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What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
ASSESSMENT AND PLAN:
Mr. ___ is a ___ M w/hx of DM, PVD, ESRD on HD who initially
presented with paronychia s/p lancing in the ED and was found to
be hyperkalemic to 5.9
.
# Hyperkalemia: Recieved Kayexalate in the ED with insulin and
his potassium transiently decreased to 4.7 but was back up to
5.9 on the morning prior to dialysis. Most likely a potassium
of 5.9 this is normal for him pre-dialysis. He adherence to
wthe renal diet and states that he normally runs high so gets a
___ K bath at HD. Although his EKG did have peaked T waves in
v4 and v5, this was consistent with his prior EKGs and was only
in 2 leads (instead of diffusely) representing his baseline EKG,
with some minor differences due to lead placement.
.
# Paronychia: S/p lacing and drainage in the ED.
- should self-resolve with soaks, remove dressing in AM
.
#. HTN: continued home Toprol XL and Nifedipine, and volume
management with dialysis.
.
#. ESRD on HD: No signs of fluid overload on exam. Patient
continued on sevelamer and sensipar as well as a renal diet. He
was dialyzed ___ morning prior to discharge.
.
#. DM2: PAtient continued on home dose of lantus 16 units qAM
and humalog SS
Also continue aspirin.
.
#. Hyperlipidemia: continue Pravastatin
.
#. s/p Renal Transplant: Failed in ___. Continued on
Prednisone 3mg PO daily.
-? why the patient is on prednisone while on dialysis and this
should be addressed with renal as an outpatient.
.
***. | CELLULITIS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ y/o F with hx of asthma, OSA, and RA who presents today with
new chest pain and afib with RVR.
.
ACTIVE ISSUES
.
# New onset atrial fibrillation: Some possible etiologies for
her new onset atrial fibrillation included hypoxia from
pulmonary causes, drug/EtOH, thyroid disease, and ischemia/CHF.
Troponins negative x2 without any history of heart disease.
Previous TTE in ___ and Stress MIBI in ___ were unremarkable.
She does have significant lung disease with asthma and OSA and
was initially hypoxic on arrival to the ER, though she was
comfortable on RA for her entire hospitalization. TSH normal at
3.3 and serum/urine tox negative. The only recent medication
change was restarting her Enbrel just days prior to this
presentation, and we hypothesized if this might have caused her
to flip into atrial fibrillation in some way. She was initially
rate controlled with metoprolol PO and diltiazem PRN. Since she
did not cardiovert overnight, she was sent for TEE/DCCV, but
spontaneously cardioverted even before attempting it. The TEE
was done and showed rapid filling of the left atrial appendage,
but not thrombus. EF was >55% and there were no other apparent
structural abnormalities. Given her CHADS2 score of 1 (HTN),
she was maintained on only aspirin 81mg, though lengthy
discussions were had about possibly anticoagulating her for 1
month. She remained in normal sinus rhythm prior to discharge.
She will receive a TTE as outpatient to rule out structural
heart disease as a cause for her bout of atrial fibrillation and
her PCP ___ decide on Cardiology ___ if she deems it
necessary. The patient was instructed to come back to the ED if
she experiences chest pain, shortness of breath, or dizziness
again with this sensation of palpitations.
.
# Chest pain: Her substernal chest pain seemed to have resolved
spontaneously since arrival to the ED. There were no EKG changes
or cardiac enzyme elevations concerning for ischemia. She had
some recurrent pain the morning following admission, but once
again the EKG was normal.
.
INACTIVE ISSUES
.
# Seronegative nonerosive rheumatoid arthritis w/ secondary
Sjogren's syndrome: She was continued on her Enbrel. Her
pilocarpine had been previously discontinued because it was not
effective.
.
# Asthma: She was comfortable and satting well on RA, without
any wheezing on exam.
Her albuterol and fluticasone inhalers were continued per her
home dosing.
.
# OSA: She was started on CPAP nightly, auto-set while in house.
.
# Depression: Previous admission to psych facility ___. No
symptoms currently. She was continued on venlafaxine and
quetiapine.
.
TRANSITIONAL ISSUES
.
# ___: She will ___ with Dr. ___ after
getting an outpatient TTE. The results will be reveiwed and
referral to Cardiology should be made if appropriate.
***. | CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year old ___ speaking lady with history of lymphedema,
atrial fibrillation on warfarin s/p PPM placement for medication
intolerance (___) presenting with acute onset left lower
extremity leg pain, erythema, fever concerning for cellulitis.
# H/o Lymphedema
# Non-purulent cellulitis
Patient with chronic history of lymphedema in lower extremities
now presenting with increased redness, warmth, drainage in left
lower extremities, in the setting of fever to at least 100.5,
leukocytosis to 10.9 concerning for SSTI. No response to <1 day
of outpatient oral antibiotics (reportedly cephalexin). She was
initially started on vancomycin while in the ___ ___, switched
to clindamycin 300 mg q6H on ___. This is technically a
non-purulent cellulitis without outpatient treatment failure, as
she received <48 hours of antibiotics prior to presentation.
Erythema improved on PO clindamycin and she remained afebrile
with downtrending leukocytosis; BCx from ___ NGTD, MRSA swab
pending. She will be discharged on clindamycin 300 mg Q6H x 5
days ending ___ to complete a 7 day course of antibiotics. We
will count D1 as ___ as she missed several doses in the setting
of hospital delirium.
