evaluation (cardiac cath findings, elevated cardiac enzymes), assessment (documented diagnosis), and treatment (medications, PCI)."
}
],
"I442": [
{
"icd_10_cm_code": "I44.2",
"icd_10_cm_code_description": "Atrioventricular block, third degree",
"Monitoring": [
{
"text": "intermittent\ncomplete heart block",
"page_numbers": [
1
]
},
{
"text": "intermittent complete heart block",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "degeneration of the\nconduction\ndisease to high-grade heart block",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "high-grade AV block",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "requiring temporary pacemaker",
"page_numbers": [
1
]
},
{
"text": "requiring temporary pacemaker",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "intermittent\ncomplete heart block",
"page_numbers": [
1
]
},
{
"evidence_text": "degeneration of the\nconduction\ndisease to high-grade heart block",
"page_numbers": [
1
]
},
{
"evidence_text": "high-grade AV block",
"page_numbers": [
1
]
},
{
"evidence_text": "intermittent complete heart block",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I44.2 is assigned for Atrioventricular block, third degree, based on documentation of 'intermittent complete heart block' and 'high-grade AV block' requiring temporary pacing. MEAT criteria are met through monitoring (documented status), evaluation (documented degeneration), assessment (documented as high-grade AV block), and treatment (temporary pacemaker)."
}
],
"E1140": [
{
"icd_10_cm_code": "E11.40",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with diabetic neuropathy, unspecified",
"Monitoring": [
{
"text": "neuropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic neuropathy"
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "neuropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic neuropathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "peripheral neuropathy",
"page_numbers": [
1
]
},
{
"evidence_text": "neuropathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.40 is assigned for Type 2 diabetes mellitus with diabetic neuropathy. The entity 'peripheral neuropathy' is documented in PMH and 'neuropathy' is mentioned as a complication of poorly controlled diabetes in the Brief Hospital Course. MEAT criteria are met for the neuropathy component via monitoring and assessment. This is a combination code requiring an additional code for the manifestation (G63.0*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"I2510": [
{
"icd_10_cm_code": "I25.10",
"icd_10_cm_code_description": "Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Monitoring": [],
"Evaluation": [
{
"text": "Selective coronary angiography of this co-dominant system\ndemonstrated three-vessel coronary artery disease",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "treated with angioplasty x 3 (10 mm/12 mm/14 mm) with\nresidual thrombus which was exported and Promus DES was placed\nin mid RCA",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty\nx 3 (10 mm/12 mm/14 mm) with residual thrombus, which was\nremoved, and Promus DES was placed in the mid RCA",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "three-vessel coronary artery disease",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I25.10 is assigned for Atherosclerotic heart disease of native coronary artery without angina pectoris. The entity 'three-vessel coronary artery disease' is documented in the cardiac cath report. MEAT criteria are met through evaluation (angiography findings), assessment (systolic dysfunction c/w CAD), and treatment (PCI of RCA)."
}
],
"I2721": [
{
"icd_10_cm_code": "I27.21",
"icd_10_cm_code_description": "Secondary pulmonary arterial hypertension",
"Monitoring": [
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I27.21 is assigned for Secondary pulmonary arterial hypertension, based on the TTE finding of 'moderate pulmonary artery systolic hypertension'. MEAT criteria are met through monitoring (documented finding), evaluation (TTE report), and assessment (documented in TTE impression and Brief Hospital Course)."
}
],
"E1121": [
{
"icd_10_cm_code": "E11.21",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with diabetic nephropathy",
"Monitoring": [
{
"text": "diabetic\nnephropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Evaluation": [
{
"text": "Creat-1.2*",
"page_numbers": [
1
],
"applies_to": [
"Diabetic nephropathy"
]
},
{
"text": "UreaN-22*",
"page_numbers": [
1
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Assessment": [
{
"text": "diabetic\nnephropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "diabetic\nnephropathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.21 is assigned for Type 2 diabetes mellitus with diabetic nephropathy. The entity 'diabetic nephropathy' is documented as a complication of poorly controlled diabetes. MEAT criteria are met for the nephropathy component via monitoring, evaluation (labs), and assessment. This is a combination code requiring an additional code for the manifestation (N08*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"E1139": [
{
"icd_10_cm_code": "E11.39",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with other diabetic ophthalmic complication",
"Monitoring": [
{
"text": "retinopathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic retinopathy"
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "retinopathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic retinopathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "retinopathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.39 is assigned for Type 2 diabetes mellitus with other diabetic ophthalmic complication. The entity 'retinopathy' is documented as a complication of poorly controlled diabetes. MEAT criteria are met for the retinopathy component via monitoring and assessment. This is a combination code requiring an additional code for the manifestation (H36*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"I5021": [
{
"icd_10_cm_code": "I50.21",
"icd_10_cm_code_description": "Acute systolic (congestive) heart failure",
"Monitoring": [
{
"text": "one episode of shortness of\nbreath and increased respiratory rate with bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "Mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "She was treated with Lasix which improved her sxs",
"page_numbers": [
2
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I50.21 is assigned for Acute systolic (congestive) heart failure. The diagnosis is documented in the Discharge Diagnosis. MEAT criteria are met through monitoring (symptoms like shortness of breath, crackles, TTE findings), evaluation (physical exam, TTE report), assessment (documented diagnosis), and treatment (Lasix/Furosemide)."
}
],
"I110": [
{
"icd_10_cm_code": "I50.21",
"icd_10_cm_code_description": "Acute systolic (congestive) heart failure",
"Monitoring": [
{
"text": "one episode of shortness of\nbreath and increased respiratory rate with bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "Mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "She was treated with Lasix which improved her sxs",
"page_numbers": [
2
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I50.21 is assigned for Acute systolic (congestive) heart failure. The diagnosis is documented in the Discharge Diagnosis. MEAT criteria are met through monitoring (symptoms like shortness of breath, crackles, TTE findings), evaluation (physical exam, TTE report), assessment (documented diagnosis), and treatment (Lasix/Furosemide)."
},
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [
{
"text": "uncontrolled hypertension",
"page_numbers": [
2
]
},
{
"text": "Patient blood pressure was well controlled on\nlow dose metoprolol",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "initial vitals were 45 96/45",
"page_numbers": [
1
]
},
{
"text": "low bps",
"page_numbers": [
2
]
}
],
"Assessment": [
{
"text": "Hypertension",
"page_numbers": [
2
]
},
{
"text": "hypertension",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "Amlodipine 10 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Chlorthalidone 25 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Lisinopril 40 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Metoprolol Succinate XL 50 mg PO DAILY",
"page_numbers": [
3
]
},
{
"text": "Lisinopril 20 mg PO DAILY",
"page_numbers": [
3
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "uncontrolled hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "hypertension",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. The diagnosis is documented multiple times. MEAT criteria are met through monitoring (uncontrolled/controlled status), evaluation (vital signs, low bps), assessment (documented as Hypertension), and treatment (multiple antihypertensive medications)."
},
{
"icd_10_cm_code": "I51.9",
"icd_10_cm_code_description": "Heart disease, unspecified",
"Monitoring": [
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"evidence_text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"evidence_text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
2
]
},
{
"evidence_text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I51.9 is assigned for Heart disease, unspecified, based on the TTE finding of 'mild regional left ventricular systolic dysfunction'. MEAT criteria are met through monitoring (documented finding), evaluation (TTE report including EF), and assessment (documented in TTE impression and Brief Hospital Course)."
}
]
}
} |
Extract only the clinical evaluation methods used for each condition, such as imaging, physical examination, or biopsy. | Admission Date: [**2144-8-1**] Discharge Date: [**2144-8-6**]
Date of Birth: [**2075-9-18**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 2888**]
Chief Complaint:
CP
Major Surgical or Invasive Procedure:
PCI with angioplasty and DES to Mid-RCA
History of Present Illness:
68-year-old woman haitian Crecole speaking only with history of
type 2 DM, hypertension and hyperlidpedemia who presented to
[**Hospital1 18**] ED with 3 days of chest pain. Patient reports that about
three days ago while she was putting her clothes in the laundry
she had suddedn onset of substernal chest pain with radiation to
her neck, right arm and her abdomen. She attributed this pain
to indigestion. The pain was [**4-16**] and remained constant. Today
at 6:30am patient patient acutely worsened [**9-16**] associated with
nasuea, diaphoresis and shonrtess of breaht.
.
In the ED, initial vitals were 45 96/45 16 100% RA. ECG showed
ST Elevation Myocardial Infarction in inferior leads. She was
given aspirin 325 mg, plavix 600 mg, eptifibatide 180 mcg/kg x 1
and heparin 4000 units IV bolus. She was noted to be bradycardic
and hypotensive and thus given atropine 1mgx2 and started on
dopamine gtt which improved her blood pressure. She was
transfer to Cath lab.
.
In the Cath lab, she was noted to acute mid RCA occlusion which
was treated with angioplasty x 3 (10 mm/12 mm/14 mm) with
residual thrombus which was exported and Promus DES was placed
in mid RCA. His cath lab course was complicated by intermittent
complete heart block requiring temporary pacemaker pre-stenting
though she was conducting 1:1 in NSR after stenting. She was
also noted to have AIVR. Dopamine at 5 mcg/kg/min was turned
off at the end of her cath lab course. A small 1.5cm hematoma
was visible at the RFV access site after the case, and manual
pressure was applied for 10 minutes.
.
In the CCU, she did not report chest pain, discomfort,
palpatations or shortness of breath. She desnies any history of
chest pain.
Past Medical History:
DM2
HTN
TB
peripheral neuropathy
aseptic thrombophlebitis of the left internal jugular in [**2130**].
Social History:
Lives with husband, ha two children who live in [**Country 2045**]. Creole
speaking from [**Country 2045**] 14 years ago. Three children. No history
of tobacco, ETOH or illicit.
Family History:
non-contributory
Physical Exam:
Admission Physical:
GENERAL: Appears well NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL. MMM
NECK: Supple with no JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Wamr and well perfused No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs:
[**2144-8-1**] 11:35AM BLOOD WBC-10.8# RBC-3.35* Hgb-10.3* Hct-30.8*
MCV-92 MCH-30.7 MCHC-33.4 RDW-12.8 Plt Ct-178
[**2144-8-1**] 11:35AM BLOOD PT-12.5 PTT-30.7 INR(PT)-1.2*
[**2144-8-1**] 11:35AM BLOOD Glucose-394* UreaN-22* Creat-1.2* Na-135
K-4.0 Cl-99 HCO3-25 AnGap-15
[**2144-8-1**] 11:35AM BLOOD CK-MB-11* MB Indx-1.2
[**2144-8-1**] 05:15PM BLOOD CK-MB-16* MB Indx-1.9
[**2144-8-2**] 05:28AM BLOOD CK-MB-10 MB Indx-1.8 cTropnT-3.44*
[**2144-8-1**] 11:35AM BLOOD CK(CPK)-891*
[**2144-8-1**] 05:15PM BLOOD CK(CPK)-821*
[**2144-8-2**] 05:28AM BLOOD CK(CPK)-555*
Cardiac Cath
1) Selective coronary angiography of this co-dominant system
demonstrated three-vessel coronary artery disease. The LMCA had
mild
luminal irregularities. The proximal-mid LAD had an 80%
trifurcation
lesion that was tightest at the large diagonal branch takeoff;
there was
a high diagonal branch (functionally a ramus) that had diffuse
proximal
70% stenosis. The LCx was a diffusely-diseased vessel with a
likely
stump-occluded OM2 and severely diseased distal vessel; it
provided a
smaller left PDA. The mid-RCA was 100% occluded without
anterograde
flow into the distal vessel; there was also haziness noted at
the AM
origin. The ostial RCA had a 30-40% stenosis.
2)
3) During the procedure, and given the degeneration of the
conduction
disease to high-grade heart block associated with hypotension, a
temporary pacing wire was inserted through the 5 French venous
sheath
with successful capture at 80 bpm and [**7-17**] mA. After the PCI,
pacing
was discontinued, and the patient remained in sinus rhythm with
1:1
conduction at a rate of 80 bpm with normotensive blood
pressures. The
temporary pacing wire was therefore removed and the dopamine was
discontinued.
4) After the procedure, the 6 French right femoral arteriotomy
site was
AngioSealed with adequate hemostasis. The 5 French right femoral
venous
sheath was left in place in case of worsening conduction disease
overnight. A small 1.5cm hematoma was noted after the
procedure.
FINAL DIAGNOSIS:
1. Inferior wall STEMI with high-grade AV block.
2. Successful emergent primary PCI of occluded mid RCA with
PTCA, export
thrombectomy, and Promus drug eluting stent.
3. Emergent temporary pacing wire placement with active pacing
during
the procedure.
.
TTE: [**2144-8-3**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with severe
hypokinesis of the inferolateral wall. The remaining segments
contract normally (LVEF = 40 %). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. There is no aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild to moderate ([**12-9**]+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD (PDA distribution).
Mild-moderate mitral regurgitation most likely due to papillary
muscle dysfunction. Pulmonary artery hypertension.
.
CLINICAL IMPLICATIONS:
Based on [**2138**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
Discharge Labs:
Brief Hospital Course:
68-year-old woman, Haitian-Creole speaking, with history of type
2 DM, hypertension, and hyperlidpedemia, presented with inferior
STEMI now s/p DES to mid RCA.
.
# STEMI: Patient with multiple cardiovascular risk factors
(uncontrolled diabetes, uncontrolled hypertension and
hyperlidemia) presented with worsening chest pain. ECG was
consistent with ST elevation myocardial infarction in inferior
leads. She was given aspirin 325 mg, plavix 600 mg, eptifibatide
180 mcg/kg x 1 and heparin 4000 units IV bolus. She was noted to
be bradycardic and hypotensive and thus given atropine 1mgx2 and
started on dopamine gtt which improved her blood pressure. She
was transfer to the Cath lab. In the Cath lab, she was noted to
have acute mid RCA occlusion which was treated with angioplasty
x 3 (10 mm/12 mm/14 mm) with residual thrombus, which was
removed, and Promus DES was placed in the mid RCA. Her Cath lab
course was complicated by intermittent complete heart block
requiring temporary pacemaker pre-stenting though she was
conducting 1:1 in NSR after stenting. She was also noted to
have AIVR. Dopamine at 5 mcg/kg/min was turned off at the end
of her Cath lab course. She had an ECHO report that showed mild
regional left ventricular systolic dysfunction with severe
hypokinesis of the inferolateral wall with EF 40%. Mild
symmetric left ventricular hypertrophy with regional systolic
dysfunction c/w CAD (PDA distribution). Mild-moderate mitral
regurgitation most likely due to papillary muscle dysfunction.
Pulmonary artery hypertension.
During her CCU course, patient had one episode of shortness of
breath and increased respiratory rate with bilateral crackles on
exam. She was treated with Lasix which improved her sxs and she
had no further episodes of chest pain or shortness of breath
during her hospital stay. Patient was evaluated by physical
therapy on the day of discharge and determined safe to go home.
Patient will follow up with Dr. [**Last Name (STitle) 10156**] in Cardiology and
with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. She was discharged on the
following medications: Lasix, metoprolol, lisinopril,
atorvastatin, and Plavix.
.
# Arrythmia: Patient had bradycardia with dropped beats and
atrial ectopy likely in the setting of reperfusion post [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 10157**]. She did not have any symptomatic episodes of
bradycardia during her CCU course. She was also started on low
dose metoprolol which she tolerated very well.
.
# Diabetes Type 2: Poorly controlled and complicated by diabetic
nephropathy, retinopathy, and neuropathy. Last A1c was 8.7 in
3/[**2143**]. She was continued on 11units of NPH and insulin sliding
scale. On discharge, she was put on ----.
.
# Anemia: Hematocrit during this admission was around 30.
Prior HCT on OMR from [**2141**] shows HCT of 37.9. Unclear etiology.
No source of obvious bleeding and normal coags. Patient will
follow up with PCP for further management.
.
# Hypertension: Patient blood pressure was well controlled on
low dose metoprolol. Her home chorthalidone, amlodopine, and
lisinopril were initally held due to low bps. She was
discharged on metoprolol, lisinopril and lasix.
.
# Hyperlidemia: Started atorvastain 80mg daily.
.
Transitional Issues:
- needs close follow-up with Cardiology, PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] recommend [**Last Name (un) **] consultation for DM
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Aspirin 81 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Ranitidine 150 mg PO BID
7. NPH 32 Units Breakfast
NPH 22 Units Dinner
Discharge Medications:
1. Aspirin EC 325 mg PO DAILY
RX *aspirin [Enteric Coated Aspirin] 325 mg one tablet(s) by
mouth daily Disp #*30 Tablet Refills:*2
2. Ranitidine 150 mg PO BID
3. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
4. Clopidogrel 75 mg PO DAILY
for the recommended duration
RX *clopidogrel 75 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
5. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg one tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. NPH 32 Units Breakfast
NPH 22 Units Dinner
8. Lisinopril 20 mg PO DAILY
RX *lisinopril 40 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*2
9. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg one tablets by mouth daily Disp #*30 Tablet
Refills:*2
10. Outpatient Lab Work
Please check Chem-7 at [**Hospital6 733**] on [**2144-8-11**] with
results to Dr. [**Last Name (STitle) 6215**] at Phone: [**Telephone/Fax (1) 2010**]
Fax: [**Telephone/Fax (1) 4004**]
ICD-9 428
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Inferolateral ST elevation myocardial infarction
acute systolic congestive heart failure
hypertension
diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 10158**],
It was a pleasure taking care of your during your admission at
[**Hospital1 18**]. You were admitted because you were having chest pain and
you were found to have a heart attack for which you had a stent
placed in your heart. You have also been started on new
medications (aspirin and clopidogrel) to prevent the stenting of
the clot which you should continue to take unless told otherwise
by your cardiologist.
Weigh yourself every day before breakfast. Call Dr. [**Last Name (STitle) **] if
weight increases more than 3 pounds in 1 day or 5 pounds in 3
days.
The visiting nurse will help you with a low salt diet.
.
Please continue to take your medications as directed in your
discharge medication sheet. Please do not stop any medication
especially clopidogrel unless told by your cardiologist. You
risk having a heart attack if you do not take this medicine
every day.
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2144-9-3**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital **] HEALTH CENTER
When: TUESDAY [**2144-8-11**] at 11:50 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
| {
"clinical_findings": {
"E785": [
{
"icd_10_cm_code": "E78.5",
"icd_10_cm_code_description": "Hyperlipidemia, unspecified",
"Monitoring": [
{
"text": "hyperlidpedemia",
"page_numbers": [
1
]
},
{
"text": "hyperlidpedemia",
"page_numbers": [
2
]
},
{
"text": "hyperlidemia",
"page_numbers": [
2
]
},
{
"text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "Started atorvastain 80mg daily",
"page_numbers": [
2
]
},
{
"text": "Atorvastatin 80 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "hyperlidpedemia",
"page_numbers": [
1
]
},
{
"evidence_text": "hyperlidpedemia",
"page_numbers": [
2
]
},
{
"evidence_text": "hyperlidemia",
"page_numbers": [
2
]
},
{
"evidence_text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E78.5 is assigned for Hyperlipidemia, unspecified. The diagnosis is documented multiple times. MEAT criteria are met through monitoring (documented diagnosis), assessment (documented as Hyperlidemia), and treatment (Atorvastatin started)."
}
],
"I2119": [
{
"icd_10_cm_code": "I21.19",
"icd_10_cm_code_description": "ST elevation myocardial infarction involving other inferior wall",
"Monitoring": [
{
"text": "ECG showed\nST Elevation Myocardial Infarction in inferior leads",
"page_numbers": [
1
]
},
{
"text": "ECG was\nconsistent with ST elevation myocardial infarction in inferior\nleads",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "mid-RCA was 100% occluded without\nanterograde\nflow into the distal vessel",
"page_numbers": [
1
]
},
{
"text": "cTropnT-3.44*",
"page_numbers": [
1
]
},
{
"text": "CK-MB-11*",
"page_numbers": [
1
]
},
{
"text": "CK(CPK)-891*",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Inferior wall STEMI",
"page_numbers": [
1
]
},
{
"text": "inferior\nSTEMI",
"page_numbers": [
2
]
},
{
"text": "Inferolateral ST elevation myocardial infarction",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "given aspirin 325 mg, plavix 600 mg, eptifibatide 180 mcg/kg x 1\nand heparin 4000 units IV bolus",
"page_numbers": [
1
]
},
{
"text": "transfer to Cath lab",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty x 3 (10 mm/12 mm/14 mm) with\nresidual thrombus which was exported and Promus DES was placed\nin mid RCA",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty\nx 3 (10 mm/12 mm/14 mm) with residual thrombus, which was\nremoved, and Promus DES was placed in the mid RCA",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "ST Elevation Myocardial Infarction in inferior leads",
"page_numbers": [
1
]
},
{
"evidence_text": "Inferior wall STEMI",
"page_numbers": [
1
]
},
{
"evidence_text": "inferior\nSTEMI",
"page_numbers": [
2
]
},
{
"evidence_text": "ST elevation myocardial infarction in inferior\nleads",
"page_numbers": [
2
]
},
{
"evidence_text": "Inferolateral ST elevation myocardial infarction",
"page_numbers": [
3
]
},
{
"evidence_text": "heart attack",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I21.19 is assigned for ST elevation myocardial infarction involving other inferior wall. The diagnosis is clearly documented multiple times, including in the final and discharge diagnoses. MEAT criteria are met through monitoring (ECG findings), evaluation (cardiac cath findings, elevated cardiac enzymes), assessment (documented diagnosis), and treatment (medications, PCI)."
}
],
"I442": [
{
"icd_10_cm_code": "I44.2",
"icd_10_cm_code_description": "Atrioventricular block, third degree",
"Monitoring": [
{
"text": "intermittent\ncomplete heart block",
"page_numbers": [
1
]
},
{
"text": "intermittent complete heart block",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "degeneration of the\nconduction\ndisease to high-grade heart block",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "high-grade AV block",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "requiring temporary pacemaker",
"page_numbers": [
1
]
},
{
"text": "requiring temporary pacemaker",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "intermittent\ncomplete heart block",
"page_numbers": [
1
]
},
{
"evidence_text": "degeneration of the\nconduction\ndisease to high-grade heart block",
"page_numbers": [
1
]
},
{
"evidence_text": "high-grade AV block",
"page_numbers": [
1
]
},
{
"evidence_text": "intermittent complete heart block",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I44.2 is assigned for Atrioventricular block, third degree, based on documentation of 'intermittent complete heart block' and 'high-grade AV block' requiring temporary pacing. MEAT criteria are met through monitoring (documented status), evaluation (documented degeneration), assessment (documented as high-grade AV block), and treatment (temporary pacemaker)."