In terms of wound care management, wound care was consulted.
Please see page 1 for instructions. Patient's daughter was
instructed on how to manage wounds as well, and we have arranged
for ___. Please consider referral to outpatient wound clinic.
# Hospital acquired delirium: On ___ evening, patient became
acutely agitated and was not redirectable despite multiple
attempts and was refusing oral medications. She received IM
haloperidol 2.5 mg x 2. On day of discharge patient returned to
baseline mental status. She reported she understood that she had
been agitated overnight and apologized for that.
# Leukocytosis: Likely in setting of SSTI infection as above.
UA/UCx negative and CXR without focal consolidation. BCx NGTD.
# HFpEF: BNP elevated 748 (below past values in system
101___-___). Clinically appears euvolemic with the exception of
lymphedema (chronic) in lower extremities.
# Afib on warfarin. HRs 120s in afib on admission, likely
exacerbated in the setting of infection as above, HR improved to
___ on discharge. She was continued on home warfarin 5mg 6x/wk
and 2.5mg 1x/wk and metoprolol 25 mg q6H (home dose metoprolol
50 mg BID). INR 2.5 on day prior to discharge, refused labs on
day of discharge. Clindamycin does not typically interact with
warfarin.
# Hypertension: Continued home amlodipine 5mg.
TRANSITIONAL ISSUES:
====================
[] Clindamycin 500 mg Q6H x 5 days ending ___
[] Please consider referral to outpatient wound care clinic
- If patient is admitted in future please note she is at high
risk for delirium
# CONTACT: Daughter ___ ___
Greater than 30 minutes was spent in care coordination and
counseling on the day of discharge. Discharge required use of
translator services as well.
***. | CELLULITIS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
PRIMARY REASON FOR HOSPITALIZATION
==================================
#) ___ FLARE & C. DIFF COLITIS: Mr. ___ primary
issue was severe abdominal pain. Given his history of numerous
admissions for ___ exacerbation and extremely refractory
disease (multiple failed biological agents), we considered this
as our primary differential. He was treated with bowel rest, IV
fluid rescusitation, analgesia (hydromorphone, cyclobenzaprine,
and lorazepam), and IV methylprednisolone with minimal
improvement in abdominal pain or stool output initially. CT
scan failed to demonstrate obstruction, nephrolithiasis, or
other acute process to suggest an alternative diagnosis. Stool
cultures were negative but PCR revealed toxigenic C. diff.
After initiating PO vancomycin his symptoms improved
dramatically. GI was consulted, (and know this patient well)
and assessed that his symptoms were likely better explained by
C. diff infection rather than ___ flare given normal ESR and
CRP. Of note, he had been taking ciprofloxacin chronically as
an outpatient. GI recommended against immediate endoscopic
investigation since he was improving clinically. His diet was
advanced and medications transitioned to PO, including
analgesia, with continued clinical improvement. His steroids
were tapered and he was discharged with instructions to taper to
pre-admission levels.
His admission occurred in a context of his disease course
(refractory ___, frequent admissions) which was
understandably frustrating to Mr. ___. After failing
numerous agents for his ___ disease he has sought surgical
intervention on several occasions at ___ and he was felt not
to be a good candidate for surgery given lack of obstruction.
He was even set to get a second opinion with a surgeon at ___.
#) AGITATION & SUICIDAL IDEATION: From records, appears to be a
common behavior pattern when he is overwhelmed and having
difficulty coping. Mr. ___ was significantly agitated
during this admission especially early on when he reported to be
and appeared to be in severe pain. He shouted at staff members,
refused certain treatments (ex. subcutaneous heparin), and
expressed extreme frustration with ___ and threatened to "call
the local news" about his "horrible care" he received here.
Patient services were notified and spoke with the patient. In
the midst of his frustration he stated that he wanted to "go
home and end it all" and threatened to sign out AMA. Psychiatry
was consulted and felt his suicidal ideation was transient and
related to his underlying medical problems. His agitation
declined as his pain became better controlled. A urine tox
screen revealed cocaine, which could also have partially
explained his behavior on admission and his improvement after
abstinence.
#) COCAINE ABUSE: Possibly contributed to abdominal symptoms via
mesenteric ischemia. Patient denied current use of ilicits and
reported a distant history of cocaine use. His urine toxicology
revealed cocaine but he continued to vehemently deny using. His
theory was that he had "shared a Pepsi with someone" who may
have been doing cocaine and this had yielded a false-positive.
TRANSITIONAL ISSUES
===================
- Address cocaine abuse and its contribution to his abdominal
pain
- Close follow-up with GI
- Consider development of a care plan with PCP (see WebOMR note
from Dr. ___ details)
- Consider work-up of "A stable nodular focus of eccentric
heterogeneity is
noted along the lateral wall of the mid sigmoid colon measuring
1.3 x 1
cm." seen on CT scan here.
***. | MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
*** with CAD s/p CABG and multiple PCIs, CHF, heart block s/p
PPM presents with GI bleed.
# GI Bleed: Patient presented with bright red blood per rectum
indicative of likely lower GI bleed. Last colonoscopy in ___
was only remarkable for rectal polyp that was removed. Pt's
history of abdominal pain was confounded by her history of
visceral neuropathy, and her lactate was normal making ischemic
bowel process less likely. Her hct on presentation was 29 which
was lower from her prior baseline of 38 in ___ indicating
active bleeding and she was transfused 2 units pRBCs. CTA was
unable to be performed due to contrast allergy. GI was consulted
and she had a colonoscopy and EGD which showed multiple polypes
with path results pending at discharge. Her hct remained stable
(35.4 at discharge) and she no longer had further bleeding.