}
],
"E1140": [
{
"icd_10_cm_code": "E11.40",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with diabetic neuropathy, unspecified",
"Monitoring": [
{
"text": "neuropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic neuropathy"
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "neuropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic neuropathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "peripheral neuropathy",
"page_numbers": [
1
]
},
{
"evidence_text": "neuropathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.40 is assigned for Type 2 diabetes mellitus with diabetic neuropathy. The entity 'peripheral neuropathy' is documented in PMH and 'neuropathy' is mentioned as a complication of poorly controlled diabetes in the Brief Hospital Course. MEAT criteria are met for the neuropathy component via monitoring and assessment. This is a combination code requiring an additional code for the manifestation (G63.0*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"I2510": [
{
"icd_10_cm_code": "I25.10",
"icd_10_cm_code_description": "Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Monitoring": [],
"Evaluation": [
{
"text": "Selective coronary angiography of this co-dominant system\ndemonstrated three-vessel coronary artery disease",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "treated with angioplasty x 3 (10 mm/12 mm/14 mm) with\nresidual thrombus which was exported and Promus DES was placed\nin mid RCA",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty\nx 3 (10 mm/12 mm/14 mm) with residual thrombus, which was\nremoved, and Promus DES was placed in the mid RCA",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "three-vessel coronary artery disease",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I25.10 is assigned for Atherosclerotic heart disease of native coronary artery without angina pectoris. The entity 'three-vessel coronary artery disease' is documented in the cardiac cath report. MEAT criteria are met through evaluation (angiography findings), assessment (systolic dysfunction c/w CAD), and treatment (PCI of RCA)."
}
],
"I2721": [
{
"icd_10_cm_code": "I27.21",
"icd_10_cm_code_description": "Secondary pulmonary arterial hypertension",
"Monitoring": [
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I27.21 is assigned for Secondary pulmonary arterial hypertension, based on the TTE finding of 'moderate pulmonary artery systolic hypertension'. MEAT criteria are met through monitoring (documented finding), evaluation (TTE report), and assessment (documented in TTE impression and Brief Hospital Course)."
}
],
"E1121": [
{
"icd_10_cm_code": "E11.21",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with diabetic nephropathy",
"Monitoring": [
{
"text": "diabetic\nnephropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Evaluation": [
{
"text": "Creat-1.2*",
"page_numbers": [
1
],
"applies_to": [
"Diabetic nephropathy"
]
},
{
"text": "UreaN-22*",
"page_numbers": [
1
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Assessment": [
{
"text": "diabetic\nnephropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "diabetic\nnephropathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.21 is assigned for Type 2 diabetes mellitus with diabetic nephropathy. The entity 'diabetic nephropathy' is documented as a complication of poorly controlled diabetes. MEAT criteria are met for the nephropathy component via monitoring, evaluation (labs), and assessment. This is a combination code requiring an additional code for the manifestation (N08*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"E1139": [
{
"icd_10_cm_code": "E11.39",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with other diabetic ophthalmic complication",
"Monitoring": [
{
"text": "retinopathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic retinopathy"
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "retinopathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic retinopathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "retinopathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.39 is assigned for Type 2 diabetes mellitus with other diabetic ophthalmic complication. The entity 'retinopathy' is documented as a complication of poorly controlled diabetes. MEAT criteria are met for the retinopathy component via monitoring and assessment. This is a combination code requiring an additional code for the manifestation (H36*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"I5021": [
{
"icd_10_cm_code": "I50.21",
"icd_10_cm_code_description": "Acute systolic (congestive) heart failure",
"Monitoring": [
{
"text": "one episode of shortness of\nbreath and increased respiratory rate with bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "Mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "She was treated with Lasix which improved her sxs",
"page_numbers": [
2
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I50.21 is assigned for Acute systolic (congestive) heart failure. The diagnosis is documented in the Discharge Diagnosis. MEAT criteria are met through monitoring (symptoms like shortness of breath, crackles, TTE findings), evaluation (physical exam, TTE report), assessment (documented diagnosis), and treatment (Lasix/Furosemide)."
}
],
"I110": [
{
"icd_10_cm_code": "I50.21",
"icd_10_cm_code_description": "Acute systolic (congestive) heart failure",
"Monitoring": [
{
"text": "one episode of shortness of\nbreath and increased respiratory rate with bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "Mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "She was treated with Lasix which improved her sxs",
"page_numbers": [
2
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I50.21 is assigned for Acute systolic (congestive) heart failure. The diagnosis is documented in the Discharge Diagnosis. MEAT criteria are met through monitoring (symptoms like shortness of breath, crackles, TTE findings), evaluation (physical exam, TTE report), assessment (documented diagnosis), and treatment (Lasix/Furosemide)."
},
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [
{
"text": "uncontrolled hypertension",
"page_numbers": [
2
]
},
{
"text": "Patient blood pressure was well controlled on\nlow dose metoprolol",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "initial vitals were 45 96/45",
"page_numbers": [
1
]
},
{
"text": "low bps",
"page_numbers": [
2
]
}
],
"Assessment": [
{
"text": "Hypertension",
"page_numbers": [
2
]
},
{
"text": "hypertension",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "Amlodipine 10 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Chlorthalidone 25 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Lisinopril 40 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Metoprolol Succinate XL 50 mg PO DAILY",
"page_numbers": [
3
]
},
{
"text": "Lisinopril 20 mg PO DAILY",
"page_numbers": [
3
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "uncontrolled hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "hypertension",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. The diagnosis is documented multiple times. MEAT criteria are met through monitoring (uncontrolled/controlled status), evaluation (vital signs, low bps), assessment (documented as Hypertension), and treatment (multiple antihypertensive medications)."
},
{
"icd_10_cm_code": "I51.9",
"icd_10_cm_code_description": "Heart disease, unspecified",
"Monitoring": [
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"evidence_text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"evidence_text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
2
]
},
{
"evidence_text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I51.9 is assigned for Heart disease, unspecified, based on the TTE finding of 'mild regional left ventricular systolic dysfunction'. MEAT criteria are met through monitoring (documented finding), evaluation (TTE report including EF), and assessment (documented in TTE impression and Brief Hospital Course)."
}
]
}
} |
Extract only the clinical assessment findings for each condition, including diagnostic conclusions and staging. | Admission Date: [**2144-8-1**] Discharge Date: [**2144-8-6**]
Date of Birth: [**2075-9-18**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 2888**]
Chief Complaint:
CP
Major Surgical or Invasive Procedure:
PCI with angioplasty and DES to Mid-RCA
History of Present Illness:
68-year-old woman haitian Crecole speaking only with history of
type 2 DM, hypertension and hyperlidpedemia who presented to
[**Hospital1 18**] ED with 3 days of chest pain. Patient reports that about
three days ago while she was putting her clothes in the laundry
she had suddedn onset of substernal chest pain with radiation to
her neck, right arm and her abdomen. She attributed this pain
to indigestion. The pain was [**4-16**] and remained constant. Today
at 6:30am patient patient acutely worsened [**9-16**] associated with
nasuea, diaphoresis and shonrtess of breaht.
.
In the ED, initial vitals were 45 96/45 16 100% RA. ECG showed
ST Elevation Myocardial Infarction in inferior leads. She was
given aspirin 325 mg, plavix 600 mg, eptifibatide 180 mcg/kg x 1
and heparin 4000 units IV bolus. She was noted to be bradycardic
and hypotensive and thus given atropine 1mgx2 and started on
dopamine gtt which improved her blood pressure. She was
transfer to Cath lab.
.
In the Cath lab, she was noted to acute mid RCA occlusion which
was treated with angioplasty x 3 (10 mm/12 mm/14 mm) with
residual thrombus which was exported and Promus DES was placed
in mid RCA. His cath lab course was complicated by intermittent
complete heart block requiring temporary pacemaker pre-stenting
though she was conducting 1:1 in NSR after stenting. She was
also noted to have AIVR. Dopamine at 5 mcg/kg/min was turned
off at the end of her cath lab course. A small 1.5cm hematoma
was visible at the RFV access site after the case, and manual
pressure was applied for 10 minutes.
.
In the CCU, she did not report chest pain, discomfort,
palpatations or shortness of breath. She desnies any history of
chest pain.
Past Medical History:
DM2
HTN
TB
peripheral neuropathy
aseptic thrombophlebitis of the left internal jugular in [**2130**].
Social History:
Lives with husband, ha two children who live in [**Country 2045**]. Creole
speaking from [**Country 2045**] 14 years ago. Three children. No history
of tobacco, ETOH or illicit.
Family History:
non-contributory
Physical Exam:
Admission Physical:
GENERAL: Appears well NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL. MMM
NECK: Supple with no JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Wamr and well perfused No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs:
[**2144-8-1**] 11:35AM BLOOD WBC-10.8# RBC-3.35* Hgb-10.3* Hct-30.8*
MCV-92 MCH-30.7 MCHC-33.4 RDW-12.8 Plt Ct-178
[**2144-8-1**] 11:35AM BLOOD PT-12.5 PTT-30.7 INR(PT)-1.2*
[**2144-8-1**] 11:35AM BLOOD Glucose-394* UreaN-22* Creat-1.2* Na-135
K-4.0 Cl-99 HCO3-25 AnGap-15
[**2144-8-1**] 11:35AM BLOOD CK-MB-11* MB Indx-1.2
[**2144-8-1**] 05:15PM BLOOD CK-MB-16* MB Indx-1.9
[**2144-8-2**] 05:28AM BLOOD CK-MB-10 MB Indx-1.8 cTropnT-3.44*
[**2144-8-1**] 11:35AM BLOOD CK(CPK)-891*
[**2144-8-1**] 05:15PM BLOOD CK(CPK)-821*
[**2144-8-2**] 05:28AM BLOOD CK(CPK)-555*
Cardiac Cath
1) Selective coronary angiography of this co-dominant system
demonstrated three-vessel coronary artery disease. The LMCA had
mild
luminal irregularities. The proximal-mid LAD had an 80%
trifurcation
lesion that was tightest at the large diagonal branch takeoff;
there was
a high diagonal branch (functionally a ramus) that had diffuse
proximal
70% stenosis. The LCx was a diffusely-diseased vessel with a
likely
stump-occluded OM2 and severely diseased distal vessel; it
provided a
smaller left PDA. The mid-RCA was 100% occluded without
anterograde
flow into the distal vessel; there was also haziness noted at
the AM
origin. The ostial RCA had a 30-40% stenosis.
2)
3) During the procedure, and given the degeneration of the
conduction
disease to high-grade heart block associated with hypotension, a
temporary pacing wire was inserted through the 5 French venous
sheath
with successful capture at 80 bpm and [**7-17**] mA. After the PCI,
pacing
was discontinued, and the patient remained in sinus rhythm with
1:1
conduction at a rate of 80 bpm with normotensive blood
pressures. The
temporary pacing wire was therefore removed and the dopamine was
discontinued.
4) After the procedure, the 6 French right femoral arteriotomy
site was
AngioSealed with adequate hemostasis. The 5 French right femoral
venous
sheath was left in place in case of worsening conduction disease
overnight. A small 1.5cm hematoma was noted after the
procedure.
FINAL DIAGNOSIS:
1. Inferior wall STEMI with high-grade AV block.
2. Successful emergent primary PCI of occluded mid RCA with
PTCA, export
thrombectomy, and Promus drug eluting stent.
3. Emergent temporary pacing wire placement with active pacing
during
the procedure.
.
TTE: [**2144-8-3**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with severe
hypokinesis of the inferolateral wall. The remaining segments
contract normally (LVEF = 40 %). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. There is no aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild to moderate ([**12-9**]+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD (PDA distribution).
Mild-moderate mitral regurgitation most likely due to papillary
muscle dysfunction. Pulmonary artery hypertension.
.
CLINICAL IMPLICATIONS:
Based on [**2138**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
Discharge Labs:
Brief Hospital Course:
68-year-old woman, Haitian-Creole speaking, with history of type
2 DM, hypertension, and hyperlidpedemia, presented with inferior
STEMI now s/p DES to mid RCA.
.
# STEMI: Patient with multiple cardiovascular risk factors
(uncontrolled diabetes, uncontrolled hypertension and
hyperlidemia) presented with worsening chest pain. ECG was
consistent with ST elevation myocardial infarction in inferior
leads. She was given aspirin 325 mg, plavix 600 mg, eptifibatide
180 mcg/kg x 1 and heparin 4000 units IV bolus. She was noted to
be bradycardic and hypotensive and thus given atropine 1mgx2 and
started on dopamine gtt which improved her blood pressure. She
was transfer to the Cath lab. In the Cath lab, she was noted to
have acute mid RCA occlusion which was treated with angioplasty
x 3 (10 mm/12 mm/14 mm) with residual thrombus, which was
removed, and Promus DES was placed in the mid RCA. Her Cath lab
course was complicated by intermittent complete heart block
requiring temporary pacemaker pre-stenting though she was
conducting 1:1 in NSR after stenting. She was also noted to
have AIVR. Dopamine at 5 mcg/kg/min was turned off at the end
of her Cath lab course. She had an ECHO report that showed mild
regional left ventricular systolic dysfunction with severe
hypokinesis of the inferolateral wall with EF 40%. Mild
symmetric left ventricular hypertrophy with regional systolic
dysfunction c/w CAD (PDA distribution). Mild-moderate mitral
regurgitation most likely due to papillary muscle dysfunction.
Pulmonary artery hypertension.
During her CCU course, patient had one episode of shortness of
breath and increased respiratory rate with bilateral crackles on
exam. She was treated with Lasix which improved her sxs and she
had no further episodes of chest pain or shortness of breath
during her hospital stay. Patient was evaluated by physical
therapy on the day of discharge and determined safe to go home.
Patient will follow up with Dr. [**Last Name (STitle) 10156**] in Cardiology and
with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. She was discharged on the
following medications: Lasix, metoprolol, lisinopril,
atorvastatin, and Plavix.
.
# Arrythmia: Patient had bradycardia with dropped beats and
atrial ectopy likely in the setting of reperfusion post [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 10157**]. She did not have any symptomatic episodes of
bradycardia during her CCU course. She was also started on low
dose metoprolol which she tolerated very well.
.
# Diabetes Type 2: Poorly controlled and complicated by diabetic
nephropathy, retinopathy, and neuropathy. Last A1c was 8.7 in
3/[**2143**]. She was continued on 11units of NPH and insulin sliding
scale. On discharge, she was put on ----.
.
# Anemia: Hematocrit during this admission was around 30.
Prior HCT on OMR from [**2141**] shows HCT of 37.9. Unclear etiology.
No source of obvious bleeding and normal coags. Patient will
follow up with PCP for further management.
.
# Hypertension: Patient blood pressure was well controlled on
low dose metoprolol. Her home chorthalidone, amlodopine, and
lisinopril were initally held due to low bps. She was
discharged on metoprolol, lisinopril and lasix.
.
# Hyperlidemia: Started atorvastain 80mg daily.
.
Transitional Issues:
- needs close follow-up with Cardiology, PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] recommend [**Last Name (un) **] consultation for DM
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Aspirin 81 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Ranitidine 150 mg PO BID
7. NPH 32 Units Breakfast
NPH 22 Units Dinner
Discharge Medications:
1. Aspirin EC 325 mg PO DAILY
RX *aspirin [Enteric Coated Aspirin] 325 mg one tablet(s) by
mouth daily Disp #*30 Tablet Refills:*2
2. Ranitidine 150 mg PO BID
3. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
4. Clopidogrel 75 mg PO DAILY
for the recommended duration
RX *clopidogrel 75 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
5. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg one tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. NPH 32 Units Breakfast
NPH 22 Units Dinner
8. Lisinopril 20 mg PO DAILY
RX *lisinopril 40 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*2
9. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg one tablets by mouth daily Disp #*30 Tablet
Refills:*2
10. Outpatient Lab Work
Please check Chem-7 at [**Hospital6 733**] on [**2144-8-11**] with
results to Dr. [**Last Name (STitle) 6215**] at Phone: [**Telephone/Fax (1) 2010**]
Fax: [**Telephone/Fax (1) 4004**]
ICD-9 428
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Inferolateral ST elevation myocardial infarction
acute systolic congestive heart failure
hypertension
diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 10158**],
It was a pleasure taking care of your during your admission at
[**Hospital1 18**]. You were admitted because you were having chest pain and
you were found to have a heart attack for which you had a stent
placed in your heart. You have also been started on new
medications (aspirin and clopidogrel) to prevent the stenting of
the clot which you should continue to take unless told otherwise
by your cardiologist.
Weigh yourself every day before breakfast. Call Dr. [**Last Name (STitle) **] if
weight increases more than 3 pounds in 1 day or 5 pounds in 3
days.
The visiting nurse will help you with a low salt diet.
.
Please continue to take your medications as directed in your
discharge medication sheet. Please do not stop any medication
especially clopidogrel unless told by your cardiologist. You
risk having a heart attack if you do not take this medicine
every day.
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2144-9-3**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital **] HEALTH CENTER
When: TUESDAY [**2144-8-11**] at 11:50 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
| {
"clinical_findings": {
"E785": [
{
"icd_10_cm_code": "E78.5",
"icd_10_cm_code_description": "Hyperlipidemia, unspecified",
"Monitoring": [
{
"text": "hyperlidpedemia",
"page_numbers": [
1
]
},
{
"text": "hyperlidpedemia",
"page_numbers": [
2
]
},
{
"text": "hyperlidemia",
"page_numbers": [
2
]
},
{
"text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "Started atorvastain 80mg daily",
"page_numbers": [
2
]
},
{
"text": "Atorvastatin 80 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "hyperlidpedemia",
"page_numbers": [
1
]
},
{
"evidence_text": "hyperlidpedemia",
"page_numbers": [
2
]
},
{
"evidence_text": "hyperlidemia",
"page_numbers": [
2
]
},
{
"evidence_text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E78.5 is assigned for Hyperlipidemia, unspecified. The diagnosis is documented multiple times. MEAT criteria are met through monitoring (documented diagnosis), assessment (documented as Hyperlidemia), and treatment (Atorvastatin started)."
}
],
"I2119": [
{
"icd_10_cm_code": "I21.19",
"icd_10_cm_code_description": "ST elevation myocardial infarction involving other inferior wall",
"Monitoring": [
{
"text": "ECG showed\nST Elevation Myocardial Infarction in inferior leads",
"page_numbers": [
1
]
},
{
"text": "ECG was\nconsistent with ST elevation myocardial infarction in inferior\nleads",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "mid-RCA was 100% occluded without\nanterograde\nflow into the distal vessel",
"page_numbers": [
1
]
},
{
"text": "cTropnT-3.44*",
"page_numbers": [
1
]
},
{
"text": "CK-MB-11*",
"page_numbers": [
1
]
},
{
"text": "CK(CPK)-891*",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Inferior wall STEMI",
"page_numbers": [
1
]
},
{
"text": "inferior\nSTEMI",
"page_numbers": [
2
]
},
{
"text": "Inferolateral ST elevation myocardial infarction",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "given aspirin 325 mg, plavix 600 mg, eptifibatide 180 mcg/kg x 1\nand heparin 4000 units IV bolus",
"page_numbers": [
1
]
},
{
"text": "transfer to Cath lab",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty x 3 (10 mm/12 mm/14 mm) with\nresidual thrombus which was exported and Promus DES was placed\nin mid RCA",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty\nx 3 (10 mm/12 mm/14 mm) with residual thrombus, which was\nremoved, and Promus DES was placed in the mid RCA",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "ST Elevation Myocardial Infarction in inferior leads",
"page_numbers": [
1
]
},
{
"evidence_text": "Inferior wall STEMI",
"page_numbers": [
1
]
},
{
"evidence_text": "inferior\nSTEMI",
"page_numbers": [
2
]
},
{
"evidence_text": "ST elevation myocardial infarction in inferior\nleads",
"page_numbers": [
2
]
},
{
"evidence_text": "Inferolateral ST elevation myocardial infarction",
"page_numbers": [
3
]
},
{
"evidence_text": "heart attack",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I21.19 is assigned for ST elevation myocardial infarction involving other inferior wall. The diagnosis is clearly documented multiple times, including in the final and discharge diagnoses. MEAT criteria are met through monitoring (ECG findings), evaluation (cardiac cath findings, elevated cardiac enzymes), assessment (documented diagnosis), and treatment (medications, PCI)."
}
],
"I442": [
{
"icd_10_cm_code": "I44.2",
"icd_10_cm_code_description": "Atrioventricular block, third degree",
"Monitoring": [
{
"text": "intermittent\ncomplete heart block",
"page_numbers": [
1
]
},
{
"text": "intermittent complete heart block",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "degeneration of the\nconduction\ndisease to high-grade heart block",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "high-grade AV block",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "requiring temporary pacemaker",
"page_numbers": [
1
]
},
{
"text": "requiring temporary pacemaker",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "intermittent\ncomplete heart block",
"page_numbers": [
1
]
},
{
"evidence_text": "degeneration of the\nconduction\ndisease to high-grade heart block",
"page_numbers": [
1
]
},
{
"evidence_text": "high-grade AV block",
"page_numbers": [
1
]
},
{
"evidence_text": "intermittent complete heart block",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I44.2 is assigned for Atrioventricular block, third degree, based on documentation of 'intermittent complete heart block' and 'high-grade AV block' requiring temporary pacing. MEAT criteria are met through monitoring (documented status), evaluation (documented degeneration), assessment (documented as high-grade AV block), and treatment (temporary pacemaker)."
}
],
"E1140": [
{
"icd_10_cm_code": "E11.40",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with diabetic neuropathy, unspecified",
"Monitoring": [
{
"text": "neuropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic neuropathy"
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "neuropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic neuropathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "peripheral neuropathy",
"page_numbers": [
1
]
},
{
"evidence_text": "neuropathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.40 is assigned for Type 2 diabetes mellitus with diabetic neuropathy. The entity 'peripheral neuropathy' is documented in PMH and 'neuropathy' is mentioned as a complication of poorly controlled diabetes in the Brief Hospital Course. MEAT criteria are met for the neuropathy component via monitoring and assessment. This is a combination code requiring an additional code for the manifestation (G63.0*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"I2510": [
{
"icd_10_cm_code": "I25.10",
"icd_10_cm_code_description": "Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Monitoring": [],
"Evaluation": [
{
"text": "Selective coronary angiography of this co-dominant system\ndemonstrated three-vessel coronary artery disease",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "treated with angioplasty x 3 (10 mm/12 mm/14 mm) with\nresidual thrombus which was exported and Promus DES was placed\nin mid RCA",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty\nx 3 (10 mm/12 mm/14 mm) with residual thrombus, which was\nremoved, and Promus DES was placed in the mid RCA",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "three-vessel coronary artery disease",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I25.10 is assigned for Atherosclerotic heart disease of native coronary artery without angina pectoris. The entity 'three-vessel coronary artery disease' is documented in the cardiac cath report. MEAT criteria are met through evaluation (angiography findings), assessment (systolic dysfunction c/w CAD), and treatment (PCI of RCA)."
}
],
"I2721": [
{
"icd_10_cm_code": "I27.21",
"icd_10_cm_code_description": "Secondary pulmonary arterial hypertension",
"Monitoring": [
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I27.21 is assigned for Secondary pulmonary arterial hypertension, based on the TTE finding of 'moderate pulmonary artery systolic hypertension'. MEAT criteria are met through monitoring (documented finding), evaluation (TTE report), and assessment (documented in TTE impression and Brief Hospital Course)."
}
],
"E1121": [
{
"icd_10_cm_code": "E11.21",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with diabetic nephropathy",
"Monitoring": [
{
"text": "diabetic\nnephropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Evaluation": [
{
"text": "Creat-1.2*",
"page_numbers": [
1
],
"applies_to": [
"Diabetic nephropathy"
]
},
{
"text": "UreaN-22*",
"page_numbers": [
1
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Assessment": [
{
"text": "diabetic\nnephropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "diabetic\nnephropathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.21 is assigned for Type 2 diabetes mellitus with diabetic nephropathy. The entity 'diabetic nephropathy' is documented as a complication of poorly controlled diabetes. MEAT criteria are met for the nephropathy component via monitoring, evaluation (labs), and assessment. This is a combination code requiring an additional code for the manifestation (N08*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"E1139": [
{
"icd_10_cm_code": "E11.39",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with other diabetic ophthalmic complication",
"Monitoring": [
{
"text": "retinopathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic retinopathy"
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "retinopathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic retinopathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "retinopathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.39 is assigned for Type 2 diabetes mellitus with other diabetic ophthalmic complication. The entity 'retinopathy' is documented as a complication of poorly controlled diabetes. MEAT criteria are met for the retinopathy component via monitoring and assessment. This is a combination code requiring an additional code for the manifestation (H36*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"I5021": [
{
"icd_10_cm_code": "I50.21",
"icd_10_cm_code_description": "Acute systolic (congestive) heart failure",
"Monitoring": [
{
"text": "one episode of shortness of\nbreath and increased respiratory rate with bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "Mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "She was treated with Lasix which improved her sxs",
"page_numbers": [
2
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I50.21 is assigned for Acute systolic (congestive) heart failure. The diagnosis is documented in the Discharge Diagnosis. MEAT criteria are met through monitoring (symptoms like shortness of breath, crackles, TTE findings), evaluation (physical exam, TTE report), assessment (documented diagnosis), and treatment (Lasix/Furosemide)."
}
],
"I110": [
{
"icd_10_cm_code": "I50.21",
"icd_10_cm_code_description": "Acute systolic (congestive) heart failure",
"Monitoring": [
{
"text": "one episode of shortness of\nbreath and increased respiratory rate with bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "Mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "She was treated with Lasix which improved her sxs",
"page_numbers": [
2
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I50.21 is assigned for Acute systolic (congestive) heart failure. The diagnosis is documented in the Discharge Diagnosis. MEAT criteria are met through monitoring (symptoms like shortness of breath, crackles, TTE findings), evaluation (physical exam, TTE report), assessment (documented diagnosis), and treatment (Lasix/Furosemide)."
},
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [
{
"text": "uncontrolled hypertension",
"page_numbers": [
2
]
},
{
"text": "Patient blood pressure was well controlled on\nlow dose metoprolol",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "initial vitals were 45 96/45",
"page_numbers": [
1
]
},
{
"text": "low bps",
"page_numbers": [
2
]
}
],
"Assessment": [
{
"text": "Hypertension",
"page_numbers": [
2
]
},
{
"text": "hypertension",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "Amlodipine 10 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Chlorthalidone 25 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Lisinopril 40 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Metoprolol Succinate XL 50 mg PO DAILY",
"page_numbers": [
3
]
},
{
"text": "Lisinopril 20 mg PO DAILY",
"page_numbers": [
3
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "uncontrolled hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "hypertension",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. The diagnosis is documented multiple times. MEAT criteria are met through monitoring (uncontrolled/controlled status), evaluation (vital signs, low bps), assessment (documented as Hypertension), and treatment (multiple antihypertensive medications)."
},
{
"icd_10_cm_code": "I51.9",
"icd_10_cm_code_description": "Heart disease, unspecified",
"Monitoring": [
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"evidence_text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"evidence_text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
2
]
},
{
"evidence_text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I51.9 is assigned for Heart disease, unspecified, based on the TTE finding of 'mild regional left ventricular systolic dysfunction'. MEAT criteria are met through monitoring (documented finding), evaluation (TTE report including EF), and assessment (documented in TTE impression and Brief Hospital Course)."
}
]
}
} |
Extract only the treatment or intervention given for each condition, including surgeries, procedures, and medications. | Admission Date: [**2144-8-1**] Discharge Date: [**2144-8-6**]
Date of Birth: [**2075-9-18**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 2888**]
Chief Complaint:
CP
Major Surgical or Invasive Procedure:
PCI with angioplasty and DES to Mid-RCA
History of Present Illness:
68-year-old woman haitian Crecole speaking only with history of
type 2 DM, hypertension and hyperlidpedemia who presented to
[**Hospital1 18**] ED with 3 days of chest pain. Patient reports that about
three days ago while she was putting her clothes in the laundry
she had suddedn onset of substernal chest pain with radiation to
her neck, right arm and her abdomen. She attributed this pain
to indigestion. The pain was [**4-16**] and remained constant. Today
at 6:30am patient patient acutely worsened [**9-16**] associated with
nasuea, diaphoresis and shonrtess of breaht.
.
In the ED, initial vitals were 45 96/45 16 100% RA. ECG showed
ST Elevation Myocardial Infarction in inferior leads. She was
given aspirin 325 mg, plavix 600 mg, eptifibatide 180 mcg/kg x 1
and heparin 4000 units IV bolus. She was noted to be bradycardic
and hypotensive and thus given atropine 1mgx2 and started on
dopamine gtt which improved her blood pressure. She was
transfer to Cath lab.
.
In the Cath lab, she was noted to acute mid RCA occlusion which
was treated with angioplasty x 3 (10 mm/12 mm/14 mm) with
residual thrombus which was exported and Promus DES was placed
in mid RCA. His cath lab course was complicated by intermittent
complete heart block requiring temporary pacemaker pre-stenting
though she was conducting 1:1 in NSR after stenting. She was
also noted to have AIVR. Dopamine at 5 mcg/kg/min was turned
off at the end of her cath lab course. A small 1.5cm hematoma
was visible at the RFV access site after the case, and manual
pressure was applied for 10 minutes.
.
In the CCU, she did not report chest pain, discomfort,
palpatations or shortness of breath. She desnies any history of
chest pain.
Past Medical History:
DM2
HTN
TB
peripheral neuropathy
aseptic thrombophlebitis of the left internal jugular in [**2130**].
Social History:
Lives with husband, ha two children who live in [**Country 2045**]. Creole
speaking from [**Country 2045**] 14 years ago. Three children. No history
of tobacco, ETOH or illicit.
Family History:
non-contributory
Physical Exam:
Admission Physical:
GENERAL: Appears well NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL. MMM
NECK: Supple with no JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Wamr and well perfused No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs:
[**2144-8-1**] 11:35AM BLOOD WBC-10.8# RBC-3.35* Hgb-10.3* Hct-30.8*
MCV-92 MCH-30.7 MCHC-33.4 RDW-12.8 Plt Ct-178
[**2144-8-1**] 11:35AM BLOOD PT-12.5 PTT-30.7 INR(PT)-1.2*
[**2144-8-1**] 11:35AM BLOOD Glucose-394* UreaN-22* Creat-1.2* Na-135
K-4.0 Cl-99 HCO3-25 AnGap-15
[**2144-8-1**] 11:35AM BLOOD CK-MB-11* MB Indx-1.2
[**2144-8-1**] 05:15PM BLOOD CK-MB-16* MB Indx-1.9
[**2144-8-2**] 05:28AM BLOOD CK-MB-10 MB Indx-1.8 cTropnT-3.44*
[**2144-8-1**] 11:35AM BLOOD CK(CPK)-891*
[**2144-8-1**] 05:15PM BLOOD CK(CPK)-821*
[**2144-8-2**] 05:28AM BLOOD CK(CPK)-555*
Cardiac Cath
1) Selective coronary angiography of this co-dominant system
demonstrated three-vessel coronary artery disease. The LMCA had
mild
luminal irregularities. The proximal-mid LAD had an 80%
trifurcation
lesion that was tightest at the large diagonal branch takeoff;
there was
a high diagonal branch (functionally a ramus) that had diffuse
proximal
70% stenosis. The LCx was a diffusely-diseased vessel with a
likely
stump-occluded OM2 and severely diseased distal vessel; it
provided a
smaller left PDA. The mid-RCA was 100% occluded without
anterograde
flow into the distal vessel; there was also haziness noted at
the AM
origin. The ostial RCA had a 30-40% stenosis.
2)
3) During the procedure, and given the degeneration of the
conduction
disease to high-grade heart block associated with hypotension, a
temporary pacing wire was inserted through the 5 French venous
sheath
with successful capture at 80 bpm and [**7-17**] mA. After the PCI,
pacing
was discontinued, and the patient remained in sinus rhythm with
1:1
conduction at a rate of 80 bpm with normotensive blood
pressures. The
temporary pacing wire was therefore removed and the dopamine was
discontinued.
4) After the procedure, the 6 French right femoral arteriotomy
site was
AngioSealed with adequate hemostasis. The 5 French right femoral
venous
sheath was left in place in case of worsening conduction disease
overnight. A small 1.5cm hematoma was noted after the
procedure.
FINAL DIAGNOSIS:
1. Inferior wall STEMI with high-grade AV block.
2. Successful emergent primary PCI of occluded mid RCA with
PTCA, export
thrombectomy, and Promus drug eluting stent.
3. Emergent temporary pacing wire placement with active pacing
during
the procedure.
.
TTE: [**2144-8-3**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with severe
hypokinesis of the inferolateral wall. The remaining segments
contract normally (LVEF = 40 %). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. There is no aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild to moderate ([**12-9**]+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD (PDA distribution).
Mild-moderate mitral regurgitation most likely due to papillary
muscle dysfunction. Pulmonary artery hypertension.
.
CLINICAL IMPLICATIONS:
Based on [**2138**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
Discharge Labs:
Brief Hospital Course:
68-year-old woman, Haitian-Creole speaking, with history of type
2 DM, hypertension, and hyperlidpedemia, presented with inferior
STEMI now s/p DES to mid RCA.
.
# STEMI: Patient with multiple cardiovascular risk factors
(uncontrolled diabetes, uncontrolled hypertension and
hyperlidemia) presented with worsening chest pain. ECG was
consistent with ST elevation myocardial infarction in inferior
leads. She was given aspirin 325 mg, plavix 600 mg, eptifibatide
180 mcg/kg x 1 and heparin 4000 units IV bolus. She was noted to
be bradycardic and hypotensive and thus given atropine 1mgx2 and
started on dopamine gtt which improved her blood pressure. She
was transfer to the Cath lab. In the Cath lab, she was noted to
have acute mid RCA occlusion which was treated with angioplasty
x 3 (10 mm/12 mm/14 mm) with residual thrombus, which was
removed, and Promus DES was placed in the mid RCA. Her Cath lab
course was complicated by intermittent complete heart block
requiring temporary pacemaker pre-stenting though she was
conducting 1:1 in NSR after stenting. She was also noted to
have AIVR. Dopamine at 5 mcg/kg/min was turned off at the end
of her Cath lab course. She had an ECHO report that showed mild
regional left ventricular systolic dysfunction with severe
hypokinesis of the inferolateral wall with EF 40%. Mild
symmetric left ventricular hypertrophy with regional systolic
dysfunction c/w CAD (PDA distribution). Mild-moderate mitral
regurgitation most likely due to papillary muscle dysfunction.
Pulmonary artery hypertension.
During her CCU course, patient had one episode of shortness of
breath and increased respiratory rate with bilateral crackles on
exam. She was treated with Lasix which improved her sxs and she
had no further episodes of chest pain or shortness of breath
during her hospital stay. Patient was evaluated by physical
therapy on the day of discharge and determined safe to go home.
Patient will follow up with Dr. [**Last Name (STitle) 10156**] in Cardiology and
with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. She was discharged on the
following medications: Lasix, metoprolol, lisinopril,
atorvastatin, and Plavix.
.
# Arrythmia: Patient had bradycardia with dropped beats and
atrial ectopy likely in the setting of reperfusion post [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 10157**]. She did not have any symptomatic episodes of
bradycardia during her CCU course. She was also started on low
dose metoprolol which she tolerated very well.
.
# Diabetes Type 2: Poorly controlled and complicated by diabetic
nephropathy, retinopathy, and neuropathy. Last A1c was 8.7 in
3/[**2143**]. She was continued on 11units of NPH and insulin sliding
scale. On discharge, she was put on ----.
.
# Anemia: Hematocrit during this admission was around 30.
Prior HCT on OMR from [**2141**] shows HCT of 37.9. Unclear etiology.
No source of obvious bleeding and normal coags. Patient will
follow up with PCP for further management.
.
# Hypertension: Patient blood pressure was well controlled on
low dose metoprolol. Her home chorthalidone, amlodopine, and
lisinopril were initally held due to low bps. She was
discharged on metoprolol, lisinopril and lasix.
.
# Hyperlidemia: Started atorvastain 80mg daily.
.
Transitional Issues:
- needs close follow-up with Cardiology, PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] recommend [**Last Name (un) **] consultation for DM
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Aspirin 81 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Ranitidine 150 mg PO BID
7. NPH 32 Units Breakfast
NPH 22 Units Dinner
Discharge Medications:
1. Aspirin EC 325 mg PO DAILY
RX *aspirin [Enteric Coated Aspirin] 325 mg one tablet(s) by
mouth daily Disp #*30 Tablet Refills:*2
2. Ranitidine 150 mg PO BID
3. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
4. Clopidogrel 75 mg PO DAILY
for the recommended duration
RX *clopidogrel 75 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
5. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg one tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. NPH 32 Units Breakfast
NPH 22 Units Dinner
8. Lisinopril 20 mg PO DAILY
RX *lisinopril 40 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*2
9. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg one tablets by mouth daily Disp #*30 Tablet
Refills:*2
10. Outpatient Lab Work
Please check Chem-7 at [**Hospital6 733**] on [**2144-8-11**] with
results to Dr. [**Last Name (STitle) 6215**] at Phone: [**Telephone/Fax (1) 2010**]
Fax: [**Telephone/Fax (1) 4004**]
ICD-9 428
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Inferolateral ST elevation myocardial infarction
acute systolic congestive heart failure
hypertension
diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 10158**],
It was a pleasure taking care of your during your admission at
[**Hospital1 18**]. You were admitted because you were having chest pain and
you were found to have a heart attack for which you had a stent
placed in your heart. You have also been started on new
medications (aspirin and clopidogrel) to prevent the stenting of
the clot which you should continue to take unless told otherwise
by your cardiologist.
Weigh yourself every day before breakfast. Call Dr. [**Last Name (STitle) **] if
weight increases more than 3 pounds in 1 day or 5 pounds in 3
days.
The visiting nurse will help you with a low salt diet.
.
Please continue to take your medications as directed in your
discharge medication sheet. Please do not stop any medication
especially clopidogrel unless told by your cardiologist. You
risk having a heart attack if you do not take this medicine
every day.
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2144-9-3**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital **] HEALTH CENTER
When: TUESDAY [**2144-8-11**] at 11:50 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
| {
"clinical_findings": {
"E785": [
{
"icd_10_cm_code": "E78.5",
"icd_10_cm_code_description": "Hyperlipidemia, unspecified",
"Monitoring": [
{
"text": "hyperlidpedemia",
"page_numbers": [
1
]
},
{
"text": "hyperlidpedemia",
"page_numbers": [
2
]
},
{
"text": "hyperlidemia",
"page_numbers": [
2
]
},
{
"text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "Started atorvastain 80mg daily",
"page_numbers": [
2
]
},
{
"text": "Atorvastatin 80 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "hyperlidpedemia",
"page_numbers": [
1
]
},
{
"evidence_text": "hyperlidpedemia",
"page_numbers": [
2
]
},
{
"evidence_text": "hyperlidemia",
"page_numbers": [
2
]
},
{
"evidence_text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E78.5 is assigned for Hyperlipidemia, unspecified. The diagnosis is documented multiple times. MEAT criteria are met through monitoring (documented diagnosis), assessment (documented as Hyperlidemia), and treatment (Atorvastatin started)."
}
],
"I2119": [
{
"icd_10_cm_code": "I21.19",
"icd_10_cm_code_description": "ST elevation myocardial infarction involving other inferior wall",
"Monitoring": [
{
"text": "ECG showed\nST Elevation Myocardial Infarction in inferior leads",
"page_numbers": [
1
]
},
{
"text": "ECG was\nconsistent with ST elevation myocardial infarction in inferior\nleads",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "mid-RCA was 100% occluded without\nanterograde\nflow into the distal vessel",
"page_numbers": [
1
]
},
{
"text": "cTropnT-3.44*",
"page_numbers": [
1
]
},
{
"text": "CK-MB-11*",
"page_numbers": [
1
]
},
{
"text": "CK(CPK)-891*",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Inferior wall STEMI",
"page_numbers": [
1
]
},
{
"text": "inferior\nSTEMI",
"page_numbers": [
2
]
},
{
"text": "Inferolateral ST elevation myocardial infarction",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "given aspirin 325 mg, plavix 600 mg, eptifibatide 180 mcg/kg x 1\nand heparin 4000 units IV bolus",
"page_numbers": [
1
]
},
{
"text": "transfer to Cath lab",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty x 3 (10 mm/12 mm/14 mm) with\nresidual thrombus which was exported and Promus DES was placed\nin mid RCA",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty\nx 3 (10 mm/12 mm/14 mm) with residual thrombus, which was\nremoved, and Promus DES was placed in the mid RCA",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "ST Elevation Myocardial Infarction in inferior leads",
"page_numbers": [
1
]
},
{
"evidence_text": "Inferior wall STEMI",
"page_numbers": [
1
]
},
{
"evidence_text": "inferior\nSTEMI",
"page_numbers": [
2
]
},
{
"evidence_text": "ST elevation myocardial infarction in inferior\nleads",
"page_numbers": [
2
]
},
{
"evidence_text": "Inferolateral ST elevation myocardial infarction",
"page_numbers": [
3
]
},
{
"evidence_text": "heart attack",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I21.19 is assigned for ST elevation myocardial infarction involving other inferior wall. The diagnosis is clearly documented multiple times, including in the final and discharge diagnoses. MEAT criteria are met through monitoring (ECG findings), evaluation (cardiac cath findings, elevated cardiac enzymes), assessment (documented diagnosis), and treatment (medications, PCI)."
}
],
"I442": [
{
"icd_10_cm_code": "I44.2",
"icd_10_cm_code_description": "Atrioventricular block, third degree",
"Monitoring": [
{
"text": "intermittent\ncomplete heart block",
"page_numbers": [
1
]
},
{
"text": "intermittent complete heart block",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "degeneration of the\nconduction\ndisease to high-grade heart block",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "high-grade AV block",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "requiring temporary pacemaker",
"page_numbers": [
1
]
},
{
"text": "requiring temporary pacemaker",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "intermittent\ncomplete heart block",
"page_numbers": [
1
]
},
{
"evidence_text": "degeneration of the\nconduction\ndisease to high-grade heart block",
"page_numbers": [
1
]
},
{
"evidence_text": "high-grade AV block",
"page_numbers": [
1
]
},
{
"evidence_text": "intermittent complete heart block",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I44.2 is assigned for Atrioventricular block, third degree, based on documentation of 'intermittent complete heart block' and 'high-grade AV block' requiring temporary pacing. MEAT criteria are met through monitoring (documented status), evaluation (documented degeneration), assessment (documented as high-grade AV block), and treatment (temporary pacemaker)."
}
],
"E1140": [
{
"icd_10_cm_code": "E11.40",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with diabetic neuropathy, unspecified",
"Monitoring": [
{
"text": "neuropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic neuropathy"
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "neuropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic neuropathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "peripheral neuropathy",
"page_numbers": [
1
]
},
{
"evidence_text": "neuropathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.40 is assigned for Type 2 diabetes mellitus with diabetic neuropathy. The entity 'peripheral neuropathy' is documented in PMH and 'neuropathy' is mentioned as a complication of poorly controlled diabetes in the Brief Hospital Course. MEAT criteria are met for the neuropathy component via monitoring and assessment. This is a combination code requiring an additional code for the manifestation (G63.0*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"I2510": [
{
"icd_10_cm_code": "I25.10",
"icd_10_cm_code_description": "Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Monitoring": [],
"Evaluation": [
{
"text": "Selective coronary angiography of this co-dominant system\ndemonstrated three-vessel coronary artery disease",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "treated with angioplasty x 3 (10 mm/12 mm/14 mm) with\nresidual thrombus which was exported and Promus DES was placed\nin mid RCA",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty\nx 3 (10 mm/12 mm/14 mm) with residual thrombus, which was\nremoved, and Promus DES was placed in the mid RCA",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "three-vessel coronary artery disease",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I25.10 is assigned for Atherosclerotic heart disease of native coronary artery without angina pectoris. The entity 'three-vessel coronary artery disease' is documented in the cardiac cath report. MEAT criteria are met through evaluation (angiography findings), assessment (systolic dysfunction c/w CAD), and treatment (PCI of RCA)."
}
],
"I2721": [
{
"icd_10_cm_code": "I27.21",
"icd_10_cm_code_description": "Secondary pulmonary arterial hypertension",
"Monitoring": [
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I27.21 is assigned for Secondary pulmonary arterial hypertension, based on the TTE finding of 'moderate pulmonary artery systolic hypertension'. MEAT criteria are met through monitoring (documented finding), evaluation (TTE report), and assessment (documented in TTE impression and Brief Hospital Course)."