# RLE Swelling: Pt noted to have right lower extremity erythema
and mild tenderness raising concern for DVT or cellulitis. ___
was negative for DVT and she had no fevers or leukocytosis to
suggest infectious process at this time. Patient also had
saphenous vein harvested from right leg so likely has some
venous insufficiency as well.
# CAD: S/p multiple PCIs (last ___ and CABG in ___. Pt's
EKG was at baseline. She was continued on aspirin and ticagrelor
to maintain stent patency in setting of multiple PCI and history
of stent failure, and was also continued on atorvastatin.
However, her imdur, metoprolol, valsartan were held in the
setting of unstable blood volume. Once pt was no longer actively
bleeding these medications were restarted.
# sCHF: EF 35-40% in ___. Pt appeared euvolemic on admission
exam. Her lasix, spironolactone were held in setting of unstable
blood volume. They were restarted once pt was hemodynamically
stable and no longer bleeding.
# Hemochromatosis: Last ferritin and LFTs were normal in ___.
Her hemochromatosis appears not to not be active issue.
# Visceral Neuropathy: Pt was continued on gabapentin
# Osteoporosis: Pt's vitamin D was held while NPO.
# Vitamin B12 Deficiency: Pt's B12 was held while NPO.
# GERD: Pt was on IV PPI as above during active GI bleed.
TRANSITIONAL ISSUES
[ ] Per GI recommendations, pt should have small bowel
evaluation as an outpatient.
[ ] Repeat colonoscopy in ___ years time if colorectal cancer
screening is desired.
[ ] Pt had single polypectomy of stomach as well as polpectomies
of colon as well. Path results pending at discharge
[ ] Will need to have repeat endoscopy with polypectomy off of
antiplatelet therapy, per GI recommendations. She can discuss
this further with her outpatient gastroenterologist.
[ ] Hr creatinine was 1.2 on the day of discharge. This should
be repeated at her follow-up appointment.
***. | G.I. HEMORRHAGE WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
*** w hypothyroidism, intermittent low back pain, prior ex-lap
for Schwannoma resection, and diagnosis of H pylori in ___
s/p treatment with triple therapy, who presents with diarrhea
and intermittent crampy abdominal pain that has been persistent
for nearly 2 months.
# Weight loss with
# Dehydration and hypovolemia from
# Diarrhea, ? acute on chronic perhaps due to
# C difficile infection: While she was initially admitted with
plan for workup of chronic diarrhea, her C diff has come back
positive for toxigenic c diff. She was treated with IVF, po
vancomycin with plan to end the course on ___ for a 14 day
course. GI followed. Other stool studies were negative. TSH wnl.
In discussion with GI the plan for possible colonoscopy with
random biopsy was deferred in the setting of the c. diff and can
be consider following competition of treatment.
# Hypothyroidism: ___ wnl. Continued levoxyl
# anemia: new, unknown cause. B12/celiac serologies/haptoglobin
not consistent with a cause, iron c/w chronic disease v acute
infection. Her counts were stable during her admission.
# hypokalemia: likely ___ diarrhea. Improved with repletion.
# microscopic hematuria: She was noted to have microscopic
hematuria. CT ABD/Pelvis was done in ___ with only a simpe
cyst noted. The patient will need follow up as outpatient.
Greater than 30 minutes was spent in care coordination and
counseling on the day of discharge.
***. | MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with of history of EtOH cirrhosis (Child Class B, MELD 21)
with recent ___ admission of alcoholic hepatitis treated with
prednisone (completed ___ who presents with fevers,
headache, and weakness x 5 days.
Your symptoms are likely due to stopping your steroids "cold
___ For this, we restarted you on prednisone, which you
should slowly decreased over 2 weeks. Instructions as follows:
40mg (4 tabs) daily x 2 days (administered in the hospital)
30mg (3 tabs) daily x 2 days
20mg (2 tabs) daily x 2 days
15mg (1.5 tabs) daily x 2 days
10mg (1 tab) daily x 2 days
5mg (0.5 tabs) daily x 2 days
OFF (first day of no steroids ___
You also had one fever in our emergency room. We tested but
could not find any infection in your lungs, urine, or blood. You
got a dose of IV antibiotics, and should complete another 4 days
of oral antibiotics.
# Fevers: Patient with general malaise with nausea, headache and
elevated white count of 20 however she was on recent steroid
therapy. Her fever was recorded at 101.2 in the ED. In the
setting of immunosuppression with steroids, infectious work up
was done. Urine and blood showed no sign of infection.
Furthermore CXR showed no evidence of focal consolidation or
infectious process. RUQ US with dopplers with patent
vasculature and small perihepatic ascites not amenable to
paracentesis. In the absence of clear infectious source,she was
treated empirically with ceftriaxone to cover for spontaneous
bacterial peritonitis. Patient reported headache with slight
neck pain but is clinically without neck stiffness or
photophobia. It was also suspected that she may have secondary
adrenal insufficiency after recent discontinuation for steroids.
The patient was restarted on prednisone and her symptoms
improved. The ceftriaxone was kept on with the intention to
treat for 5 days. She was stable on discharge and prescribed a
prednisone taper.