}
],
"E1121": [
{
"icd_10_cm_code": "E11.21",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with diabetic nephropathy",
"Monitoring": [
{
"text": "diabetic\nnephropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Evaluation": [
{
"text": "Creat-1.2*",
"page_numbers": [
1
],
"applies_to": [
"Diabetic nephropathy"
]
},
{
"text": "UreaN-22*",
"page_numbers": [
1
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Assessment": [
{
"text": "diabetic\nnephropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "diabetic\nnephropathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.21 is assigned for Type 2 diabetes mellitus with diabetic nephropathy. The entity 'diabetic nephropathy' is documented as a complication of poorly controlled diabetes. MEAT criteria are met for the nephropathy component via monitoring, evaluation (labs), and assessment. This is a combination code requiring an additional code for the manifestation (N08*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"E1139": [
{
"icd_10_cm_code": "E11.39",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with other diabetic ophthalmic complication",
"Monitoring": [
{
"text": "retinopathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic retinopathy"
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "retinopathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic retinopathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "retinopathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.39 is assigned for Type 2 diabetes mellitus with other diabetic ophthalmic complication. The entity 'retinopathy' is documented as a complication of poorly controlled diabetes. MEAT criteria are met for the retinopathy component via monitoring and assessment. This is a combination code requiring an additional code for the manifestation (H36*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"I5021": [
{
"icd_10_cm_code": "I50.21",
"icd_10_cm_code_description": "Acute systolic (congestive) heart failure",
"Monitoring": [
{
"text": "one episode of shortness of\nbreath and increased respiratory rate with bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "Mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "She was treated with Lasix which improved her sxs",
"page_numbers": [
2
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I50.21 is assigned for Acute systolic (congestive) heart failure. The diagnosis is documented in the Discharge Diagnosis. MEAT criteria are met through monitoring (symptoms like shortness of breath, crackles, TTE findings), evaluation (physical exam, TTE report), assessment (documented diagnosis), and treatment (Lasix/Furosemide)."
}
],
"I110": [
{
"icd_10_cm_code": "I50.21",
"icd_10_cm_code_description": "Acute systolic (congestive) heart failure",
"Monitoring": [
{
"text": "one episode of shortness of\nbreath and increased respiratory rate with bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "Mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "She was treated with Lasix which improved her sxs",
"page_numbers": [
2
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I50.21 is assigned for Acute systolic (congestive) heart failure. The diagnosis is documented in the Discharge Diagnosis. MEAT criteria are met through monitoring (symptoms like shortness of breath, crackles, TTE findings), evaluation (physical exam, TTE report), assessment (documented diagnosis), and treatment (Lasix/Furosemide)."
},
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [
{
"text": "uncontrolled hypertension",
"page_numbers": [
2
]
},
{
"text": "Patient blood pressure was well controlled on\nlow dose metoprolol",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "initial vitals were 45 96/45",
"page_numbers": [
1
]
},
{
"text": "low bps",
"page_numbers": [
2
]
}
],
"Assessment": [
{
"text": "Hypertension",
"page_numbers": [
2
]
},
{
"text": "hypertension",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "Amlodipine 10 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Chlorthalidone 25 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Lisinopril 40 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Metoprolol Succinate XL 50 mg PO DAILY",
"page_numbers": [
3
]
},
{
"text": "Lisinopril 20 mg PO DAILY",
"page_numbers": [
3
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "uncontrolled hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "hypertension",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. The diagnosis is documented multiple times. MEAT criteria are met through monitoring (uncontrolled/controlled status), evaluation (vital signs, low bps), assessment (documented as Hypertension), and treatment (multiple antihypertensive medications)."
},
{
"icd_10_cm_code": "I51.9",
"icd_10_cm_code_description": "Heart disease, unspecified",
"Monitoring": [
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"evidence_text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"evidence_text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
2
]
},
{
"evidence_text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I51.9 is assigned for Heart disease, unspecified, based on the TTE finding of 'mild regional left ventricular systolic dysfunction'. MEAT criteria are met through monitoring (documented finding), evaluation (TTE report including EF), and assessment (documented in TTE impression and Brief Hospital Course)."
}
]
}
} |
Extract only the evidence from the discharge summary that supports the existence of each condition. | Admission Date: [**2144-8-1**] Discharge Date: [**2144-8-6**]
Date of Birth: [**2075-9-18**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 2888**]
Chief Complaint:
CP
Major Surgical or Invasive Procedure:
PCI with angioplasty and DES to Mid-RCA
History of Present Illness:
68-year-old woman haitian Crecole speaking only with history of
type 2 DM, hypertension and hyperlidpedemia who presented to
[**Hospital1 18**] ED with 3 days of chest pain. Patient reports that about
three days ago while she was putting her clothes in the laundry
she had suddedn onset of substernal chest pain with radiation to
her neck, right arm and her abdomen. She attributed this pain
to indigestion. The pain was [**4-16**] and remained constant. Today
at 6:30am patient patient acutely worsened [**9-16**] associated with
nasuea, diaphoresis and shonrtess of breaht.
.
In the ED, initial vitals were 45 96/45 16 100% RA. ECG showed
ST Elevation Myocardial Infarction in inferior leads. She was
given aspirin 325 mg, plavix 600 mg, eptifibatide 180 mcg/kg x 1
and heparin 4000 units IV bolus. She was noted to be bradycardic
and hypotensive and thus given atropine 1mgx2 and started on
dopamine gtt which improved her blood pressure. She was
transfer to Cath lab.
.
In the Cath lab, she was noted to acute mid RCA occlusion which
was treated with angioplasty x 3 (10 mm/12 mm/14 mm) with
residual thrombus which was exported and Promus DES was placed
in mid RCA. His cath lab course was complicated by intermittent
complete heart block requiring temporary pacemaker pre-stenting
though she was conducting 1:1 in NSR after stenting. She was
also noted to have AIVR. Dopamine at 5 mcg/kg/min was turned
off at the end of her cath lab course. A small 1.5cm hematoma
was visible at the RFV access site after the case, and manual
pressure was applied for 10 minutes.
.
In the CCU, she did not report chest pain, discomfort,
palpatations or shortness of breath. She desnies any history of
chest pain.
Past Medical History:
DM2
HTN
TB
peripheral neuropathy
aseptic thrombophlebitis of the left internal jugular in [**2130**].
Social History:
Lives with husband, ha two children who live in [**Country 2045**]. Creole
speaking from [**Country 2045**] 14 years ago. Three children. No history
of tobacco, ETOH or illicit.
Family History:
non-contributory
Physical Exam:
Admission Physical:
GENERAL: Appears well NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL. MMM
NECK: Supple with no JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Wamr and well perfused No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs:
[**2144-8-1**] 11:35AM BLOOD WBC-10.8# RBC-3.35* Hgb-10.3* Hct-30.8*
MCV-92 MCH-30.7 MCHC-33.4 RDW-12.8 Plt Ct-178
[**2144-8-1**] 11:35AM BLOOD PT-12.5 PTT-30.7 INR(PT)-1.2*
[**2144-8-1**] 11:35AM BLOOD Glucose-394* UreaN-22* Creat-1.2* Na-135
K-4.0 Cl-99 HCO3-25 AnGap-15
[**2144-8-1**] 11:35AM BLOOD CK-MB-11* MB Indx-1.2
[**2144-8-1**] 05:15PM BLOOD CK-MB-16* MB Indx-1.9
[**2144-8-2**] 05:28AM BLOOD CK-MB-10 MB Indx-1.8 cTropnT-3.44*
[**2144-8-1**] 11:35AM BLOOD CK(CPK)-891*
[**2144-8-1**] 05:15PM BLOOD CK(CPK)-821*
[**2144-8-2**] 05:28AM BLOOD CK(CPK)-555*
Cardiac Cath
1) Selective coronary angiography of this co-dominant system
demonstrated three-vessel coronary artery disease. The LMCA had
mild
luminal irregularities. The proximal-mid LAD had an 80%
trifurcation
lesion that was tightest at the large diagonal branch takeoff;
there was
a high diagonal branch (functionally a ramus) that had diffuse
proximal
70% stenosis. The LCx was a diffusely-diseased vessel with a
likely
stump-occluded OM2 and severely diseased distal vessel; it
provided a
smaller left PDA. The mid-RCA was 100% occluded without
anterograde
flow into the distal vessel; there was also haziness noted at
the AM
origin. The ostial RCA had a 30-40% stenosis.
2)
3) During the procedure, and given the degeneration of the
conduction
disease to high-grade heart block associated with hypotension, a
temporary pacing wire was inserted through the 5 French venous
sheath
with successful capture at 80 bpm and [**7-17**] mA. After the PCI,
pacing
was discontinued, and the patient remained in sinus rhythm with
1:1
conduction at a rate of 80 bpm with normotensive blood
pressures. The
temporary pacing wire was therefore removed and the dopamine was
discontinued.
4) After the procedure, the 6 French right femoral arteriotomy
site was
AngioSealed with adequate hemostasis. The 5 French right femoral
venous
sheath was left in place in case of worsening conduction disease
overnight. A small 1.5cm hematoma was noted after the
procedure.
FINAL DIAGNOSIS:
1. Inferior wall STEMI with high-grade AV block.
2. Successful emergent primary PCI of occluded mid RCA with
PTCA, export
thrombectomy, and Promus drug eluting stent.
3. Emergent temporary pacing wire placement with active pacing
during
the procedure.
.
TTE: [**2144-8-3**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with severe
hypokinesis of the inferolateral wall. The remaining segments
contract normally (LVEF = 40 %). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. There is no aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild to moderate ([**12-9**]+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD (PDA distribution).
Mild-moderate mitral regurgitation most likely due to papillary
muscle dysfunction. Pulmonary artery hypertension.
.
CLINICAL IMPLICATIONS:
Based on [**2138**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
Discharge Labs:
Brief Hospital Course:
68-year-old woman, Haitian-Creole speaking, with history of type
2 DM, hypertension, and hyperlidpedemia, presented with inferior
STEMI now s/p DES to mid RCA.
.
# STEMI: Patient with multiple cardiovascular risk factors
(uncontrolled diabetes, uncontrolled hypertension and
hyperlidemia) presented with worsening chest pain. ECG was
consistent with ST elevation myocardial infarction in inferior
leads. She was given aspirin 325 mg, plavix 600 mg, eptifibatide
180 mcg/kg x 1 and heparin 4000 units IV bolus. She was noted to
be bradycardic and hypotensive and thus given atropine 1mgx2 and
started on dopamine gtt which improved her blood pressure. She
was transfer to the Cath lab. In the Cath lab, she was noted to
have acute mid RCA occlusion which was treated with angioplasty
x 3 (10 mm/12 mm/14 mm) with residual thrombus, which was
removed, and Promus DES was placed in the mid RCA. Her Cath lab
course was complicated by intermittent complete heart block
requiring temporary pacemaker pre-stenting though she was
conducting 1:1 in NSR after stenting. She was also noted to
have AIVR. Dopamine at 5 mcg/kg/min was turned off at the end
of her Cath lab course. She had an ECHO report that showed mild
regional left ventricular systolic dysfunction with severe
hypokinesis of the inferolateral wall with EF 40%. Mild
symmetric left ventricular hypertrophy with regional systolic
dysfunction c/w CAD (PDA distribution). Mild-moderate mitral
regurgitation most likely due to papillary muscle dysfunction.
Pulmonary artery hypertension.
During her CCU course, patient had one episode of shortness of
breath and increased respiratory rate with bilateral crackles on
exam. She was treated with Lasix which improved her sxs and she
had no further episodes of chest pain or shortness of breath
during her hospital stay. Patient was evaluated by physical
therapy on the day of discharge and determined safe to go home.
Patient will follow up with Dr. [**Last Name (STitle) 10156**] in Cardiology and
with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. She was discharged on the
following medications: Lasix, metoprolol, lisinopril,
atorvastatin, and Plavix.
.
# Arrythmia: Patient had bradycardia with dropped beats and
atrial ectopy likely in the setting of reperfusion post [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 10157**]. She did not have any symptomatic episodes of
bradycardia during her CCU course. She was also started on low
dose metoprolol which she tolerated very well.
.
# Diabetes Type 2: Poorly controlled and complicated by diabetic
nephropathy, retinopathy, and neuropathy. Last A1c was 8.7 in
3/[**2143**]. She was continued on 11units of NPH and insulin sliding
scale. On discharge, she was put on ----.
.
# Anemia: Hematocrit during this admission was around 30.
Prior HCT on OMR from [**2141**] shows HCT of 37.9. Unclear etiology.
No source of obvious bleeding and normal coags. Patient will
follow up with PCP for further management.
.
# Hypertension: Patient blood pressure was well controlled on
low dose metoprolol. Her home chorthalidone, amlodopine, and
lisinopril were initally held due to low bps. She was
discharged on metoprolol, lisinopril and lasix.
.
# Hyperlidemia: Started atorvastain 80mg daily.
.
Transitional Issues:
- needs close follow-up with Cardiology, PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] recommend [**Last Name (un) **] consultation for DM
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Aspirin 81 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Ranitidine 150 mg PO BID
7. NPH 32 Units Breakfast
NPH 22 Units Dinner
Discharge Medications:
1. Aspirin EC 325 mg PO DAILY
RX *aspirin [Enteric Coated Aspirin] 325 mg one tablet(s) by
mouth daily Disp #*30 Tablet Refills:*2
2. Ranitidine 150 mg PO BID
3. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
4. Clopidogrel 75 mg PO DAILY
for the recommended duration
RX *clopidogrel 75 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
5. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg one tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. NPH 32 Units Breakfast
NPH 22 Units Dinner
8. Lisinopril 20 mg PO DAILY
RX *lisinopril 40 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*2
9. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg one tablets by mouth daily Disp #*30 Tablet
Refills:*2
10. Outpatient Lab Work
Please check Chem-7 at [**Hospital6 733**] on [**2144-8-11**] with
results to Dr. [**Last Name (STitle) 6215**] at Phone: [**Telephone/Fax (1) 2010**]
Fax: [**Telephone/Fax (1) 4004**]
ICD-9 428
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Inferolateral ST elevation myocardial infarction
acute systolic congestive heart failure
hypertension
diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 10158**],
It was a pleasure taking care of your during your admission at
[**Hospital1 18**]. You were admitted because you were having chest pain and
you were found to have a heart attack for which you had a stent
placed in your heart. You have also been started on new
medications (aspirin and clopidogrel) to prevent the stenting of
the clot which you should continue to take unless told otherwise
by your cardiologist.
Weigh yourself every day before breakfast. Call Dr. [**Last Name (STitle) **] if
weight increases more than 3 pounds in 1 day or 5 pounds in 3
days.
The visiting nurse will help you with a low salt diet.
.
Please continue to take your medications as directed in your
discharge medication sheet. Please do not stop any medication
especially clopidogrel unless told by your cardiologist. You
risk having a heart attack if you do not take this medicine
every day.
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2144-9-3**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital **] HEALTH CENTER
When: TUESDAY [**2144-8-11**] at 11:50 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
| {
"clinical_findings": {
"E785": [
{
"icd_10_cm_code": "E78.5",
"icd_10_cm_code_description": "Hyperlipidemia, unspecified",
"Monitoring": [
{
"text": "hyperlidpedemia",
"page_numbers": [
1
]
},
{
"text": "hyperlidpedemia",
"page_numbers": [
2
]
},
{
"text": "hyperlidemia",
"page_numbers": [
2
]
},
{
"text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "Started atorvastain 80mg daily",
"page_numbers": [
2
]
},
{
"text": "Atorvastatin 80 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "hyperlidpedemia",
"page_numbers": [
1
]
},
{
"evidence_text": "hyperlidpedemia",
"page_numbers": [
2
]
},
{
"evidence_text": "hyperlidemia",
"page_numbers": [
2
]
},
{
"evidence_text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E78.5 is assigned for Hyperlipidemia, unspecified. The diagnosis is documented multiple times. MEAT criteria are met through monitoring (documented diagnosis), assessment (documented as Hyperlidemia), and treatment (Atorvastatin started)."
}
],
"I2119": [
{
"icd_10_cm_code": "I21.19",
"icd_10_cm_code_description": "ST elevation myocardial infarction involving other inferior wall",
"Monitoring": [
{
"text": "ECG showed\nST Elevation Myocardial Infarction in inferior leads",
"page_numbers": [
1
]
},
{
"text": "ECG was\nconsistent with ST elevation myocardial infarction in inferior\nleads",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "mid-RCA was 100% occluded without\nanterograde\nflow into the distal vessel",
"page_numbers": [
1
]
},
{
"text": "cTropnT-3.44*",
"page_numbers": [
1
]
},
{
"text": "CK-MB-11*",
"page_numbers": [
1
]
},
{
"text": "CK(CPK)-891*",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Inferior wall STEMI",
"page_numbers": [
1
]
},
{
"text": "inferior\nSTEMI",
"page_numbers": [
2
]
},
{
"text": "Inferolateral ST elevation myocardial infarction",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "given aspirin 325 mg, plavix 600 mg, eptifibatide 180 mcg/kg x 1\nand heparin 4000 units IV bolus",
"page_numbers": [
1
]
},
{
"text": "transfer to Cath lab",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty x 3 (10 mm/12 mm/14 mm) with\nresidual thrombus which was exported and Promus DES was placed\nin mid RCA",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty\nx 3 (10 mm/12 mm/14 mm) with residual thrombus, which was\nremoved, and Promus DES was placed in the mid RCA",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "ST Elevation Myocardial Infarction in inferior leads",
"page_numbers": [
1
]
},
{
"evidence_text": "Inferior wall STEMI",
"page_numbers": [
1
]
},
{
"evidence_text": "inferior\nSTEMI",
"page_numbers": [
2
]
},
{
"evidence_text": "ST elevation myocardial infarction in inferior\nleads",
"page_numbers": [
2
]
},
{
"evidence_text": "Inferolateral ST elevation myocardial infarction",
"page_numbers": [
3
]
},
{
"evidence_text": "heart attack",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I21.19 is assigned for ST elevation myocardial infarction involving other inferior wall. The diagnosis is clearly documented multiple times, including in the final and discharge diagnoses. MEAT criteria are met through monitoring (ECG findings), evaluation (cardiac cath findings, elevated cardiac enzymes), assessment (documented diagnosis), and treatment (medications, PCI)."
}
],
"I442": [
{
"icd_10_cm_code": "I44.2",
"icd_10_cm_code_description": "Atrioventricular block, third degree",
"Monitoring": [
{
"text": "intermittent\ncomplete heart block",
"page_numbers": [
1
]
},
{
"text": "intermittent complete heart block",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "degeneration of the\nconduction\ndisease to high-grade heart block",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "high-grade AV block",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "requiring temporary pacemaker",
"page_numbers": [
1
]
},
{
"text": "requiring temporary pacemaker",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "intermittent\ncomplete heart block",
"page_numbers": [
1
]
},
{
"evidence_text": "degeneration of the\nconduction\ndisease to high-grade heart block",
"page_numbers": [
1
]
},
{
"evidence_text": "high-grade AV block",
"page_numbers": [
1
]
},
{
"evidence_text": "intermittent complete heart block",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I44.2 is assigned for Atrioventricular block, third degree, based on documentation of 'intermittent complete heart block' and 'high-grade AV block' requiring temporary pacing. MEAT criteria are met through monitoring (documented status), evaluation (documented degeneration), assessment (documented as high-grade AV block), and treatment (temporary pacemaker)."
}
],
"E1140": [
{
"icd_10_cm_code": "E11.40",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with diabetic neuropathy, unspecified",
"Monitoring": [
{
"text": "neuropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic neuropathy"
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "neuropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic neuropathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "peripheral neuropathy",
"page_numbers": [
1
]
},
{
"evidence_text": "neuropathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.40 is assigned for Type 2 diabetes mellitus with diabetic neuropathy. The entity 'peripheral neuropathy' is documented in PMH and 'neuropathy' is mentioned as a complication of poorly controlled diabetes in the Brief Hospital Course. MEAT criteria are met for the neuropathy component via monitoring and assessment. This is a combination code requiring an additional code for the manifestation (G63.0*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"I2510": [
{
"icd_10_cm_code": "I25.10",
"icd_10_cm_code_description": "Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Monitoring": [],
"Evaluation": [
{
"text": "Selective coronary angiography of this co-dominant system\ndemonstrated three-vessel coronary artery disease",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "treated with angioplasty x 3 (10 mm/12 mm/14 mm) with\nresidual thrombus which was exported and Promus DES was placed\nin mid RCA",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty\nx 3 (10 mm/12 mm/14 mm) with residual thrombus, which was\nremoved, and Promus DES was placed in the mid RCA",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "three-vessel coronary artery disease",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I25.10 is assigned for Atherosclerotic heart disease of native coronary artery without angina pectoris. The entity 'three-vessel coronary artery disease' is documented in the cardiac cath report. MEAT criteria are met through evaluation (angiography findings), assessment (systolic dysfunction c/w CAD), and treatment (PCI of RCA)."
}
],
"I2721": [
{
"icd_10_cm_code": "I27.21",
"icd_10_cm_code_description": "Secondary pulmonary arterial hypertension",
"Monitoring": [
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I27.21 is assigned for Secondary pulmonary arterial hypertension, based on the TTE finding of 'moderate pulmonary artery systolic hypertension'. MEAT criteria are met through monitoring (documented finding), evaluation (TTE report), and assessment (documented in TTE impression and Brief Hospital Course)."
}
],
"E1121": [
{
"icd_10_cm_code": "E11.21",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with diabetic nephropathy",
"Monitoring": [
{
"text": "diabetic\nnephropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Evaluation": [
{
"text": "Creat-1.2*",
"page_numbers": [
1
],
"applies_to": [
"Diabetic nephropathy"
]
},
{
"text": "UreaN-22*",
"page_numbers": [
1
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Assessment": [
{
"text": "diabetic\nnephropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "diabetic\nnephropathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.21 is assigned for Type 2 diabetes mellitus with diabetic nephropathy. The entity 'diabetic nephropathy' is documented as a complication of poorly controlled diabetes. MEAT criteria are met for the nephropathy component via monitoring, evaluation (labs), and assessment. This is a combination code requiring an additional code for the manifestation (N08*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"E1139": [
{
"icd_10_cm_code": "E11.39",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with other diabetic ophthalmic complication",
"Monitoring": [
{
"text": "retinopathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic retinopathy"
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "retinopathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic retinopathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "retinopathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.39 is assigned for Type 2 diabetes mellitus with other diabetic ophthalmic complication. The entity 'retinopathy' is documented as a complication of poorly controlled diabetes. MEAT criteria are met for the retinopathy component via monitoring and assessment. This is a combination code requiring an additional code for the manifestation (H36*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"I5021": [
{
"icd_10_cm_code": "I50.21",
"icd_10_cm_code_description": "Acute systolic (congestive) heart failure",
"Monitoring": [
{
"text": "one episode of shortness of\nbreath and increased respiratory rate with bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "Mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "She was treated with Lasix which improved her sxs",
"page_numbers": [
2
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I50.21 is assigned for Acute systolic (congestive) heart failure. The diagnosis is documented in the Discharge Diagnosis. MEAT criteria are met through monitoring (symptoms like shortness of breath, crackles, TTE findings), evaluation (physical exam, TTE report), assessment (documented diagnosis), and treatment (Lasix/Furosemide)."