# Malaise: Patient presented with fever suggestive of possible
infection (work-up and treatment per above), but given steroids
for four weeks stopped recently it was suspected patient may
have secondary adrenal insufficiency from chronic steroids.
Patient was restarted on prednisone 40mg daily and started to
improve. She was discharged on a taper.
# Alcoholic cirrhosis: Most recently liver biopsy in ___
with early cirrhosis (stage ___ fibrosis). Most recent ___
EGD showing portal-hypertensive gastropathy but no varices. No
history of hepatic encephalopathy or ascites. MELD 21 with
worsening liver function tests but no clinical evidence of
decompensation with hepatic encephalopathy or GI
bleeding.Patient was continued on home lactulose, multivitamin,
thiamine and folate. She was stable on discharge.
TRANSLATIONAL ISSUES
MEDICATIONS
- STARTED on 2 week Prednisone taper as follows
40mg daily x 2 days (last day ___
30mg daily x 2 days
20mg daily x 2 days
15mg daily x 2 days
10mg daily x 2 days
5mg daily x 2 days
OFF (first day of no steroids ___
- Started on empiric SBP treatment with ciprofloxacin x 5 days
(last day ___
FOLLOW-UP
- Patient to follow-up as scheduled at ___ clinic
on ___
***. | ENDOCRINE DISORDERS WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ yo with Afib, on coumadin with pacer with full territory left
MCA infarct with resulting global aphasia and right sided
paralysis, CTA with large proximal M1 clot, now CMO. A family
meeting was held shortly afte patient was admitted. Dr. ___
(___) was also included in this meeting. After discussion of
what the family felt the patient would have wanted in the
setting of his current medical situation and prognosis, the
family decided to make the patient comfort measures only. He was
placed on a morphine drip and scopolamine patch. The patient
passed away on ___ at approximately 6:50PM.
***. | INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ y/o M with CAD and CHF poorly differentiated esophageal
neoplasm most c/w large cell neuroendocrine carcinoma of GE
junction with mets to L adrenal and pulm nodules presents for
dizziness/headache, found to have profound pancytopenia.
# Neutropenic fever - neutropenia improving and afebrile > 48
hours. CXR negative and blood cultures are still pending. Urine
CX showing Klebsiella oxytoca sensitive to cephalosporin,
quinolones, and Bactrim.
# Pancytopenia, no differential today, WBC 1.7
# Recent UTI - pt states he has been taking amoxicillin for UTI
for 2 weeks now was told he has a few more days left of the
course.
- will d/c IV cefepime, start oral vantin. Avoid quinolone and
Bactrim due to recent pancytopenia and possible marrow
suppression.
- recheck CBC with diff tomorrow and hopefully, neutropenia will
have resolved.
- Onc consult appreciated
- Transfuse if Hb<7.0 or platelet<10K unless otherwise e/o
bleeding
- has active T&S
# Dizziness/lightheadedness - Pt reports significant feeling of
exertional dizziness and headache, similar to prior episode of
?volume depletion/arrhythmia (pt states his ICD fired in this
setting). He has been monitored on tele w/out e/o further
arrhythmia at this time. NCHCT and CT head with contrast were
negative for obvious lesions. ___ be recurrent volume depletion
vs. chemo side effect. ___ also be reflective of symptomatic
anemia. Orthostatics negative but BP's have been soft.
- telemetry
- Getting another 1L LR bolus today as BP's have been soft
- see mgmt. of anemia below and treat for infections above
# Esophageal cancer - C2D1 chemo last ___.
- Atrius Onc following, appreciate recs
# CAD - cont home atorvastatin, lisinopril, metoprolol, not
taking ASA currently as was told to hold while on chemo
- holding lisinpril for now with plan to resume ___, will also
reduce metoprolol dose and fractionate for now, until trend of
CBC trajectory is clearly stable and nothing to suggest bleed
***. | KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is a ___ lady with obesity, HTN, DM, and early CAD
s/p BMS to mid-LAD in ___ and BMS to ___ for UA who
presented with chest pain that likely represented unstable
angina. She underwent cardiac catheterization which revealed
distal RCA stent re-stenosis, and she received a drug-eluting
stent. She was discharged home.
ACTIVE ISSUES
#. Chest pain in patient with early CAD: unstable angina, now
s/p PCI.
Similar chest pain with exertion as during her prior UA. Very
subtle inferolateral EKG changes. No cardiac enzymes leaked.
Cath showed distal RCA stent re-stenosis and she received a DES.
She remained chest pain free for the duration of her
hospitalization. She continues on Aspirin (but was advised that
she can drop to 81mg daily) - note that patient admitted to
missing a few doses of ASA; the importance of compliance to
prevent stent closure was reinforced and she understood. She
was started on Plavix (which she understands she must take
uninterrupted for at least ___ year). Continues on a beta blocker
and statin. She needs outpatient follow-up with her PCP and
___ for her CAD (including cholesterol, with LDL goal
<70). Should follow-up with Cardiology (Dr. ___ in 2 months.
Should have an outpatient TTE within ___ months to ensure no
decline in pump function.
#. HTN: BP poorly controlled.
Patient admitted to missing some doses of Amlodipine due to
running out of her prescription. She had SBP 130-160 this
admission. She continues on Amlodipine, HCTZ, and Losartan.
Should have ongoing outpatient titration of BP meds for optimal
control.
#. Headache: tension-type.
Patient's major complaint this admission was a headache which
started ___ days prior to admission. It was right-sided,
burning. Not associated with any concerning features on history
and she had a normal neuro exam. Note that she did have Bell's
palsy earlier this year with headache, but she felt this was of
a different nature. It is reassuring that she had negative head
imaging (including MRI) earlier this year. Still, she did
undergo a head CT w/o contrast to ensure no head bleed. She
felt that Tylenol, rest, and Morphine made the pain better. She
was discharged home with a small supply of Oxycodone, with
instructions to follow-up at ___ for an episodic visit if her
headache did not resolve by the next day.
#. DM2: poorly controlled.
Patient with HbA1c 9.2& seven months ago. Blood sugars were
poorly controlled in the 200's range. She was continued on home
regimen of Lantus and sliding scale. She was advised to follow
up with her PCP and also ___, where she has had poor
follow-up.
#. Neuropathy: stable
She was continued on Gabapentin (renally dosed).
TRANSITIONAL ISSUES
#. Headache: She was discharged home with a small supply of
Oxycodone, with instructions to follow-up at ___ for an episodic
visit if her headache did not resolve by the next day.
#. Echo: Should have an outpatient TTE within ___ months to
ensure no decline in pump function.
#. Cholesterol: LDL goal <70
#. Poor medication compliance: She admitted to missing doses of
ASA and Amlodipine at home.
#. Poorly controlled BP: Should have ongoing outpatient
titration of BP meds for optimal control.
#. Poorly controlled DM2: She should follow up at ___.
#. Cardiology follow-up: Should follow-up with Dr. ___ in 2
months (not scheduled yet).
***. | PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with history of ___ Dementia presented with acute on
chronic mental status changes, syncopal episode. Patient was
found to have UA positive consistent with complicated urinary
tract infection. Patient was treated with IV fluids and IV
antibiotics, transitioned to oral antibiotics with clinical
stability. Patient did not have any additional electrolyte
abnormalities and did not have cardiac arrhythmias noted while
monitored on telemetry to explain her symptoms. Patient was then
discharged home with plan for close primary care follow up.
# Syncopal episode: Most likely secondary to increased vagal
tone with recent large bowel movement as well as urinary tract
infection and volume depletion. Patient did not have any
preceding symptoms, no EKG abnormalities, no events on 24 hours
of telemetry to suggest underlying cardiac etiology. Patient was
monitored closely without any subsequent pre-syncopal or
syncopal events.
#UTI: Patient with syncopal event, UA with WBC, lg leuks, few
bacteria to suggest urinary tract infection. Patient was treated
empirically with ceftriaxone, transitioned to oral cefpedoxime
based upon previous culture data. Plan for total 7 day course
given complicated UTI.
# ___ Disease : Ms. ___ suffers from progressive,
advanced dementia. History provided by caregiver states she can
become agitated due to her underlying disease. Patient did not
have any focal neurologic deficits on exam to suggest acute
stroke. Patient was continued on home medications, risperidone
0.25mg prn agitation, trazodone qhs prn insomnia.
=====================
Transitional ISSUES:
=====================
[ ] UTI- f/u pending urine cultures, based on previous senses,
patient transitioned to PO cefpedoxime 200mg PO daily for
planned 7 day course, last dose ___
CODE STATUS: DNR/DNI
CONTACT: Care taker ___ ___
___ (son) ___ (c)
***. | KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is a ___ female with past medical history
significant for several months of LLE malleolar and heel
ulcerations of unclear etiology who was referred by her PCP for
expedited evaluation and treatment.
# LLE ulcerations
The patient presented with lower extremity wounds of unclear
etiology she was seen by both dermatology and infectious disease
consult services. Dermatology performed a biopsy which showed
some bacteria it is not clear if these are pathogens therefore
the patient was not started on antibiotics. Final pathology is
pending on discharge. Was felt that the patient's wounds were
not likel due to an deep fungal infection therefore
itraconazole was discontinued The patient also had an MRI of
her ankle which did not show a deep infection, osteomyelitis or
joint infection. The patient should continue Vaseline
dressings. She will follow-up with infectious disease next week
for biopsy results and discussion regarding treatment. She was
continued on at bedtime gabapentin for pain with very low dose
oxycodone.
# COPD - continue inhalers and PRN albuterol. Patient reports
breathing is at baseline.
# Hypertension - Coninued Norvasc
# Chronic LBP - Celecoxib was replaced with Ibuprofen ___ the
hospital and resumed on discharge.
# Hyperlipidemia - patient can resume lipitor as itraconazole
was discontinued
Transitional issues:
- Patient discharged with biopsy results pending and plan for
close follow up with infectious disease.
- The patient will follow up with her dermatologist
Code: Full
HCP: Son, ___ ___
I have seen and examined the patient on day of discharge and she
is stable for discharge home. >30 minutes on counseling and
coordination of care.
***. | SKIN ULCERS WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is a pleasant ___ your ___ male who was
admitted to the Urology service after undergoing:
1. Robotic-assisted laparoscopic radical cystectomy.
2. Robotic-assisted laparoscopic bilateral pelvic lymph node
dissection.