}
],
"I110": [
{
"icd_10_cm_code": "I50.21",
"icd_10_cm_code_description": "Acute systolic (congestive) heart failure",
"Monitoring": [
{
"text": "one episode of shortness of\nbreath and increased respiratory rate with bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "Mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "She was treated with Lasix which improved her sxs",
"page_numbers": [
2
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I50.21 is assigned for Acute systolic (congestive) heart failure. The diagnosis is documented in the Discharge Diagnosis. MEAT criteria are met through monitoring (symptoms like shortness of breath, crackles, TTE findings), evaluation (physical exam, TTE report), assessment (documented diagnosis), and treatment (Lasix/Furosemide)."
},
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [
{
"text": "uncontrolled hypertension",
"page_numbers": [
2
]
},
{
"text": "Patient blood pressure was well controlled on\nlow dose metoprolol",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "initial vitals were 45 96/45",
"page_numbers": [
1
]
},
{
"text": "low bps",
"page_numbers": [
2
]
}
],
"Assessment": [
{
"text": "Hypertension",
"page_numbers": [
2
]
},
{
"text": "hypertension",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "Amlodipine 10 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Chlorthalidone 25 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Lisinopril 40 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Metoprolol Succinate XL 50 mg PO DAILY",
"page_numbers": [
3
]
},
{
"text": "Lisinopril 20 mg PO DAILY",
"page_numbers": [
3
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "uncontrolled hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "hypertension",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. The diagnosis is documented multiple times. MEAT criteria are met through monitoring (uncontrolled/controlled status), evaluation (vital signs, low bps), assessment (documented as Hypertension), and treatment (multiple antihypertensive medications)."
},
{
"icd_10_cm_code": "I51.9",
"icd_10_cm_code_description": "Heart disease, unspecified",
"Monitoring": [
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"evidence_text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"evidence_text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
2
]
},
{
"evidence_text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I51.9 is assigned for Heart disease, unspecified, based on the TTE finding of 'mild regional left ventricular systolic dysfunction'. MEAT criteria are met through monitoring (documented finding), evaluation (TTE report including EF), and assessment (documented in TTE impression and Brief Hospital Course)."
}
]
}
} |
Extract only the text-based justification for assigning the ICD-10-CM code to each condition. | Admission Date: [**2144-8-1**] Discharge Date: [**2144-8-6**]
Date of Birth: [**2075-9-18**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 2888**]
Chief Complaint:
CP
Major Surgical or Invasive Procedure:
PCI with angioplasty and DES to Mid-RCA
History of Present Illness:
68-year-old woman haitian Crecole speaking only with history of
type 2 DM, hypertension and hyperlidpedemia who presented to
[**Hospital1 18**] ED with 3 days of chest pain. Patient reports that about
three days ago while she was putting her clothes in the laundry
she had suddedn onset of substernal chest pain with radiation to
her neck, right arm and her abdomen. She attributed this pain
to indigestion. The pain was [**4-16**] and remained constant. Today
at 6:30am patient patient acutely worsened [**9-16**] associated with
nasuea, diaphoresis and shonrtess of breaht.
.
In the ED, initial vitals were 45 96/45 16 100% RA. ECG showed
ST Elevation Myocardial Infarction in inferior leads. She was
given aspirin 325 mg, plavix 600 mg, eptifibatide 180 mcg/kg x 1
and heparin 4000 units IV bolus. She was noted to be bradycardic
and hypotensive and thus given atropine 1mgx2 and started on
dopamine gtt which improved her blood pressure. She was
transfer to Cath lab.
.
In the Cath lab, she was noted to acute mid RCA occlusion which
was treated with angioplasty x 3 (10 mm/12 mm/14 mm) with
residual thrombus which was exported and Promus DES was placed
in mid RCA. His cath lab course was complicated by intermittent
complete heart block requiring temporary pacemaker pre-stenting
though she was conducting 1:1 in NSR after stenting. She was
also noted to have AIVR. Dopamine at 5 mcg/kg/min was turned
off at the end of her cath lab course. A small 1.5cm hematoma
was visible at the RFV access site after the case, and manual
pressure was applied for 10 minutes.
.
In the CCU, she did not report chest pain, discomfort,
palpatations or shortness of breath. She desnies any history of
chest pain.
Past Medical History:
DM2
HTN
TB
peripheral neuropathy
aseptic thrombophlebitis of the left internal jugular in [**2130**].
Social History:
Lives with husband, ha two children who live in [**Country 2045**]. Creole
speaking from [**Country 2045**] 14 years ago. Three children. No history
of tobacco, ETOH or illicit.
Family History:
non-contributory
Physical Exam:
Admission Physical:
GENERAL: Appears well NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL. MMM
NECK: Supple with no JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Wamr and well perfused No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs:
[**2144-8-1**] 11:35AM BLOOD WBC-10.8# RBC-3.35* Hgb-10.3* Hct-30.8*
MCV-92 MCH-30.7 MCHC-33.4 RDW-12.8 Plt Ct-178
[**2144-8-1**] 11:35AM BLOOD PT-12.5 PTT-30.7 INR(PT)-1.2*
[**2144-8-1**] 11:35AM BLOOD Glucose-394* UreaN-22* Creat-1.2* Na-135
K-4.0 Cl-99 HCO3-25 AnGap-15
[**2144-8-1**] 11:35AM BLOOD CK-MB-11* MB Indx-1.2
[**2144-8-1**] 05:15PM BLOOD CK-MB-16* MB Indx-1.9
[**2144-8-2**] 05:28AM BLOOD CK-MB-10 MB Indx-1.8 cTropnT-3.44*
[**2144-8-1**] 11:35AM BLOOD CK(CPK)-891*
[**2144-8-1**] 05:15PM BLOOD CK(CPK)-821*
[**2144-8-2**] 05:28AM BLOOD CK(CPK)-555*
Cardiac Cath
1) Selective coronary angiography of this co-dominant system
demonstrated three-vessel coronary artery disease. The LMCA had
mild
luminal irregularities. The proximal-mid LAD had an 80%
trifurcation
lesion that was tightest at the large diagonal branch takeoff;
there was
a high diagonal branch (functionally a ramus) that had diffuse
proximal
70% stenosis. The LCx was a diffusely-diseased vessel with a
likely
stump-occluded OM2 and severely diseased distal vessel; it
provided a
smaller left PDA. The mid-RCA was 100% occluded without
anterograde
flow into the distal vessel; there was also haziness noted at
the AM
origin. The ostial RCA had a 30-40% stenosis.
2)
3) During the procedure, and given the degeneration of the
conduction
disease to high-grade heart block associated with hypotension, a
temporary pacing wire was inserted through the 5 French venous
sheath
with successful capture at 80 bpm and [**7-17**] mA. After the PCI,
pacing
was discontinued, and the patient remained in sinus rhythm with
1:1
conduction at a rate of 80 bpm with normotensive blood
pressures. The
temporary pacing wire was therefore removed and the dopamine was
discontinued.
4) After the procedure, the 6 French right femoral arteriotomy
site was
AngioSealed with adequate hemostasis. The 5 French right femoral
venous
sheath was left in place in case of worsening conduction disease
overnight. A small 1.5cm hematoma was noted after the
procedure.
FINAL DIAGNOSIS:
1. Inferior wall STEMI with high-grade AV block.
2. Successful emergent primary PCI of occluded mid RCA with
PTCA, export
thrombectomy, and Promus drug eluting stent.
3. Emergent temporary pacing wire placement with active pacing
during
the procedure.
.
TTE: [**2144-8-3**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with severe
hypokinesis of the inferolateral wall. The remaining segments
contract normally (LVEF = 40 %). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. There is no aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild to moderate ([**12-9**]+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD (PDA distribution).
Mild-moderate mitral regurgitation most likely due to papillary
muscle dysfunction. Pulmonary artery hypertension.
.
CLINICAL IMPLICATIONS:
Based on [**2138**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
Discharge Labs:
Brief Hospital Course:
68-year-old woman, Haitian-Creole speaking, with history of type
2 DM, hypertension, and hyperlidpedemia, presented with inferior
STEMI now s/p DES to mid RCA.
.
# STEMI: Patient with multiple cardiovascular risk factors
(uncontrolled diabetes, uncontrolled hypertension and
hyperlidemia) presented with worsening chest pain. ECG was
consistent with ST elevation myocardial infarction in inferior
leads. She was given aspirin 325 mg, plavix 600 mg, eptifibatide
180 mcg/kg x 1 and heparin 4000 units IV bolus. She was noted to
be bradycardic and hypotensive and thus given atropine 1mgx2 and
started on dopamine gtt which improved her blood pressure. She
was transfer to the Cath lab. In the Cath lab, she was noted to
have acute mid RCA occlusion which was treated with angioplasty
x 3 (10 mm/12 mm/14 mm) with residual thrombus, which was
removed, and Promus DES was placed in the mid RCA. Her Cath lab
course was complicated by intermittent complete heart block
requiring temporary pacemaker pre-stenting though she was
conducting 1:1 in NSR after stenting. She was also noted to
have AIVR. Dopamine at 5 mcg/kg/min was turned off at the end
of her Cath lab course. She had an ECHO report that showed mild
regional left ventricular systolic dysfunction with severe
hypokinesis of the inferolateral wall with EF 40%. Mild
symmetric left ventricular hypertrophy with regional systolic
dysfunction c/w CAD (PDA distribution). Mild-moderate mitral
regurgitation most likely due to papillary muscle dysfunction.
Pulmonary artery hypertension.
During her CCU course, patient had one episode of shortness of
breath and increased respiratory rate with bilateral crackles on
exam. She was treated with Lasix which improved her sxs and she
had no further episodes of chest pain or shortness of breath
during her hospital stay. Patient was evaluated by physical
therapy on the day of discharge and determined safe to go home.
Patient will follow up with Dr. [**Last Name (STitle) 10156**] in Cardiology and
with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. She was discharged on the
following medications: Lasix, metoprolol, lisinopril,
atorvastatin, and Plavix.
.
# Arrythmia: Patient had bradycardia with dropped beats and
atrial ectopy likely in the setting of reperfusion post [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 10157**]. She did not have any symptomatic episodes of
bradycardia during her CCU course. She was also started on low
dose metoprolol which she tolerated very well.
.
# Diabetes Type 2: Poorly controlled and complicated by diabetic
nephropathy, retinopathy, and neuropathy. Last A1c was 8.7 in
3/[**2143**]. She was continued on 11units of NPH and insulin sliding
scale. On discharge, she was put on ----.
.
# Anemia: Hematocrit during this admission was around 30.
Prior HCT on OMR from [**2141**] shows HCT of 37.9. Unclear etiology.
No source of obvious bleeding and normal coags. Patient will
follow up with PCP for further management.
.
# Hypertension: Patient blood pressure was well controlled on
low dose metoprolol. Her home chorthalidone, amlodopine, and
lisinopril were initally held due to low bps. She was
discharged on metoprolol, lisinopril and lasix.
.
# Hyperlidemia: Started atorvastain 80mg daily.
.
Transitional Issues:
- needs close follow-up with Cardiology, PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] recommend [**Last Name (un) **] consultation for DM
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Aspirin 81 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Ranitidine 150 mg PO BID
7. NPH 32 Units Breakfast
NPH 22 Units Dinner
Discharge Medications:
1. Aspirin EC 325 mg PO DAILY
RX *aspirin [Enteric Coated Aspirin] 325 mg one tablet(s) by
mouth daily Disp #*30 Tablet Refills:*2
2. Ranitidine 150 mg PO BID
3. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
4. Clopidogrel 75 mg PO DAILY
for the recommended duration
RX *clopidogrel 75 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
5. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg one tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. NPH 32 Units Breakfast
NPH 22 Units Dinner
8. Lisinopril 20 mg PO DAILY
RX *lisinopril 40 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*2
9. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg one tablets by mouth daily Disp #*30 Tablet
Refills:*2
10. Outpatient Lab Work
Please check Chem-7 at [**Hospital6 733**] on [**2144-8-11**] with
results to Dr. [**Last Name (STitle) 6215**] at Phone: [**Telephone/Fax (1) 2010**]
Fax: [**Telephone/Fax (1) 4004**]
ICD-9 428
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Inferolateral ST elevation myocardial infarction
acute systolic congestive heart failure
hypertension
diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 10158**],
It was a pleasure taking care of your during your admission at
[**Hospital1 18**]. You were admitted because you were having chest pain and
you were found to have a heart attack for which you had a stent
placed in your heart. You have also been started on new
medications (aspirin and clopidogrel) to prevent the stenting of
the clot which you should continue to take unless told otherwise
by your cardiologist.
Weigh yourself every day before breakfast. Call Dr. [**Last Name (STitle) **] if
weight increases more than 3 pounds in 1 day or 5 pounds in 3
days.
The visiting nurse will help you with a low salt diet.
.
Please continue to take your medications as directed in your
discharge medication sheet. Please do not stop any medication
especially clopidogrel unless told by your cardiologist. You
risk having a heart attack if you do not take this medicine
every day.
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2144-9-3**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital **] HEALTH CENTER
When: TUESDAY [**2144-8-11**] at 11:50 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
| {
"clinical_findings": {
"E785": [
{
"icd_10_cm_code": "E78.5",
"icd_10_cm_code_description": "Hyperlipidemia, unspecified",
"Monitoring": [
{
"text": "hyperlidpedemia",
"page_numbers": [
1
]
},
{
"text": "hyperlidpedemia",
"page_numbers": [
2
]
},
{
"text": "hyperlidemia",
"page_numbers": [
2
]
},
{
"text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "Started atorvastain 80mg daily",
"page_numbers": [
2
]
},
{
"text": "Atorvastatin 80 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "hyperlidpedemia",
"page_numbers": [
1
]
},
{
"evidence_text": "hyperlidpedemia",
"page_numbers": [
2
]
},
{
"evidence_text": "hyperlidemia",
"page_numbers": [
2
]
},
{
"evidence_text": "Hyperlidemia",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E78.5 is assigned for Hyperlipidemia, unspecified. The diagnosis is documented multiple times. MEAT criteria are met through monitoring (documented diagnosis), assessment (documented as Hyperlidemia), and treatment (Atorvastatin started)."
}
],
"I2119": [
{
"icd_10_cm_code": "I21.19",
"icd_10_cm_code_description": "ST elevation myocardial infarction involving other inferior wall",
"Monitoring": [
{
"text": "ECG showed\nST Elevation Myocardial Infarction in inferior leads",
"page_numbers": [
1
]
},
{
"text": "ECG was\nconsistent with ST elevation myocardial infarction in inferior\nleads",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "mid-RCA was 100% occluded without\nanterograde\nflow into the distal vessel",
"page_numbers": [
1
]
},
{
"text": "cTropnT-3.44*",
"page_numbers": [
1
]
},
{
"text": "CK-MB-11*",
"page_numbers": [
1
]
},
{
"text": "CK(CPK)-891*",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Inferior wall STEMI",
"page_numbers": [
1
]
},
{
"text": "inferior\nSTEMI",
"page_numbers": [
2
]
},
{
"text": "Inferolateral ST elevation myocardial infarction",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "given aspirin 325 mg, plavix 600 mg, eptifibatide 180 mcg/kg x 1\nand heparin 4000 units IV bolus",
"page_numbers": [
1
]
},
{
"text": "transfer to Cath lab",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty x 3 (10 mm/12 mm/14 mm) with\nresidual thrombus which was exported and Promus DES was placed\nin mid RCA",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty\nx 3 (10 mm/12 mm/14 mm) with residual thrombus, which was\nremoved, and Promus DES was placed in the mid RCA",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "ST Elevation Myocardial Infarction in inferior leads",
"page_numbers": [
1
]
},
{
"evidence_text": "Inferior wall STEMI",
"page_numbers": [
1
]
},
{
"evidence_text": "inferior\nSTEMI",
"page_numbers": [
2
]
},
{
"evidence_text": "ST elevation myocardial infarction in inferior\nleads",
"page_numbers": [
2
]
},
{
"evidence_text": "Inferolateral ST elevation myocardial infarction",
"page_numbers": [
3
]
},
{
"evidence_text": "heart attack",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I21.19 is assigned for ST elevation myocardial infarction involving other inferior wall. The diagnosis is clearly documented multiple times, including in the final and discharge diagnoses. MEAT criteria are met through monitoring (ECG findings), evaluation (cardiac cath findings, elevated cardiac enzymes), assessment (documented diagnosis), and treatment (medications, PCI)."
}
],
"I442": [
{
"icd_10_cm_code": "I44.2",
"icd_10_cm_code_description": "Atrioventricular block, third degree",
"Monitoring": [
{
"text": "intermittent\ncomplete heart block",
"page_numbers": [
1
]
},
{
"text": "intermittent complete heart block",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "degeneration of the\nconduction\ndisease to high-grade heart block",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "high-grade AV block",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "requiring temporary pacemaker",
"page_numbers": [
1
]
},
{
"text": "requiring temporary pacemaker",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "intermittent\ncomplete heart block",
"page_numbers": [
1
]
},
{
"evidence_text": "degeneration of the\nconduction\ndisease to high-grade heart block",
"page_numbers": [
1
]
},
{
"evidence_text": "high-grade AV block",
"page_numbers": [
1
]
},
{
"evidence_text": "intermittent complete heart block",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I44.2 is assigned for Atrioventricular block, third degree, based on documentation of 'intermittent complete heart block' and 'high-grade AV block' requiring temporary pacing. MEAT criteria are met through monitoring (documented status), evaluation (documented degeneration), assessment (documented as high-grade AV block), and treatment (temporary pacemaker)."
}
],
"E1140": [
{
"icd_10_cm_code": "E11.40",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with diabetic neuropathy, unspecified",
"Monitoring": [
{
"text": "neuropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic neuropathy"
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "neuropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic neuropathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "peripheral neuropathy",
"page_numbers": [
1
]
},
{
"evidence_text": "neuropathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.40 is assigned for Type 2 diabetes mellitus with diabetic neuropathy. The entity 'peripheral neuropathy' is documented in PMH and 'neuropathy' is mentioned as a complication of poorly controlled diabetes in the Brief Hospital Course. MEAT criteria are met for the neuropathy component via monitoring and assessment. This is a combination code requiring an additional code for the manifestation (G63.0*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"I2510": [
{
"icd_10_cm_code": "I25.10",
"icd_10_cm_code_description": "Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Monitoring": [],
"Evaluation": [
{
"text": "Selective coronary angiography of this co-dominant system\ndemonstrated three-vessel coronary artery disease",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"Treatment": [
{
"text": "treated with angioplasty x 3 (10 mm/12 mm/14 mm) with\nresidual thrombus which was exported and Promus DES was placed\nin mid RCA",
"page_numbers": [
1
]
},
{
"text": "treated with angioplasty\nx 3 (10 mm/12 mm/14 mm) with residual thrombus, which was\nremoved, and Promus DES was placed in the mid RCA",
"page_numbers": [
2
]
}
],
"condition_evidence": [
{
"evidence_text": "three-vessel coronary artery disease",
"page_numbers": [
1
]
}
],
"justification": "ICD-10-CM code I25.10 is assigned for Atherosclerotic heart disease of native coronary artery without angina pectoris. The entity 'three-vessel coronary artery disease' is documented in the cardiac cath report. MEAT criteria are met through evaluation (angiography findings), assessment (systolic dysfunction c/w CAD), and treatment (PCI of RCA)."
}
],
"I2721": [
{
"icd_10_cm_code": "I27.21",
"icd_10_cm_code_description": "Secondary pulmonary arterial hypertension",
"Monitoring": [
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Pulmonary artery hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "Pulmonary artery hypertension",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I27.21 is assigned for Secondary pulmonary arterial hypertension, based on the TTE finding of 'moderate pulmonary artery systolic hypertension'. MEAT criteria are met through monitoring (documented finding), evaluation (TTE report), and assessment (documented in TTE impression and Brief Hospital Course)."
}
],
"E1121": [
{
"icd_10_cm_code": "E11.21",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with diabetic nephropathy",
"Monitoring": [
{
"text": "diabetic\nnephropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Evaluation": [
{
"text": "Creat-1.2*",
"page_numbers": [
1
],
"applies_to": [
"Diabetic nephropathy"
]
},
{
"text": "UreaN-22*",
"page_numbers": [
1
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Assessment": [
{
"text": "diabetic\nnephropathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic nephropathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "diabetic\nnephropathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.21 is assigned for Type 2 diabetes mellitus with diabetic nephropathy. The entity 'diabetic nephropathy' is documented as a complication of poorly controlled diabetes. MEAT criteria are met for the nephropathy component via monitoring, evaluation (labs), and assessment. This is a combination code requiring an additional code for the manifestation (N08*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"E1139": [
{
"icd_10_cm_code": "E11.39",
"icd_10_cm_code_description": "Type 2 diabetes mellitus with other diabetic ophthalmic complication",
"Monitoring": [
{
"text": "retinopathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic retinopathy"
]
}
],
"Evaluation": [],
"Assessment": [
{
"text": "retinopathy",
"page_numbers": [
2
],
"applies_to": [
"Diabetic retinopathy"
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "retinopathy",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code E11.39 is assigned for Type 2 diabetes mellitus with other diabetic ophthalmic complication. The entity 'retinopathy' is documented as a complication of poorly controlled diabetes. MEAT criteria are met for the retinopathy component via monitoring and assessment. This is a combination code requiring an additional code for the manifestation (H36*), which is supported by the entity evidence. MEAT for the diabetes component is met separately (E11.9)."