3. Robotic-assisted laparoscopic prostatectomy, and
4. Laparoscopic ileal conduit urinary diversion.
No concerning intrao-perative events occurred; please see
dictated operative note for details. Patient received
___ intravenous antibiotic prophylaxis and deep vein
thrombosis prophylaxis with subcutaneous heparin. The
post-operative course was essentially unremarkable. With the
eventual passage of flatus, diet was gradually advanced and the
patient was transitioned from IV pain medication to oral pain
medications. The ostomy nurse saw the patient for ostomy
teaching. At the time of discharge the wound was healing well
with no evidence of erythema, swelling, or purulent drainage.
The ostomy was perfused and patent and the ureteral stents were
visible. Post-operative follow up appointments were
arranged/discussed and the patient was discharged home with
visiting nurse services to further assist the transition to home
with ostomy care.
***. | MAJOR BLADDER PROCEDURES WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year old female with history of NASH cirrhosis, portal
hypertension and GAVE (Gastric Antral Vascular Ectasia) with
chronic blood loss presenting s/p TIPS for GAVE.
# HypoNa: Admission Na of 140 on ___. TIPS on ___. Developed
hypoNa to 131 on ___. Initially, likely there was a significant
component of hypovolemic hypoNa with FeNa<1, ___. But hypoNa
persisted despite ___ resolving and pt hydrating well. Likely
due to low effective intravascular volume in the setting of
cirrhosis. Gave albumin, with improvement to 130 on discharge.
Cortisol and TSH normal. Will follow up as an outpatient. Will
get labs checked on ___, sent to Dr. ___
and follow up with PCP and hepatologist.
# ___: Up from baseline 1.1 to 1.9. appeared pre-renal with
urine Na <10, and FeNA <1. There was also likely a component of
CIN given higher than normal contrast load during TIPS. Gave
albumin for pre-renal ___ with resolution. Discharge Cr of 1.2.
# UCx: UCx notable for enterococcus ___, VRE, but no urinary
symptoms. no systemtic symptoms. unlikely to be UTI. not treated
# s/p TIPS: Difficult due to stiff liver. Necessitated trans
hepatic portal access, trans hepatic stick, and ___
transabdominal stick. Succesful TIPS with PSG 16 -> 5 mmHG.
Given multiple sticks, including transabdominal, there was
concern for hepatic encephalopathy/peritonitis, but no
confusion/abdominal pain throughout hospitalization.
# Low UOP: Had low urine output s/p TIPS procedure that resolved
with hydration and no further intervention.
# Leuckocytosis: no infectious symptoms w/ no fever, cough,
diarrhea, abdominal pain. UA bland. resolved without abx.
# GAVE: s/p TIPS. no signs of bleeding.
- transfused 2 units during hospital stay for Hgb<7
- continued home iron supplement
# NASH cirrhosis: c/b GAVE, portal hypertension, grade I
___ now s/p TIPS. no ascities
- continued home nadolol at lower dose(since also used for HTN),
as below consider switching to an alternative BP med
# Hypertension: on nadolol at home(also for variceal bleeding
ppx), s/p TIPS continued at a lower dose of nadolol 20mg daily.
Now s/p succesful TIPS, might better to transition patient to
another blood pressure lowering agent such as a calcium channel
blocker
# Type 2 diabetes:
- on home glargine and ISS
- discontinued home metformin given chronic kidney disease,
might need an alternative oral agent
# GERD:
- continued omeprazole 40mg BID
# Gout: discontinued colchicine in the setting of both renal and
hepatic impairement, can be restarted as an outpatient
=================================
TRANSITIONAL ISSUES
=================================
[ ] Will have complete metabolic panel checked on ___
and sent to Dr. ___
[ ] Discontinued colchicine in the setting of both renal and
hepatic impairement, can be restarted as an outpatient
[ ] Discontinued home metformin given chronic kidney disease,
might need an alternative oral agent
[ ] s/p TIPS nadolol continued at a lower dose of 20mg daily.
Now s/p succesful TIPS, might better to transition patient to
another blood pressure lowering agent such as a calcium channel
blocker
CODE: FULL
#CONTACT: Name of health care proxy: ___
Relationship: niece
Phone number: ___
Cell phone: ___
***. | STOMACH ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
BRIEF HOSPITAL COURSE
=================================
Ms. ___ is a ___ yo F with history of moderate/severe aortic
stenosis, A Fib on warfarin, HTN, and previous PE who presented
to ___ with chest pain radiating to her left arm,
intermittent shortness of breath, and neck pain. She also
reported multiple episodes of dizziness over the past couple
weeks. She had a full neurological workup including MRI/MRA that
showed no acute process but did show subclavian stenosis and
diminutive left vertebral artery without evidence of dissection,
with reversal of flow suggestive of subclavian steal syndrome.
Upon admission to ___, she reported that her dizziness has
mostly resolved. She had a vascular medicine consult who
recommended cardiac catheterization with upper extremity
evaluation, to evaluate her aortic valve, coronary arteries, and
intervene on subclavian stenosis. The catheterization
demonstrated moderate non-obstructive coronary artery disease,
moderate aortic stenosis, and severe left subclavian artery
disease just proximal to take off of vertebral artery, now s/p
stent placement with good anterograde flow. She was started on
triple therapy for the stent with aspirin, Plavix, and Eliquis
BID. She did well and remained hemodynamically stable.
TRANSITIONAL ISSUES:
=================================
[] There is approximately 40% stenosis of the left cervical
internal carotid artery by NASCET criteria and 70% stenosis of
the right cervical internal carotid artery by NASCET criteria.