}
],
"I5021": [
{
"icd_10_cm_code": "I50.21",
"icd_10_cm_code_description": "Acute systolic (congestive) heart failure",
"Monitoring": [
{
"text": "one episode of shortness of\nbreath and increased respiratory rate with bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "Mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "She was treated with Lasix which improved her sxs",
"page_numbers": [
2
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I50.21 is assigned for Acute systolic (congestive) heart failure. The diagnosis is documented in the Discharge Diagnosis. MEAT criteria are met through monitoring (symptoms like shortness of breath, crackles, TTE findings), evaluation (physical exam, TTE report), assessment (documented diagnosis), and treatment (Lasix/Furosemide)."
}
],
"I110": [
{
"icd_10_cm_code": "I50.21",
"icd_10_cm_code_description": "Acute systolic (congestive) heart failure",
"Monitoring": [
{
"text": "one episode of shortness of\nbreath and increased respiratory rate with bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "Mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "bilateral crackles on\nexam",
"page_numbers": [
2
]
},
{
"text": "mild regional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "severe\nhypokinesis of the inferolateral wall",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
},
{
"text": "Mild to moderate ([**12-9**]+) mitral regurgitation",
"page_numbers": [
1
]
},
{
"text": "moderate pulmonary artery systolic hypertension",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "She was treated with Lasix which improved her sxs",
"page_numbers": [
2
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "acute systolic congestive heart failure",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I50.21 is assigned for Acute systolic (congestive) heart failure. The diagnosis is documented in the Discharge Diagnosis. MEAT criteria are met through monitoring (symptoms like shortness of breath, crackles, TTE findings), evaluation (physical exam, TTE report), assessment (documented diagnosis), and treatment (Lasix/Furosemide)."
},
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [
{
"text": "uncontrolled hypertension",
"page_numbers": [
2
]
},
{
"text": "Patient blood pressure was well controlled on\nlow dose metoprolol",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "initial vitals were 45 96/45",
"page_numbers": [
1
]
},
{
"text": "low bps",
"page_numbers": [
2
]
}
],
"Assessment": [
{
"text": "Hypertension",
"page_numbers": [
2
]
},
{
"text": "hypertension",
"page_numbers": [
3
]
}
],
"Treatment": [
{
"text": "Amlodipine 10 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Chlorthalidone 25 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Lisinopril 40 mg PO DAILY",
"page_numbers": [
2
]
},
{
"text": "Metoprolol Succinate XL 50 mg PO DAILY",
"page_numbers": [
3
]
},
{
"text": "Lisinopril 20 mg PO DAILY",
"page_numbers": [
3
]
},
{
"text": "Furosemide 20 mg PO DAILY",
"page_numbers": [
3
]
}
],
"condition_evidence": [
{
"evidence_text": "hypertension",
"page_numbers": [
1
]
},
{
"evidence_text": "HTN",
"page_numbers": [
1
]
},
{
"evidence_text": "hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "uncontrolled hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "Hypertension",
"page_numbers": [
2
]
},
{
"evidence_text": "hypertension",
"page_numbers": [
3
]
}
],
"justification": "ICD-10-CM code I10 is assigned for Essential (primary) hypertension. The diagnosis is documented multiple times. MEAT criteria are met through monitoring (uncontrolled/controlled status), evaluation (vital signs, low bps), assessment (documented as Hypertension), and treatment (multiple antihypertensive medications)."
},
{
"icd_10_cm_code": "I51.9",
"icd_10_cm_code_description": "Heart disease, unspecified",
"Monitoring": [
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
2
]
}
],
"Evaluation": [
{
"text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"text": "EF = 40 %",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"Treatment": [],
"condition_evidence": [
{
"evidence_text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
1
]
},
{
"evidence_text": "regional systolic dysfunction c/w CAD (PDA distribution)",
"page_numbers": [
1
]
},
{
"evidence_text": "mild\nregional left ventricular systolic dysfunction",
"page_numbers": [
2
]
},
{
"evidence_text": "regional systolic\ndysfunction c/w CAD (PDA distribution)",
"page_numbers": [
2
]
}
],
"justification": "ICD-10-CM code I51.9 is assigned for Heart disease, unspecified, based on the TTE finding of 'mild regional left ventricular systolic dysfunction'. MEAT criteria are met through monitoring (documented finding), evaluation (TTE report including EF), and assessment (documented in TTE impression and Brief Hospital Course)."
}
]
}
} |
Extract the ICD-10-CM code assigned to each clinical condition mentioned in the discharge summary. | Admission Date: [**2119-6-24**] Discharge Date: [**2119-6-28**]
Date of Birth: [**2067-8-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
51 y/o M w/IPF on home O2 who presented to the ED last night
with worsening dyspnea. This has been slowly worsening for the
past few weeks, but over 2 days severely worsened to the point
where he was short of breath at rest. He also has had a cough
productive of yellow blood-tinged sputum for 2 days (normally
has a non-productive cough at baseline). According to his
pulmonary rehab notes, he has been increasingly unable to
exercise due to hypoxemia with exertion despite supplemental O2.
He has also had anterior chest pain which he associates with
coughing. The chest pain is not exertional. He denies
orthopnea and LE edema. He has had chills over the past couple
of days, but no fevers.
In the ED, he was intermittently hypoxic to the 70s and 80s on
4L so was switched to a NRB. He was also tachycardic in the
110s. He was given levofloxacin for pna. Because of the
tachycardia and hypoxia, he underwent a CTA which was negative
for PE but showed multifocal airspace disease. He was admitted
to the [**Hospital Unit Name 153**].
Past Medical History:
1. IPF: Diagnosed on VATS [**2116**], treated with gamma-interferon
for one year around that time. Has also been on
N-acetylcysteine but stopped last year. Not a candidate for
BUILD3 due to FVC <50%. Has never been treated with steroids.
Undergoing transplant w/u at [**Hospital1 112**] (per pt, currently contingent
on weight loss but remainder of w/u done). In pulmonary rehab
here, and at home is on 2L O2 continuous with 4L O2 for
exertion. Most recent PFTs [**2-17**]: FEV1 1.58 (51%), FVC 1.84
(44%), FEV1/FVC 86%, TLC 2.61 (43% in [**12-17**]), DLCO 8.6 (32% in
[**12-17**]).
2. OSA, on CPAP
3. GERD
4. HTN
5. DM
6. Depression
[**Last Name (un) 1724**]: albuterol MDI prn, atenolol 50 mg daily, bupropion SR 200
mg qAM, celexa 40 mg daily, hctz 25 mg daily, lantus 14 U qhs,
metformin 1000 mg [**Hospital1 **], trazodone 50 mg qhs:prn, aspirin 325 mg
daily, amino acids, omeprazole 20 mg daily, flovent 220 mcg 2
puffs qAM (recently restarted at pulmonary rehab)
Social History:
Occupation: Currently unable to work but formerly worked for
Merchant Marine
Drugs: No
Tobacco: Never
Alcohol: No
Other: No animals at home. No sick contacts.
Family History:
non-contributory.
Physical Exam:
General Appearance: Overweight / Obese, tachypneic, in mild
respiratory distress
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic), Unable to appreciate loud P2
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Dullness : bilateral bases), (Breath Sounds: Crackles : [**1-11**] way
on R, [**1-12**] way on L, No(t) Wheezes : ), egophony at bilateral
bases
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)
Clubbing
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Responds to: Verbal stimuli, Movement:
Not assessed, Tone: Not assessed
Pertinent Results:
patient expired
Brief Hospital Course:
51 yoM w/ a h/o of IPF presented with a significant worsening of
his IPF. Moving in bed would cause his O2 sat to drop to 60%
while on FiO2 100%. Patient was DNR / DNI. Not on the
transplant list due to BMI > 30 and evaluated at the [**Hospital1 112**].
[**Hospital6 **] was contact[**Name (NI) **] who confirmed the fact that
the patient was not on the list and there was no way to place
him on a list for an urgent lung transplant. Discussion with
the family led to the decision to make the patient comfort
measures only. Patient Died on [**2119-6-28**].
Medications on Admission:
patient expired
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
| {
"clinical_findings": {
"J84112": [
{
"icd_10_cm_code": "J84.112",
"icd_10_cm_code_description": "Idiopathic pulmonary fibrosis",
"Monitoring": [
{
"text": "worsening dyspnea",
"page_numbers": [
1
]
},
{
"text": "short of breath at rest",
"page_numbers": [
1
]
},
{
"text": "cough\nproductive of yellow blood-tinged sputum",
"page_numbers": [
1
]
},
{
"text": "hypoxemia with exertion",
"page_numbers": [
1
]
},
{
"text": "on home O2",
"page_numbers": [
1
]
},
{
"text": "tachypneic",
"page_numbers": [
1
]
},
{
"text": "in mild\nrespiratory distress",
"page_numbers": [
1
]
},
{
"text": "Dullness : bilateral bases",
"page_numbers": [
1
]
},
{
"text": "Crackles : [**1-11**] way\non R, [**1-12**] way on L",
"page_numbers": [
1
]
},
{
"text": "egophony at bilateral\nbases",
"page_numbers": [
1
]
},
{
"text": "O2 sat to drop to 60%\nwhile on FiO2 100%",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "PFTs [**2-17**]: FEV1 1.58 (51%), FVC 1.84\n(44%), FEV1/FVC 86%, TLC 2.61 (43% in [**12-17**]), DLCO 8.6 (32% in\n[**12-17**])",
"page_numbers": [
1
]
},
{
"text": "CTA which was negative\nfor PE but showed multifocal airspace disease",
"page_numbers": [
1
]
},
{
"text": "Physical Exam: Overweight / Obese, tachypneic, in mild\nrespiratory distress",
"page_numbers": [
1
]
},
{
"text": "Dullness : bilateral bases",
"page_numbers": [
1
]
},
{
"text": "Breath Sounds: Crackles : [**1-11**] way\non R, [**1-12**] way on L",
"page_numbers": [
1
]
},
{
"text": "egophony at bilateral\nbases",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "significant worsening of\nhis IPF",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "on home O2",
"page_numbers": [
1
]
},
{
"text": "switched to a NRB",
"page_numbers": [
1
]
},
{
"text": "flovent 220 mcg 2\npuffs qAM",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "significant worsening of\nhis IPF",
"page_numbers": [
1
]
}
],
"justification": "The entity 'IPF' is documented in the History of Present Illness, Past Medical History, and Brief Hospital Course. MEAT criteria are met with extensive documentation of monitoring (symptoms, O2 saturation, physical exam findings), evaluation (PFTs, CTA, physical exam), assessment (significant worsening), and treatment (home O2, NRB, Flovent). The code J84.112 is the specific ICD-10-CM code for Idiopathic pulmonary fibrosis."
}
],
"I10": [
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "atenolol 50 mg daily",
"page_numbers": [
1
]
},
{
"text": "hctz 25 mg daily",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HTN' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('atenolol 50 mg daily', 'hctz 25 mg daily'). The code I10 is the appropriate ICD-10-CM code for Essential (primary) hypertension."
}
],
"E119": [
{
"icd_10_cm_code": "E11.9",
"icd_10_cm_code_description": "Type 2 diabetes mellitus without complications",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "lantus 14 U qhs",
"page_numbers": [
1
]
},
{
"text": "metformin 1000 mg",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "DM",
"page_numbers": [
1
]
}
],
"justification": "The entity 'DM' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('lantus 14 U qhs', 'metformin 1000 mg'). The code E11.9 is the appropriate ICD-10-CM code for Type 2 diabetes mellitus without complications, as no complications are documented in the entities."
}
],
"F329": [
{
"icd_10_cm_code": "F32.9",
"icd_10_cm_code_description": "Major depressive disorder, single episode, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "bupropion SR 200\nmg qAM",
"page_numbers": [
1
]
},
{
"text": "celexa 40 mg daily",
"page_numbers": [
1
]
},
{
"text": "trazodone 50 mg qhs:prn",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "Depression",
"page_numbers": [
1
]
}
],
"justification": "The entity 'Depression' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('bupropion SR 200 mg qAM', 'celexa 40 mg daily', 'trazodone 50 mg qhs:prn'). The code F32.9 is the appropriate ICD-10-CM code for Major depressive disorder, single episode, unspecified, based on the entity text."
}
]
}
} |
Extract the ICD-10-CM code description for each clinical condition mentioned in the discharge summary. | Admission Date: [**2119-6-24**] Discharge Date: [**2119-6-28**]
Date of Birth: [**2067-8-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
51 y/o M w/IPF on home O2 who presented to the ED last night
with worsening dyspnea. This has been slowly worsening for the
past few weeks, but over 2 days severely worsened to the point
where he was short of breath at rest. He also has had a cough
productive of yellow blood-tinged sputum for 2 days (normally
has a non-productive cough at baseline). According to his
pulmonary rehab notes, he has been increasingly unable to
exercise due to hypoxemia with exertion despite supplemental O2.
He has also had anterior chest pain which he associates with
coughing. The chest pain is not exertional. He denies
orthopnea and LE edema. He has had chills over the past couple
of days, but no fevers.
In the ED, he was intermittently hypoxic to the 70s and 80s on
4L so was switched to a NRB. He was also tachycardic in the
110s. He was given levofloxacin for pna. Because of the
tachycardia and hypoxia, he underwent a CTA which was negative
for PE but showed multifocal airspace disease. He was admitted
to the [**Hospital Unit Name 153**].
Past Medical History:
1. IPF: Diagnosed on VATS [**2116**], treated with gamma-interferon
for one year around that time. Has also been on
N-acetylcysteine but stopped last year. Not a candidate for
BUILD3 due to FVC <50%. Has never been treated with steroids.
Undergoing transplant w/u at [**Hospital1 112**] (per pt, currently contingent
on weight loss but remainder of w/u done). In pulmonary rehab
here, and at home is on 2L O2 continuous with 4L O2 for
exertion. Most recent PFTs [**2-17**]: FEV1 1.58 (51%), FVC 1.84
(44%), FEV1/FVC 86%, TLC 2.61 (43% in [**12-17**]), DLCO 8.6 (32% in
[**12-17**]).
2. OSA, on CPAP
3. GERD
4. HTN
5. DM
6. Depression
[**Last Name (un) 1724**]: albuterol MDI prn, atenolol 50 mg daily, bupropion SR 200
mg qAM, celexa 40 mg daily, hctz 25 mg daily, lantus 14 U qhs,
metformin 1000 mg [**Hospital1 **], trazodone 50 mg qhs:prn, aspirin 325 mg
daily, amino acids, omeprazole 20 mg daily, flovent 220 mcg 2
puffs qAM (recently restarted at pulmonary rehab)
Social History:
Occupation: Currently unable to work but formerly worked for
Merchant Marine
Drugs: No
Tobacco: Never
Alcohol: No
Other: No animals at home. No sick contacts.
Family History:
non-contributory.
Physical Exam:
General Appearance: Overweight / Obese, tachypneic, in mild
respiratory distress
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic), Unable to appreciate loud P2
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Dullness : bilateral bases), (Breath Sounds: Crackles : [**1-11**] way
on R, [**1-12**] way on L, No(t) Wheezes : ), egophony at bilateral
bases
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)
Clubbing
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Responds to: Verbal stimuli, Movement:
Not assessed, Tone: Not assessed
Pertinent Results:
patient expired
Brief Hospital Course:
51 yoM w/ a h/o of IPF presented with a significant worsening of
his IPF. Moving in bed would cause his O2 sat to drop to 60%
while on FiO2 100%. Patient was DNR / DNI. Not on the
transplant list due to BMI > 30 and evaluated at the [**Hospital1 112**].
[**Hospital6 **] was contact[**Name (NI) **] who confirmed the fact that
the patient was not on the list and there was no way to place
him on a list for an urgent lung transplant. Discussion with
the family led to the decision to make the patient comfort
measures only. Patient Died on [**2119-6-28**].
Medications on Admission:
patient expired
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
| {
"clinical_findings": {
"J84112": [
{
"icd_10_cm_code": "J84.112",
"icd_10_cm_code_description": "Idiopathic pulmonary fibrosis",
"Monitoring": [
{
"text": "worsening dyspnea",
"page_numbers": [
1
]
},
{
"text": "short of breath at rest",
"page_numbers": [
1
]
},
{
"text": "cough\nproductive of yellow blood-tinged sputum",
"page_numbers": [
1
]
},
{
"text": "hypoxemia with exertion",
"page_numbers": [
1
]
},
{
"text": "on home O2",
"page_numbers": [
1
]
},
{
"text": "tachypneic",
"page_numbers": [
1
]
},
{
"text": "in mild\nrespiratory distress",
"page_numbers": [
1
]
},
{
"text": "Dullness : bilateral bases",
"page_numbers": [
1
]
},
{
"text": "Crackles : [**1-11**] way\non R, [**1-12**] way on L",
"page_numbers": [
1
]
},
{
"text": "egophony at bilateral\nbases",
"page_numbers": [
1
]
},
{
"text": "O2 sat to drop to 60%\nwhile on FiO2 100%",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "PFTs [**2-17**]: FEV1 1.58 (51%), FVC 1.84\n(44%), FEV1/FVC 86%, TLC 2.61 (43% in [**12-17**]), DLCO 8.6 (32% in\n[**12-17**])",
"page_numbers": [
1
]
},
{
"text": "CTA which was negative\nfor PE but showed multifocal airspace disease",
"page_numbers": [
1
]
},
{
"text": "Physical Exam: Overweight / Obese, tachypneic, in mild\nrespiratory distress",
"page_numbers": [
1
]
},
{
"text": "Dullness : bilateral bases",
"page_numbers": [
1
]
},
{
"text": "Breath Sounds: Crackles : [**1-11**] way\non R, [**1-12**] way on L",
"page_numbers": [
1
]
},
{
"text": "egophony at bilateral\nbases",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "significant worsening of\nhis IPF",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "on home O2",
"page_numbers": [
1
]
},
{
"text": "switched to a NRB",
"page_numbers": [
1
]
},
{
"text": "flovent 220 mcg 2\npuffs qAM",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "significant worsening of\nhis IPF",
"page_numbers": [
1
]
}
],
"justification": "The entity 'IPF' is documented in the History of Present Illness, Past Medical History, and Brief Hospital Course. MEAT criteria are met with extensive documentation of monitoring (symptoms, O2 saturation, physical exam findings), evaluation (PFTs, CTA, physical exam), assessment (significant worsening), and treatment (home O2, NRB, Flovent). The code J84.112 is the specific ICD-10-CM code for Idiopathic pulmonary fibrosis."
}
],
"I10": [
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "atenolol 50 mg daily",
"page_numbers": [
1
]
},
{
"text": "hctz 25 mg daily",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HTN' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('atenolol 50 mg daily', 'hctz 25 mg daily'). The code I10 is the appropriate ICD-10-CM code for Essential (primary) hypertension."
}
],
"E119": [
{
"icd_10_cm_code": "E11.9",
"icd_10_cm_code_description": "Type 2 diabetes mellitus without complications",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "lantus 14 U qhs",
"page_numbers": [
1
]
},
{
"text": "metformin 1000 mg",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "DM",
"page_numbers": [
1
]
}
],
"justification": "The entity 'DM' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('lantus 14 U qhs', 'metformin 1000 mg'). The code E11.9 is the appropriate ICD-10-CM code for Type 2 diabetes mellitus without complications, as no complications are documented in the entities."
}
],
"F329": [
{
"icd_10_cm_code": "F32.9",
"icd_10_cm_code_description": "Major depressive disorder, single episode, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "bupropion SR 200\nmg qAM",
"page_numbers": [
1
]
},
{
"text": "celexa 40 mg daily",
"page_numbers": [
1
]
},
{
"text": "trazodone 50 mg qhs:prn",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "Depression",
"page_numbers": [
1
]
}
],
"justification": "The entity 'Depression' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('bupropion SR 200 mg qAM', 'celexa 40 mg daily', 'trazodone 50 mg qhs:prn'). The code F32.9 is the appropriate ICD-10-CM code for Major depressive disorder, single episode, unspecified, based on the entity text."
}
]
}
} |
Extract only the monitoring information related to each clinical condition, such as vital signs, labs, or telemetry data. | Admission Date: [**2119-6-24**] Discharge Date: [**2119-6-28**]
Date of Birth: [**2067-8-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
51 y/o M w/IPF on home O2 who presented to the ED last night
with worsening dyspnea. This has been slowly worsening for the
past few weeks, but over 2 days severely worsened to the point
where he was short of breath at rest. He also has had a cough
productive of yellow blood-tinged sputum for 2 days (normally
has a non-productive cough at baseline). According to his
pulmonary rehab notes, he has been increasingly unable to
exercise due to hypoxemia with exertion despite supplemental O2.
He has also had anterior chest pain which he associates with
coughing. The chest pain is not exertional. He denies
orthopnea and LE edema. He has had chills over the past couple
of days, but no fevers.
In the ED, he was intermittently hypoxic to the 70s and 80s on
4L so was switched to a NRB. He was also tachycardic in the
110s. He was given levofloxacin for pna. Because of the
tachycardia and hypoxia, he underwent a CTA which was negative
for PE but showed multifocal airspace disease. He was admitted
to the [**Hospital Unit Name 153**].
Past Medical History:
1. IPF: Diagnosed on VATS [**2116**], treated with gamma-interferon
for one year around that time. Has also been on
N-acetylcysteine but stopped last year. Not a candidate for
BUILD3 due to FVC <50%. Has never been treated with steroids.
Undergoing transplant w/u at [**Hospital1 112**] (per pt, currently contingent
on weight loss but remainder of w/u done). In pulmonary rehab
here, and at home is on 2L O2 continuous with 4L O2 for
exertion. Most recent PFTs [**2-17**]: FEV1 1.58 (51%), FVC 1.84
(44%), FEV1/FVC 86%, TLC 2.61 (43% in [**12-17**]), DLCO 8.6 (32% in
[**12-17**]).
2. OSA, on CPAP
3. GERD
4. HTN
5. DM
6. Depression
[**Last Name (un) 1724**]: albuterol MDI prn, atenolol 50 mg daily, bupropion SR 200
mg qAM, celexa 40 mg daily, hctz 25 mg daily, lantus 14 U qhs,
metformin 1000 mg [**Hospital1 **], trazodone 50 mg qhs:prn, aspirin 325 mg
daily, amino acids, omeprazole 20 mg daily, flovent 220 mcg 2
puffs qAM (recently restarted at pulmonary rehab)
Social History:
Occupation: Currently unable to work but formerly worked for
Merchant Marine
Drugs: No
Tobacco: Never
Alcohol: No
Other: No animals at home. No sick contacts.
Family History:
non-contributory.
Physical Exam:
General Appearance: Overweight / Obese, tachypneic, in mild
respiratory distress
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic), Unable to appreciate loud P2
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Dullness : bilateral bases), (Breath Sounds: Crackles : [**1-11**] way
on R, [**1-12**] way on L, No(t) Wheezes : ), egophony at bilateral
bases
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)
Clubbing
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Responds to: Verbal stimuli, Movement:
Not assessed, Tone: Not assessed
Pertinent Results:
patient expired
Brief Hospital Course:
51 yoM w/ a h/o of IPF presented with a significant worsening of
his IPF. Moving in bed would cause his O2 sat to drop to 60%
while on FiO2 100%. Patient was DNR / DNI. Not on the
transplant list due to BMI > 30 and evaluated at the [**Hospital1 112**].
[**Hospital6 **] was contact[**Name (NI) **] who confirmed the fact that
the patient was not on the list and there was no way to place
him on a list for an urgent lung transplant. Discussion with
the family led to the decision to make the patient comfort
measures only. Patient Died on [**2119-6-28**].
Medications on Admission:
patient expired
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
| {
"clinical_findings": {
"J84112": [
{
"icd_10_cm_code": "J84.112",
"icd_10_cm_code_description": "Idiopathic pulmonary fibrosis",
"Monitoring": [
{
"text": "worsening dyspnea",
"page_numbers": [
1
]
},
{
"text": "short of breath at rest",
"page_numbers": [
1
]
},
{
"text": "cough\nproductive of yellow blood-tinged sputum",
"page_numbers": [
1
]
},
{
"text": "hypoxemia with exertion",
"page_numbers": [
1
]
},
{
"text": "on home O2",
"page_numbers": [
1
]
},
{
"text": "tachypneic",
"page_numbers": [
1
]
},
{
"text": "in mild\nrespiratory distress",
"page_numbers": [
1
]
},
{
"text": "Dullness : bilateral bases",
"page_numbers": [
1
]
},
{
"text": "Crackles : [**1-11**] way\non R, [**1-12**] way on L",
"page_numbers": [
1
]
},
{
"text": "egophony at bilateral\nbases",
"page_numbers": [
1
]
},
{
"text": "O2 sat to drop to 60%\nwhile on FiO2 100%",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "PFTs [**2-17**]: FEV1 1.58 (51%), FVC 1.84\n(44%), FEV1/FVC 86%, TLC 2.61 (43% in [**12-17**]), DLCO 8.6 (32% in\n[**12-17**])",
"page_numbers": [
1
]
},
{
"text": "CTA which was negative\nfor PE but showed multifocal airspace disease",
"page_numbers": [
1
]
},
{
"text": "Physical Exam: Overweight / Obese, tachypneic, in mild\nrespiratory distress",
"page_numbers": [
1
]
},
{
"text": "Dullness : bilateral bases",
"page_numbers": [
1
]
},
{
"text": "Breath Sounds: Crackles : [**1-11**] way\non R, [**1-12**] way on L",
"page_numbers": [
1
]
},
{
"text": "egophony at bilateral\nbases",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "significant worsening of\nhis IPF",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "on home O2",
"page_numbers": [
1
]
},
{
"text": "switched to a NRB",
"page_numbers": [
1
]
},
{
"text": "flovent 220 mcg 2\npuffs qAM",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "significant worsening of\nhis IPF",
"page_numbers": [
1
]
}
],
"justification": "The entity 'IPF' is documented in the History of Present Illness, Past Medical History, and Brief Hospital Course. MEAT criteria are met with extensive documentation of monitoring (symptoms, O2 saturation, physical exam findings), evaluation (PFTs, CTA, physical exam), assessment (significant worsening), and treatment (home O2, NRB, Flovent). The code J84.112 is the specific ICD-10-CM code for Idiopathic pulmonary fibrosis."
}
],
"I10": [
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "atenolol 50 mg daily",
"page_numbers": [
1
]
},
{
"text": "hctz 25 mg daily",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HTN' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('atenolol 50 mg daily', 'hctz 25 mg daily'). The code I10 is the appropriate ICD-10-CM code for Essential (primary) hypertension."
}
],
"E119": [
{
"icd_10_cm_code": "E11.9",
"icd_10_cm_code_description": "Type 2 diabetes mellitus without complications",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "lantus 14 U qhs",
"page_numbers": [
1
]
},
{
"text": "metformin 1000 mg",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "DM",
"page_numbers": [
1
]
}
],
"justification": "The entity 'DM' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('lantus 14 U qhs', 'metformin 1000 mg'). The code E11.9 is the appropriate ICD-10-CM code for Type 2 diabetes mellitus without complications, as no complications are documented in the entities."
}
],
"F329": [
{
"icd_10_cm_code": "F32.9",
"icd_10_cm_code_description": "Major depressive disorder, single episode, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "bupropion SR 200\nmg qAM",
"page_numbers": [
1
]
},
{
"text": "celexa 40 mg daily",
"page_numbers": [
1
]
},
{
"text": "trazodone 50 mg qhs:prn",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "Depression",
"page_numbers": [
1
]
}
],
"justification": "The entity 'Depression' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('bupropion SR 200 mg qAM', 'celexa 40 mg daily', 'trazodone 50 mg qhs:prn'). The code F32.9 is the appropriate ICD-10-CM code for Major depressive disorder, single episode, unspecified, based on the entity text."
}
]
}
} |
Extract only the clinical evaluation methods used for each condition, such as imaging, physical examination, or biopsy. | Admission Date: [**2119-6-24**] Discharge Date: [**2119-6-28**]
Date of Birth: [**2067-8-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
51 y/o M w/IPF on home O2 who presented to the ED last night
with worsening dyspnea. This has been slowly worsening for the
past few weeks, but over 2 days severely worsened to the point
where he was short of breath at rest. He also has had a cough
productive of yellow blood-tinged sputum for 2 days (normally
has a non-productive cough at baseline). According to his
pulmonary rehab notes, he has been increasingly unable to
exercise due to hypoxemia with exertion despite supplemental O2.
He has also had anterior chest pain which he associates with
coughing. The chest pain is not exertional. He denies
orthopnea and LE edema. He has had chills over the past couple
of days, but no fevers.
In the ED, he was intermittently hypoxic to the 70s and 80s on
4L so was switched to a NRB. He was also tachycardic in the
110s. He was given levofloxacin for pna. Because of the
tachycardia and hypoxia, he underwent a CTA which was negative
for PE but showed multifocal airspace disease. He was admitted
to the [**Hospital Unit Name 153**].
Past Medical History:
1. IPF: Diagnosed on VATS [**2116**], treated with gamma-interferon
for one year around that time. Has also been on
N-acetylcysteine but stopped last year. Not a candidate for
BUILD3 due to FVC <50%. Has never been treated with steroids.
Undergoing transplant w/u at [**Hospital1 112**] (per pt, currently contingent
on weight loss but remainder of w/u done). In pulmonary rehab
here, and at home is on 2L O2 continuous with 4L O2 for
exertion. Most recent PFTs [**2-17**]: FEV1 1.58 (51%), FVC 1.84
(44%), FEV1/FVC 86%, TLC 2.61 (43% in [**12-17**]), DLCO 8.6 (32% in
[**12-17**]).
2. OSA, on CPAP
3. GERD
4. HTN
5. DM
6. Depression
[**Last Name (un) 1724**]: albuterol MDI prn, atenolol 50 mg daily, bupropion SR 200
mg qAM, celexa 40 mg daily, hctz 25 mg daily, lantus 14 U qhs,
metformin 1000 mg [**Hospital1 **], trazodone 50 mg qhs:prn, aspirin 325 mg
daily, amino acids, omeprazole 20 mg daily, flovent 220 mcg 2
puffs qAM (recently restarted at pulmonary rehab)
Social History:
Occupation: Currently unable to work but formerly worked for
Merchant Marine
Drugs: No
Tobacco: Never
Alcohol: No
Other: No animals at home. No sick contacts.
Family History:
non-contributory.
Physical Exam:
General Appearance: Overweight / Obese, tachypneic, in mild
respiratory distress
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic), Unable to appreciate loud P2
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Dullness : bilateral bases), (Breath Sounds: Crackles : [**1-11**] way
on R, [**1-12**] way on L, No(t) Wheezes : ), egophony at bilateral
bases
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)
Clubbing
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Responds to: Verbal stimuli, Movement:
Not assessed, Tone: Not assessed
Pertinent Results:
patient expired
Brief Hospital Course:
51 yoM w/ a h/o of IPF presented with a significant worsening of
his IPF. Moving in bed would cause his O2 sat to drop to 60%
while on FiO2 100%. Patient was DNR / DNI. Not on the
transplant list due to BMI > 30 and evaluated at the [**Hospital1 112**].
[**Hospital6 **] was contact[**Name (NI) **] who confirmed the fact that
the patient was not on the list and there was no way to place
him on a list for an urgent lung transplant. Discussion with
the family led to the decision to make the patient comfort
measures only. Patient Died on [**2119-6-28**].
Medications on Admission:
patient expired
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
| {
"clinical_findings": {
"J84112": [
{
"icd_10_cm_code": "J84.112",
"icd_10_cm_code_description": "Idiopathic pulmonary fibrosis",
"Monitoring": [
{
"text": "worsening dyspnea",
"page_numbers": [
1
]
},
{
"text": "short of breath at rest",
"page_numbers": [
1
]
},
{
"text": "cough\nproductive of yellow blood-tinged sputum",
"page_numbers": [
1
]
},
{
"text": "hypoxemia with exertion",
"page_numbers": [
1
]
},
{
"text": "on home O2",
"page_numbers": [
1
]
},
{
"text": "tachypneic",
"page_numbers": [
1
]
},
{
"text": "in mild\nrespiratory distress",
"page_numbers": [
1
]
},
{
"text": "Dullness : bilateral bases",
"page_numbers": [
1
]
},
{
"text": "Crackles : [**1-11**] way\non R, [**1-12**] way on L",
"page_numbers": [
1
]
},
{
"text": "egophony at bilateral\nbases",
"page_numbers": [
1
]
},
{
"text": "O2 sat to drop to 60%\nwhile on FiO2 100%",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "PFTs [**2-17**]: FEV1 1.58 (51%), FVC 1.84\n(44%), FEV1/FVC 86%, TLC 2.61 (43% in [**12-17**]), DLCO 8.6 (32% in\n[**12-17**])",
"page_numbers": [
1
]
},
{
"text": "CTA which was negative\nfor PE but showed multifocal airspace disease",
"page_numbers": [
1
]
},
{
"text": "Physical Exam: Overweight / Obese, tachypneic, in mild\nrespiratory distress",
"page_numbers": [
1
]
},
{
"text": "Dullness : bilateral bases",
"page_numbers": [
1
]
},
{
"text": "Breath Sounds: Crackles : [**1-11**] way\non R, [**1-12**] way on L",
"page_numbers": [
1
]
},
{
"text": "egophony at bilateral\nbases",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "significant worsening of\nhis IPF",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "on home O2",
"page_numbers": [
1
]
},
{
"text": "switched to a NRB",
"page_numbers": [
1
]
},
{
"text": "flovent 220 mcg 2\npuffs qAM",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "significant worsening of\nhis IPF",
"page_numbers": [
1
]
}
],
"justification": "The entity 'IPF' is documented in the History of Present Illness, Past Medical History, and Brief Hospital Course. MEAT criteria are met with extensive documentation of monitoring (symptoms, O2 saturation, physical exam findings), evaluation (PFTs, CTA, physical exam), assessment (significant worsening), and treatment (home O2, NRB, Flovent). The code J84.112 is the specific ICD-10-CM code for Idiopathic pulmonary fibrosis."
}
],
"I10": [
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "atenolol 50 mg daily",
"page_numbers": [
1
]
},
{
"text": "hctz 25 mg daily",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HTN' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('atenolol 50 mg daily', 'hctz 25 mg daily'). The code I10 is the appropriate ICD-10-CM code for Essential (primary) hypertension."
}
],
"E119": [
{
"icd_10_cm_code": "E11.9",
"icd_10_cm_code_description": "Type 2 diabetes mellitus without complications",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "lantus 14 U qhs",
"page_numbers": [
1
]
},
{
"text": "metformin 1000 mg",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "DM",
"page_numbers": [
1
]
}
],
"justification": "The entity 'DM' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('lantus 14 U qhs', 'metformin 1000 mg'). The code E11.9 is the appropriate ICD-10-CM code for Type 2 diabetes mellitus without complications, as no complications are documented in the entities."
}
],
"F329": [
{
"icd_10_cm_code": "F32.9",
"icd_10_cm_code_description": "Major depressive disorder, single episode, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "bupropion SR 200\nmg qAM",
"page_numbers": [
1
]
},
{
"text": "celexa 40 mg daily",
"page_numbers": [
1
]
},
{
"text": "trazodone 50 mg qhs:prn",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "Depression",
"page_numbers": [
1
]
}
],
"justification": "The entity 'Depression' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('bupropion SR 200 mg qAM', 'celexa 40 mg daily', 'trazodone 50 mg qhs:prn'). The code F32.9 is the appropriate ICD-10-CM code for Major depressive disorder, single episode, unspecified, based on the entity text."
}
]
}
} |
Extract only the clinical assessment findings for each condition, including diagnostic conclusions and staging. | Admission Date: [**2119-6-24**] Discharge Date: [**2119-6-28**]
Date of Birth: [**2067-8-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
51 y/o M w/IPF on home O2 who presented to the ED last night
with worsening dyspnea. This has been slowly worsening for the
past few weeks, but over 2 days severely worsened to the point
where he was short of breath at rest. He also has had a cough
productive of yellow blood-tinged sputum for 2 days (normally
has a non-productive cough at baseline). According to his
pulmonary rehab notes, he has been increasingly unable to
exercise due to hypoxemia with exertion despite supplemental O2.
He has also had anterior chest pain which he associates with
coughing. The chest pain is not exertional. He denies
orthopnea and LE edema. He has had chills over the past couple
of days, but no fevers.
In the ED, he was intermittently hypoxic to the 70s and 80s on
4L so was switched to a NRB. He was also tachycardic in the
110s. He was given levofloxacin for pna. Because of the
tachycardia and hypoxia, he underwent a CTA which was negative
for PE but showed multifocal airspace disease. He was admitted
to the [**Hospital Unit Name 153**].
Past Medical History:
1. IPF: Diagnosed on VATS [**2116**], treated with gamma-interferon
for one year around that time. Has also been on
N-acetylcysteine but stopped last year. Not a candidate for
BUILD3 due to FVC <50%. Has never been treated with steroids.
Undergoing transplant w/u at [**Hospital1 112**] (per pt, currently contingent
on weight loss but remainder of w/u done). In pulmonary rehab
here, and at home is on 2L O2 continuous with 4L O2 for
exertion. Most recent PFTs [**2-17**]: FEV1 1.58 (51%), FVC 1.84
(44%), FEV1/FVC 86%, TLC 2.61 (43% in [**12-17**]), DLCO 8.6 (32% in
[**12-17**]).
2. OSA, on CPAP
3. GERD
4. HTN
5. DM
6. Depression
[**Last Name (un) 1724**]: albuterol MDI prn, atenolol 50 mg daily, bupropion SR 200
mg qAM, celexa 40 mg daily, hctz 25 mg daily, lantus 14 U qhs,
metformin 1000 mg [**Hospital1 **], trazodone 50 mg qhs:prn, aspirin 325 mg
daily, amino acids, omeprazole 20 mg daily, flovent 220 mcg 2
puffs qAM (recently restarted at pulmonary rehab)
Social History:
Occupation: Currently unable to work but formerly worked for
Merchant Marine
Drugs: No
Tobacco: Never
Alcohol: No
Other: No animals at home. No sick contacts.
Family History:
non-contributory.
Physical Exam:
General Appearance: Overweight / Obese, tachypneic, in mild
respiratory distress
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic), Unable to appreciate loud P2
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Dullness : bilateral bases), (Breath Sounds: Crackles : [**1-11**] way
on R, [**1-12**] way on L, No(t) Wheezes : ), egophony at bilateral
bases
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)
Clubbing
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Responds to: Verbal stimuli, Movement:
Not assessed, Tone: Not assessed
Pertinent Results:
patient expired
Brief Hospital Course:
51 yoM w/ a h/o of IPF presented with a significant worsening of
his IPF. Moving in bed would cause his O2 sat to drop to 60%
while on FiO2 100%. Patient was DNR / DNI. Not on the
transplant list due to BMI > 30 and evaluated at the [**Hospital1 112**].
[**Hospital6 **] was contact[**Name (NI) **] who confirmed the fact that
the patient was not on the list and there was no way to place
him on a list for an urgent lung transplant. Discussion with
the family led to the decision to make the patient comfort
measures only. Patient Died on [**2119-6-28**].
Medications on Admission:
patient expired
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
| {
"clinical_findings": {
"J84112": [
{
"icd_10_cm_code": "J84.112",
"icd_10_cm_code_description": "Idiopathic pulmonary fibrosis",
"Monitoring": [
{
"text": "worsening dyspnea",
"page_numbers": [
1
]
},
{
"text": "short of breath at rest",
"page_numbers": [
1
]
},
{
"text": "cough\nproductive of yellow blood-tinged sputum",
"page_numbers": [
1
]
},
{
"text": "hypoxemia with exertion",
"page_numbers": [
1
]
},
{
"text": "on home O2",
"page_numbers": [
1
]
},
{
"text": "tachypneic",
"page_numbers": [
1
]
},
{
"text": "in mild\nrespiratory distress",
"page_numbers": [
1
]
},
{
"text": "Dullness : bilateral bases",
"page_numbers": [
1
]
},
{
"text": "Crackles : [**1-11**] way\non R, [**1-12**] way on L",
"page_numbers": [
1
]
},
{
"text": "egophony at bilateral\nbases",
"page_numbers": [
1
]
},
{
"text": "O2 sat to drop to 60%\nwhile on FiO2 100%",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "PFTs [**2-17**]: FEV1 1.58 (51%), FVC 1.84\n(44%), FEV1/FVC 86%, TLC 2.61 (43% in [**12-17**]), DLCO 8.6 (32% in\n[**12-17**])",
"page_numbers": [
1
]
},
{
"text": "CTA which was negative\nfor PE but showed multifocal airspace disease",
"page_numbers": [
1
]
},
{
"text": "Physical Exam: Overweight / Obese, tachypneic, in mild\nrespiratory distress",
"page_numbers": [
1
]
},
{
"text": "Dullness : bilateral bases",
"page_numbers": [
1
]
},
{
"text": "Breath Sounds: Crackles : [**1-11**] way\non R, [**1-12**] way on L",
"page_numbers": [
1
]
},
{
"text": "egophony at bilateral\nbases",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "significant worsening of\nhis IPF",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "on home O2",
"page_numbers": [
1
]
},
{
"text": "switched to a NRB",
"page_numbers": [
1
]
},
{
"text": "flovent 220 mcg 2\npuffs qAM",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "significant worsening of\nhis IPF",
"page_numbers": [
1
]
}
],
"justification": "The entity 'IPF' is documented in the History of Present Illness, Past Medical History, and Brief Hospital Course. MEAT criteria are met with extensive documentation of monitoring (symptoms, O2 saturation, physical exam findings), evaluation (PFTs, CTA, physical exam), assessment (significant worsening), and treatment (home O2, NRB, Flovent). The code J84.112 is the specific ICD-10-CM code for Idiopathic pulmonary fibrosis."
}
],
"I10": [
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "atenolol 50 mg daily",
"page_numbers": [
1
]
},
{
"text": "hctz 25 mg daily",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HTN' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('atenolol 50 mg daily', 'hctz 25 mg daily'). The code I10 is the appropriate ICD-10-CM code for Essential (primary) hypertension."
}
],
"E119": [
{
"icd_10_cm_code": "E11.9",
"icd_10_cm_code_description": "Type 2 diabetes mellitus without complications",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "lantus 14 U qhs",
"page_numbers": [
1
]
},
{
"text": "metformin 1000 mg",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "DM",
"page_numbers": [
1
]
}
],
"justification": "The entity 'DM' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('lantus 14 U qhs', 'metformin 1000 mg'). The code E11.9 is the appropriate ICD-10-CM code for Type 2 diabetes mellitus without complications, as no complications are documented in the entities."
}
],
"F329": [
{
"icd_10_cm_code": "F32.9",
"icd_10_cm_code_description": "Major depressive disorder, single episode, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "bupropion SR 200\nmg qAM",
"page_numbers": [
1
]
},
{
"text": "celexa 40 mg daily",
"page_numbers": [
1
]
},
{
"text": "trazodone 50 mg qhs:prn",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "Depression",
"page_numbers": [
1
]
}
],
"justification": "The entity 'Depression' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('bupropion SR 200 mg qAM', 'celexa 40 mg daily', 'trazodone 50 mg qhs:prn'). The code F32.9 is the appropriate ICD-10-CM code for Major depressive disorder, single episode, unspecified, based on the entity text."
}
]
}
} |
Extract only the treatment or intervention given for each condition, including surgeries, procedures, and medications. | Admission Date: [**2119-6-24**] Discharge Date: [**2119-6-28**]
Date of Birth: [**2067-8-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
51 y/o M w/IPF on home O2 who presented to the ED last night
with worsening dyspnea. This has been slowly worsening for the
past few weeks, but over 2 days severely worsened to the point
where he was short of breath at rest. He also has had a cough
productive of yellow blood-tinged sputum for 2 days (normally
has a non-productive cough at baseline). According to his
pulmonary rehab notes, he has been increasingly unable to
exercise due to hypoxemia with exertion despite supplemental O2.
He has also had anterior chest pain which he associates with
coughing. The chest pain is not exertional. He denies
orthopnea and LE edema. He has had chills over the past couple
of days, but no fevers.
In the ED, he was intermittently hypoxic to the 70s and 80s on
4L so was switched to a NRB. He was also tachycardic in the
110s. He was given levofloxacin for pna. Because of the
tachycardia and hypoxia, he underwent a CTA which was negative
for PE but showed multifocal airspace disease. He was admitted
to the [**Hospital Unit Name 153**].
Past Medical History:
1. IPF: Diagnosed on VATS [**2116**], treated with gamma-interferon
for one year around that time. Has also been on
N-acetylcysteine but stopped last year. Not a candidate for
BUILD3 due to FVC <50%. Has never been treated with steroids.
Undergoing transplant w/u at [**Hospital1 112**] (per pt, currently contingent
on weight loss but remainder of w/u done). In pulmonary rehab
here, and at home is on 2L O2 continuous with 4L O2 for
exertion. Most recent PFTs [**2-17**]: FEV1 1.58 (51%), FVC 1.84
(44%), FEV1/FVC 86%, TLC 2.61 (43% in [**12-17**]), DLCO 8.6 (32% in
[**12-17**]).