Follow up as outpatient
[] plan to continue triple therapy for 1 month and then
discontinue aspirin 81 mg --> please ensure patient stops
aspirin after 1 month (approximately ___
[] follow up if left arm numbness/tingling symptoms have
resolved after stent placement
MEDICATIONS:
- New Meds: plavix 75 mg daily, aspirin 81 mg daily, Eliquis 5
mg BID
- Stopped Meds: warfarin
- Changed Meds: simvastatin --> rosuvastatin 20 mg nightly
# CODE: Full
# CONTACT: ___ ___
___ ___
ACUTE ISSUES:
==========
# Subclavian steal syndrome:
MRA with subclavian stenosis and reversal of vertebral artery
flow. Her symptoms of intermittent lightheadedness with left arm
pain/numbness were consistent with a diagnosis of subclavian
steal syndrome. She was evaluated by the vascular medicine team
(see below) and underwent a cardiac angiogram with stent placed
in left subclavian artery.
# Low flow, low gradient mild-moderate aortic stenosis
Patient with history of aortic stenosis. She had an echo done
inpatient that showed moderate to severe aortic valve stenosis
with thickened/deformed leaflets and trace
aortic regurgitation. On coronary cath, however, she had normal
augmentation with dobutamine, without increase in gradient,
suggesting the presence of low flow, low gradient AS, with
severity overestimated by echo due to low flow state. Her AS
should be classified as mild-moderate based on cath.
# Atrial fibrillation
Patient with history of A Fib on anticoagulation. She was
maintained on daily dose of warfarin with goal INR ___ until
cath scheduled. Warfarin was held in the setting of cath and day
of INR was 1.9. Her warfarin was restarted for goal INR ___.
# Difficult venous access
Patient with very difficult venous access with inability to get
labs despite multiple attempts by experienced IV nurses. ___ had
a PICC placed for lab draws and this resolved the issue.
CHRONIC ISSUES:
============
# Hypothyroidism
- Continue home levothyroxine 100mg
***. | OTHER VASCULAR PROCEDURES WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
This is a ___ employed, domiciled man, no formal
psychiatric history, no prior medical history, who presented to
the emergency department due to concerns of significant
psychosis in the setting of substantial marijuana use.
.
Interview with patient limited, given frank psychosis but review
of the medical record and collateral from his family and
girlfriend concerning for acute onset of psychosis without a
compelling history of preceding mood symptoms or prodromal phase
that would be concerning for mood disorder with psychotic
features or a primary psychotic disorder. Mental status
examination is concerning for severe psychosis with hyper
religious delusions, paranoia, disorganized thought process with
derailments and looseness of associations.
.
Given above history and presentation with unremarkable medical
workup, there is a high suspicion of etiology of presentation
being secondary to substance use, likely cannabis vs. other
substance. Family and girlfriend deny any concern for mania or
depression prior to presentation, making mood disorder with
psychosis less likely. Again, no history concerning for
prodromal symptoms-- patient was functioning well at work and
socially prior to admission.
.
#. Legal/Safety: Patient was admitted to Deaconess 4 on a
___, upon admission, he refused to sign a CV. Given the
severity of his psychosis with concern regarding his ability to
care for himself with very limited insight, a section 7&8b was
filed. However, patient's condition had improved significantly
during his hospitalization with significant clearing of his
psychosis, and so the 7&8b petition was withdrawn at time of
discharge prior to court hearing. Of note, he maintained his
safety throughout his admission on 15 minute checks and not
require physical or chemical restraints.
#. Substance induced psychosis:
The patient initially presented to the ___ ED due to worsening
paranoia and hyper-religious delusions reported by is family.
These symptoms developed in the setting of recent marijuana use.
On admission the patient reported hyper-religiosity and denied
VH, paranoid, IOR, SI, and HI. Mental status exam on admission
was notable for blunted affect, latent speech pattern, concrete
thinking, and increase in
sexually themed thoughts. On initial interviews on the inpatient
unit the patient appeared internally preoccupied with
disorganized thought process and paranoia/grandiosity. He was
started on Risperidone (0.5mg PO BID) with PRN Lorazepam. He
refused these medications early in admission.
.
Initially, the patient's presentation was concerning for
substance induced psychotic disorder vs a first presentation of
a primary psychotic disorder. Given the patient's rapid
improvement with infrequent antipsychotic doses (given patient's
refusal of medications), his presentation appears most
consistent with Substance induced psychosis secondary to
cannabis use as well as cannabis use disorder. By discharge he
denied ongoing psychotic symptoms with resolution of SI, HI, VH,
and paranoia. He did not display behavior concerning for
grandiosity or paranoia. His insight improved during admission.
The risks and benefits of antipsychotic medication as well as
lack of treatment was discussed with the patient. He voiced
understanding of these risks and benefits and was agreeable to
continuing the low dose Risperidone and Ativan as needed for
agitation and anxiety. Mr. ___ was also agreeable to
following up with a counselor at ___ for therapy and
possible referral to a psychiatrist for ongoing evaluation and
management of psychosis and substance use. He also follow up
with his PCP as noted in discharge instructions. Of note, by
time of discharge he was noted to be compliant in attending
groups where he participated appropriately.
.
The team was in frequent contact with the patient's familyduring
admission. The patient's father reported that the patient had
returned to his baseline behavior prior to discharge and
advocated strongly for his son to leave the hospital.
.