2. OSA, on CPAP
3. GERD
4. HTN
5. DM
6. Depression
[**Last Name (un) 1724**]: albuterol MDI prn, atenolol 50 mg daily, bupropion SR 200
mg qAM, celexa 40 mg daily, hctz 25 mg daily, lantus 14 U qhs,
metformin 1000 mg [**Hospital1 **], trazodone 50 mg qhs:prn, aspirin 325 mg
daily, amino acids, omeprazole 20 mg daily, flovent 220 mcg 2
puffs qAM (recently restarted at pulmonary rehab)
Social History:
Occupation: Currently unable to work but formerly worked for
Merchant Marine
Drugs: No
Tobacco: Never
Alcohol: No
Other: No animals at home. No sick contacts.
Family History:
non-contributory.
Physical Exam:
General Appearance: Overweight / Obese, tachypneic, in mild
respiratory distress
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic), Unable to appreciate loud P2
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Dullness : bilateral bases), (Breath Sounds: Crackles : [**1-11**] way
on R, [**1-12**] way on L, No(t) Wheezes : ), egophony at bilateral
bases
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)
Clubbing
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Responds to: Verbal stimuli, Movement:
Not assessed, Tone: Not assessed
Pertinent Results:
patient expired
Brief Hospital Course:
51 yoM w/ a h/o of IPF presented with a significant worsening of
his IPF. Moving in bed would cause his O2 sat to drop to 60%
while on FiO2 100%. Patient was DNR / DNI. Not on the
transplant list due to BMI > 30 and evaluated at the [**Hospital1 112**].
[**Hospital6 **] was contact[**Name (NI) **] who confirmed the fact that
the patient was not on the list and there was no way to place
him on a list for an urgent lung transplant. Discussion with
the family led to the decision to make the patient comfort
measures only. Patient Died on [**2119-6-28**].
Medications on Admission:
patient expired
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
| {
"clinical_findings": {
"J84112": [
{
"icd_10_cm_code": "J84.112",
"icd_10_cm_code_description": "Idiopathic pulmonary fibrosis",
"Monitoring": [
{
"text": "worsening dyspnea",
"page_numbers": [
1
]
},
{
"text": "short of breath at rest",
"page_numbers": [
1
]
},
{
"text": "cough\nproductive of yellow blood-tinged sputum",
"page_numbers": [
1
]
},
{
"text": "hypoxemia with exertion",
"page_numbers": [
1
]
},
{
"text": "on home O2",
"page_numbers": [
1
]
},
{
"text": "tachypneic",
"page_numbers": [
1
]
},
{
"text": "in mild\nrespiratory distress",
"page_numbers": [
1
]
},
{
"text": "Dullness : bilateral bases",
"page_numbers": [
1
]
},
{
"text": "Crackles : [**1-11**] way\non R, [**1-12**] way on L",
"page_numbers": [
1
]
},
{
"text": "egophony at bilateral\nbases",
"page_numbers": [
1
]
},
{
"text": "O2 sat to drop to 60%\nwhile on FiO2 100%",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "PFTs [**2-17**]: FEV1 1.58 (51%), FVC 1.84\n(44%), FEV1/FVC 86%, TLC 2.61 (43% in [**12-17**]), DLCO 8.6 (32% in\n[**12-17**])",
"page_numbers": [
1
]
},
{
"text": "CTA which was negative\nfor PE but showed multifocal airspace disease",
"page_numbers": [
1
]
},
{
"text": "Physical Exam: Overweight / Obese, tachypneic, in mild\nrespiratory distress",
"page_numbers": [
1
]
},
{
"text": "Dullness : bilateral bases",
"page_numbers": [
1
]
},
{
"text": "Breath Sounds: Crackles : [**1-11**] way\non R, [**1-12**] way on L",
"page_numbers": [
1
]
},
{
"text": "egophony at bilateral\nbases",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "significant worsening of\nhis IPF",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "on home O2",
"page_numbers": [
1
]
},
{
"text": "switched to a NRB",
"page_numbers": [
1
]
},
{
"text": "flovent 220 mcg 2\npuffs qAM",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "significant worsening of\nhis IPF",
"page_numbers": [
1
]
}
],
"justification": "The entity 'IPF' is documented in the History of Present Illness, Past Medical History, and Brief Hospital Course. MEAT criteria are met with extensive documentation of monitoring (symptoms, O2 saturation, physical exam findings), evaluation (PFTs, CTA, physical exam), assessment (significant worsening), and treatment (home O2, NRB, Flovent). The code J84.112 is the specific ICD-10-CM code for Idiopathic pulmonary fibrosis."
}
],
"I10": [
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "atenolol 50 mg daily",
"page_numbers": [
1
]
},
{
"text": "hctz 25 mg daily",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HTN' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('atenolol 50 mg daily', 'hctz 25 mg daily'). The code I10 is the appropriate ICD-10-CM code for Essential (primary) hypertension."
}
],
"E119": [
{
"icd_10_cm_code": "E11.9",
"icd_10_cm_code_description": "Type 2 diabetes mellitus without complications",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "lantus 14 U qhs",
"page_numbers": [
1
]
},
{
"text": "metformin 1000 mg",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "DM",
"page_numbers": [
1
]
}
],
"justification": "The entity 'DM' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('lantus 14 U qhs', 'metformin 1000 mg'). The code E11.9 is the appropriate ICD-10-CM code for Type 2 diabetes mellitus without complications, as no complications are documented in the entities."
}
],
"F329": [
{
"icd_10_cm_code": "F32.9",
"icd_10_cm_code_description": "Major depressive disorder, single episode, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "bupropion SR 200\nmg qAM",
"page_numbers": [
1
]
},
{
"text": "celexa 40 mg daily",
"page_numbers": [
1
]
},
{
"text": "trazodone 50 mg qhs:prn",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "Depression",
"page_numbers": [
1
]
}
],
"justification": "The entity 'Depression' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('bupropion SR 200 mg qAM', 'celexa 40 mg daily', 'trazodone 50 mg qhs:prn'). The code F32.9 is the appropriate ICD-10-CM code for Major depressive disorder, single episode, unspecified, based on the entity text."
}
]
}
} |
Extract only the evidence from the discharge summary that supports the existence of each condition. | Admission Date: [**2119-6-24**] Discharge Date: [**2119-6-28**]
Date of Birth: [**2067-8-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
51 y/o M w/IPF on home O2 who presented to the ED last night
with worsening dyspnea. This has been slowly worsening for the
past few weeks, but over 2 days severely worsened to the point
where he was short of breath at rest. He also has had a cough
productive of yellow blood-tinged sputum for 2 days (normally
has a non-productive cough at baseline). According to his
pulmonary rehab notes, he has been increasingly unable to
exercise due to hypoxemia with exertion despite supplemental O2.
He has also had anterior chest pain which he associates with
coughing. The chest pain is not exertional. He denies
orthopnea and LE edema. He has had chills over the past couple
of days, but no fevers.
In the ED, he was intermittently hypoxic to the 70s and 80s on
4L so was switched to a NRB. He was also tachycardic in the
110s. He was given levofloxacin for pna. Because of the
tachycardia and hypoxia, he underwent a CTA which was negative
for PE but showed multifocal airspace disease. He was admitted
to the [**Hospital Unit Name 153**].
Past Medical History:
1. IPF: Diagnosed on VATS [**2116**], treated with gamma-interferon
for one year around that time. Has also been on
N-acetylcysteine but stopped last year. Not a candidate for
BUILD3 due to FVC <50%. Has never been treated with steroids.
Undergoing transplant w/u at [**Hospital1 112**] (per pt, currently contingent
on weight loss but remainder of w/u done). In pulmonary rehab
here, and at home is on 2L O2 continuous with 4L O2 for
exertion. Most recent PFTs [**2-17**]: FEV1 1.58 (51%), FVC 1.84
(44%), FEV1/FVC 86%, TLC 2.61 (43% in [**12-17**]), DLCO 8.6 (32% in
[**12-17**]).
2. OSA, on CPAP
3. GERD
4. HTN
5. DM
6. Depression
[**Last Name (un) 1724**]: albuterol MDI prn, atenolol 50 mg daily, bupropion SR 200
mg qAM, celexa 40 mg daily, hctz 25 mg daily, lantus 14 U qhs,
metformin 1000 mg [**Hospital1 **], trazodone 50 mg qhs:prn, aspirin 325 mg
daily, amino acids, omeprazole 20 mg daily, flovent 220 mcg 2
puffs qAM (recently restarted at pulmonary rehab)
Social History:
Occupation: Currently unable to work but formerly worked for
Merchant Marine
Drugs: No
Tobacco: Never
Alcohol: No
Other: No animals at home. No sick contacts.
Family History:
non-contributory.
Physical Exam:
General Appearance: Overweight / Obese, tachypneic, in mild
respiratory distress
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic), Unable to appreciate loud P2
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Dullness : bilateral bases), (Breath Sounds: Crackles : [**1-11**] way
on R, [**1-12**] way on L, No(t) Wheezes : ), egophony at bilateral
bases
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)
Clubbing
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Responds to: Verbal stimuli, Movement:
Not assessed, Tone: Not assessed
Pertinent Results:
patient expired
Brief Hospital Course:
51 yoM w/ a h/o of IPF presented with a significant worsening of
his IPF. Moving in bed would cause his O2 sat to drop to 60%
while on FiO2 100%. Patient was DNR / DNI. Not on the
transplant list due to BMI > 30 and evaluated at the [**Hospital1 112**].
[**Hospital6 **] was contact[**Name (NI) **] who confirmed the fact that
the patient was not on the list and there was no way to place
him on a list for an urgent lung transplant. Discussion with
the family led to the decision to make the patient comfort
measures only. Patient Died on [**2119-6-28**].
Medications on Admission:
patient expired
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
| {
"clinical_findings": {
"J84112": [
{
"icd_10_cm_code": "J84.112",
"icd_10_cm_code_description": "Idiopathic pulmonary fibrosis",
"Monitoring": [
{
"text": "worsening dyspnea",
"page_numbers": [
1
]
},
{
"text": "short of breath at rest",
"page_numbers": [
1
]
},
{
"text": "cough\nproductive of yellow blood-tinged sputum",
"page_numbers": [
1
]
},
{
"text": "hypoxemia with exertion",
"page_numbers": [
1
]
},
{
"text": "on home O2",
"page_numbers": [
1
]
},
{
"text": "tachypneic",
"page_numbers": [
1
]
},
{
"text": "in mild\nrespiratory distress",
"page_numbers": [
1
]
},
{
"text": "Dullness : bilateral bases",
"page_numbers": [
1
]
},
{
"text": "Crackles : [**1-11**] way\non R, [**1-12**] way on L",
"page_numbers": [
1
]
},
{
"text": "egophony at bilateral\nbases",
"page_numbers": [
1
]
},
{
"text": "O2 sat to drop to 60%\nwhile on FiO2 100%",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "PFTs [**2-17**]: FEV1 1.58 (51%), FVC 1.84\n(44%), FEV1/FVC 86%, TLC 2.61 (43% in [**12-17**]), DLCO 8.6 (32% in\n[**12-17**])",
"page_numbers": [
1
]
},
{
"text": "CTA which was negative\nfor PE but showed multifocal airspace disease",
"page_numbers": [
1
]
},
{
"text": "Physical Exam: Overweight / Obese, tachypneic, in mild\nrespiratory distress",
"page_numbers": [
1
]
},
{
"text": "Dullness : bilateral bases",
"page_numbers": [
1
]
},
{
"text": "Breath Sounds: Crackles : [**1-11**] way\non R, [**1-12**] way on L",
"page_numbers": [
1
]
},
{
"text": "egophony at bilateral\nbases",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "significant worsening of\nhis IPF",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "on home O2",
"page_numbers": [
1
]
},
{
"text": "switched to a NRB",
"page_numbers": [
1
]
},
{
"text": "flovent 220 mcg 2\npuffs qAM",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "significant worsening of\nhis IPF",
"page_numbers": [
1
]
}
],
"justification": "The entity 'IPF' is documented in the History of Present Illness, Past Medical History, and Brief Hospital Course. MEAT criteria are met with extensive documentation of monitoring (symptoms, O2 saturation, physical exam findings), evaluation (PFTs, CTA, physical exam), assessment (significant worsening), and treatment (home O2, NRB, Flovent). The code J84.112 is the specific ICD-10-CM code for Idiopathic pulmonary fibrosis."
}
],
"I10": [
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "atenolol 50 mg daily",
"page_numbers": [
1
]
},
{
"text": "hctz 25 mg daily",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HTN' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('atenolol 50 mg daily', 'hctz 25 mg daily'). The code I10 is the appropriate ICD-10-CM code for Essential (primary) hypertension."
}
],
"E119": [
{
"icd_10_cm_code": "E11.9",
"icd_10_cm_code_description": "Type 2 diabetes mellitus without complications",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "lantus 14 U qhs",
"page_numbers": [
1
]
},
{
"text": "metformin 1000 mg",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "DM",
"page_numbers": [
1
]
}
],
"justification": "The entity 'DM' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('lantus 14 U qhs', 'metformin 1000 mg'). The code E11.9 is the appropriate ICD-10-CM code for Type 2 diabetes mellitus without complications, as no complications are documented in the entities."
}
],
"F329": [
{
"icd_10_cm_code": "F32.9",
"icd_10_cm_code_description": "Major depressive disorder, single episode, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "bupropion SR 200\nmg qAM",
"page_numbers": [
1
]
},
{
"text": "celexa 40 mg daily",
"page_numbers": [
1
]
},
{
"text": "trazodone 50 mg qhs:prn",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "Depression",
"page_numbers": [
1
]
}
],
"justification": "The entity 'Depression' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('bupropion SR 200 mg qAM', 'celexa 40 mg daily', 'trazodone 50 mg qhs:prn'). The code F32.9 is the appropriate ICD-10-CM code for Major depressive disorder, single episode, unspecified, based on the entity text."
}
]
}
} |
Extract only the text-based justification for assigning the ICD-10-CM code to each condition. | Admission Date: [**2119-6-24**] Discharge Date: [**2119-6-28**]
Date of Birth: [**2067-8-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
51 y/o M w/IPF on home O2 who presented to the ED last night
with worsening dyspnea. This has been slowly worsening for the
past few weeks, but over 2 days severely worsened to the point
where he was short of breath at rest. He also has had a cough
productive of yellow blood-tinged sputum for 2 days (normally
has a non-productive cough at baseline). According to his
pulmonary rehab notes, he has been increasingly unable to
exercise due to hypoxemia with exertion despite supplemental O2.
He has also had anterior chest pain which he associates with
coughing. The chest pain is not exertional. He denies
orthopnea and LE edema. He has had chills over the past couple
of days, but no fevers.
In the ED, he was intermittently hypoxic to the 70s and 80s on
4L so was switched to a NRB. He was also tachycardic in the
110s. He was given levofloxacin for pna. Because of the
tachycardia and hypoxia, he underwent a CTA which was negative
for PE but showed multifocal airspace disease. He was admitted
to the [**Hospital Unit Name 153**].
Past Medical History:
1. IPF: Diagnosed on VATS [**2116**], treated with gamma-interferon
for one year around that time. Has also been on
N-acetylcysteine but stopped last year. Not a candidate for
BUILD3 due to FVC <50%. Has never been treated with steroids.
Undergoing transplant w/u at [**Hospital1 112**] (per pt, currently contingent
on weight loss but remainder of w/u done). In pulmonary rehab
here, and at home is on 2L O2 continuous with 4L O2 for
exertion. Most recent PFTs [**2-17**]: FEV1 1.58 (51%), FVC 1.84
(44%), FEV1/FVC 86%, TLC 2.61 (43% in [**12-17**]), DLCO 8.6 (32% in
[**12-17**]).
2. OSA, on CPAP
3. GERD
4. HTN
5. DM
6. Depression
[**Last Name (un) 1724**]: albuterol MDI prn, atenolol 50 mg daily, bupropion SR 200
mg qAM, celexa 40 mg daily, hctz 25 mg daily, lantus 14 U qhs,
metformin 1000 mg [**Hospital1 **], trazodone 50 mg qhs:prn, aspirin 325 mg
daily, amino acids, omeprazole 20 mg daily, flovent 220 mcg 2
puffs qAM (recently restarted at pulmonary rehab)
Social History:
Occupation: Currently unable to work but formerly worked for
Merchant Marine
Drugs: No
Tobacco: Never
Alcohol: No
Other: No animals at home. No sick contacts.
Family History:
non-contributory.
Physical Exam:
General Appearance: Overweight / Obese, tachypneic, in mild
respiratory distress
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic), Unable to appreciate loud P2
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Dullness : bilateral bases), (Breath Sounds: Crackles : [**1-11**] way
on R, [**1-12**] way on L, No(t) Wheezes : ), egophony at bilateral
bases
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)
Clubbing
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Responds to: Verbal stimuli, Movement:
Not assessed, Tone: Not assessed
Pertinent Results:
patient expired
Brief Hospital Course:
51 yoM w/ a h/o of IPF presented with a significant worsening of
his IPF. Moving in bed would cause his O2 sat to drop to 60%
while on FiO2 100%. Patient was DNR / DNI. Not on the
transplant list due to BMI > 30 and evaluated at the [**Hospital1 112**].
[**Hospital6 **] was contact[**Name (NI) **] who confirmed the fact that
the patient was not on the list and there was no way to place
him on a list for an urgent lung transplant. Discussion with
the family led to the decision to make the patient comfort
measures only. Patient Died on [**2119-6-28**].
Medications on Admission:
patient expired
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
| {
"clinical_findings": {
"J84112": [
{
"icd_10_cm_code": "J84.112",
"icd_10_cm_code_description": "Idiopathic pulmonary fibrosis",
"Monitoring": [
{
"text": "worsening dyspnea",
"page_numbers": [
1
]
},
{
"text": "short of breath at rest",
"page_numbers": [
1
]
},
{
"text": "cough\nproductive of yellow blood-tinged sputum",
"page_numbers": [
1
]
},
{
"text": "hypoxemia with exertion",
"page_numbers": [
1
]
},
{
"text": "on home O2",
"page_numbers": [
1
]
},
{
"text": "tachypneic",
"page_numbers": [
1
]
},
{
"text": "in mild\nrespiratory distress",
"page_numbers": [
1
]
},
{
"text": "Dullness : bilateral bases",
"page_numbers": [
1
]
},
{
"text": "Crackles : [**1-11**] way\non R, [**1-12**] way on L",
"page_numbers": [
1
]
},
{
"text": "egophony at bilateral\nbases",
"page_numbers": [
1
]
},
{
"text": "O2 sat to drop to 60%\nwhile on FiO2 100%",
"page_numbers": [
1
]
}
],
"Evaluation": [
{
"text": "PFTs [**2-17**]: FEV1 1.58 (51%), FVC 1.84\n(44%), FEV1/FVC 86%, TLC 2.61 (43% in [**12-17**]), DLCO 8.6 (32% in\n[**12-17**])",
"page_numbers": [
1
]
},
{
"text": "CTA which was negative\nfor PE but showed multifocal airspace disease",
"page_numbers": [
1
]
},
{
"text": "Physical Exam: Overweight / Obese, tachypneic, in mild\nrespiratory distress",
"page_numbers": [
1
]
},
{
"text": "Dullness : bilateral bases",
"page_numbers": [
1
]
},
{
"text": "Breath Sounds: Crackles : [**1-11**] way\non R, [**1-12**] way on L",
"page_numbers": [
1
]
},
{
"text": "egophony at bilateral\nbases",
"page_numbers": [
1
]
}
],
"Assessment": [
{
"text": "significant worsening of\nhis IPF",
"page_numbers": [
1
]
}
],
"Treatment": [
{
"text": "on home O2",
"page_numbers": [
1
]
},
{
"text": "switched to a NRB",
"page_numbers": [
1
]
},
{
"text": "flovent 220 mcg 2\npuffs qAM",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "IPF",
"page_numbers": [
1
]
},
{
"evidence_text": "significant worsening of\nhis IPF",
"page_numbers": [
1
]
}
],
"justification": "The entity 'IPF' is documented in the History of Present Illness, Past Medical History, and Brief Hospital Course. MEAT criteria are met with extensive documentation of monitoring (symptoms, O2 saturation, physical exam findings), evaluation (PFTs, CTA, physical exam), assessment (significant worsening), and treatment (home O2, NRB, Flovent). The code J84.112 is the specific ICD-10-CM code for Idiopathic pulmonary fibrosis."
}
],
"I10": [
{
"icd_10_cm_code": "I10",
"icd_10_cm_code_description": "Essential (primary) hypertension",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "atenolol 50 mg daily",
"page_numbers": [
1
]
},
{
"text": "hctz 25 mg daily",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "HTN",
"page_numbers": [
1
]
}
],
"justification": "The entity 'HTN' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('atenolol 50 mg daily', 'hctz 25 mg daily'). The code I10 is the appropriate ICD-10-CM code for Essential (primary) hypertension."
}
],
"E119": [
{
"icd_10_cm_code": "E11.9",
"icd_10_cm_code_description": "Type 2 diabetes mellitus without complications",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "lantus 14 U qhs",
"page_numbers": [
1
]
},
{
"text": "metformin 1000 mg",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "DM",
"page_numbers": [
1
]
}
],
"justification": "The entity 'DM' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('lantus 14 U qhs', 'metformin 1000 mg'). The code E11.9 is the appropriate ICD-10-CM code for Type 2 diabetes mellitus without complications, as no complications are documented in the entities."
}
],
"F329": [
{
"icd_10_cm_code": "F32.9",
"icd_10_cm_code_description": "Major depressive disorder, single episode, unspecified",
"Monitoring": [],
"Evaluation": [],
"Assessment": [],
"Treatment": [
{
"text": "bupropion SR 200\nmg qAM",
"page_numbers": [
1
]
},
{
"text": "celexa 40 mg daily",
"page_numbers": [
1
]
},
{
"text": "trazodone 50 mg qhs:prn",
"page_numbers": [
1
]
}
],
"condition_evidence": [
{
"evidence_text": "Depression",
"page_numbers": [
1
]
}
],
"justification": "The entity 'Depression' is documented in the Past Medical History. MEAT criteria are met with documentation of ongoing treatment ('bupropion SR 200 mg qAM', 'celexa 40 mg daily', 'trazodone 50 mg qhs:prn'). The code F32.9 is the appropriate ICD-10-CM code for Major depressive disorder, single episode, unspecified, based on the entity text."
}
]
}
} |
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