#. Cannabis use disorder: As above, the patient's recent
cannabis use likely contributed to the patient's admitting
psychotic symptoms. During admission he was given
psychoeducation regarding the relationship between cannabis use
and onset of psychosis. He was strongly encouraged not to use
cannabis, other substances, or other unregulated herbal
supplements. He agreed to avoid substance use upon discharge and
voiced understanding of the risks of substance use upon
discharge.
***. | ALCOHOL DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ presented to ___ after he suffered a left leg
injury while using a chainsaw. He had normal ABIs on
presentation; but was noted to have a wound approximately 20 x
15 x 1 cm over the left thigh, and penetrating through the
muscle belly. The wound was too extensive to close and irrigate
at the bedside due to considerable pain and inability to
visualize the deeper wound bed. He was therefore taken to the
operating suite where his wound was irrigated and closed.
Please see the operative report for further detail. Mr. ___
was recovered in PACU and transferred to the inpatient ward for
further management and observation.
The patient was started on cefazolin while inpatient. He was
tolerating a regular diet and had no issue voding. He had no
respiratory or cardiovascular issues during his recovery. He
was evaluated by physical therapy in preparation for discharge.
Based on their recommendations, the patient was given crutches
to utilize while ambulating.
In preparation for discharge, the patient was given a
prescription for oral antibiotics (Keflex) for seven days. ___
services were established for the patient. Instructions were
provided indicating that his left ACE wrap and dressing should
be removed tomorrow, ___. A one week follow-up appointment
with ACS was also provided.
Mr. ___ was afebrile, hemodynamically stable and in no acute
distress at the time of discharge.
***. | OTHER SKIN SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Psychiatric:
Latuda was discontinued and pt was getting 10 mg of saphris and
15 mg of abilify throughout hospitalization. Her affect appeared
flat on the admission and she was quite guarded, but on the unit
her affect was near normal range and euthymic, she was
cooperative, seen interacting well with patients, smiling. She
reported no AVH since her admission to the unit. She explained
she experienced a "side effect of Saphris" when she would have
an urge to stare at the letters "a" that she could find in the
environment - that was happening prior to admission. Since
admission, she had one such an episode reported as mild, "didn't
bother" her. The plan to maintain her on the medication regimen
above was discussed with Dr. ___. Pt underwent
neuropsychiatric testing and the results were c/w schizophrenia.
Of note, initially pt was planning to leave to ___ on ___
with her family. However Dr. ___ reported she has had
recent cycles of waxing and waning symptoms when she would get
better and then would soon relapse to her psychotic symptoms and
he recommended that she delays the trip. The pt and family
agreed on it.
Throughout the hospitalization pt had good insight into the
nature of her condition but her judgement remained questionable
even though she seemed very cooperative with staff's advice. She
consistently denied any SI or hallucinations since her admission
to the unit.
Medical:
- Pt had symptoms of nasal congestion similar to the allergy
symptoms she has had in the past for ___ she has been taking
zyrtec. She was written for fexofenadine 60 mg BID PRN in place
of zyrtec since we din't have the formulation with very good
effect.
Family: patients parent were very involved in her care and staff
had frequent conversations with them. The mother requested that
we do not use the word "schizophrenia" when speaking with her
daughter since she thought based on her cultural beliefs that
this would put her daughter more at risk of suicide, and we
respected this request.
Legal: ___
Safety plan: evert 15 min checks
***. | PSYCHOSES |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Patient was admitted to transplant surgery service and underwent
laparoscopic converted to open cholecystectomy on ___. For
full details of procedure please refer to operative report. On
POD 1 the patient was started on clears while continuing
maintenance IV fluids. His pain was controlled with IV dilaudid
and tylenol, and he began working with physical therapy. On
POD2, the patient's foley was discontinued and he was able to
void spontaneously. He began to develop some hiccups and
abdominal distension. He had not yet passed flatus or had a
bowel movement. A KUB was obtained that showed a large gastric
bubble and c/f ileus. An NG tube was placed and the patient was
made NPO. On the morning of ___, the patient had 2 large
bowel movements, and his NG tube output had decreased. The NG
tube was discontinued at this time, and the patient was slowly
started back on a diet of clears.
He was advanced slowly back to regular diet with the resolution
of the ileus as treated with NPO status and NG tube.
The surgical clips were d/c'd and steri strips placed on day of
discharge. The incision was clean dry and intact. He was
ambulatory with the aid of a walker and will receive home
physical therapy.
***. | CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
*)Preeclampsia
She had been previously diagnosed with mild preeclampsia by
24-hour urine and blood pressure on hospitalization earlier in
the week. At that time she signed out against medical advise
despite a fetal heart rate tracing with some decelerations. She
returned to the antepartum testing unit on ___ and again
was found to
have fetal heart rate decelerations on her nonstress test. She
was counseled to be admitted for further monitoring, and again
declined and left against medical advice. She presented to OB
triage on the day of delivery complaining of general malaise, as
well as for routine testing. Her fetal heart rate tracing showed
no accelerations and occasional decelerations without any clear
relation to contractions. Her transabdominal ultrasound
demonstrated a biophysical profile of ___ with no
breathing motions, gross movements, or tone. She had a normal
amniotic fluid volume. The fetus was noted to be in breech
presentation as well. The patient was advised that fetal testing
was nonreassuring and in the setting of preeclampsia and
non-reassuring fetal heart rate tracing, she was advised to
proceed with delivery via Cesarean section due to breech
presentation. The infant was delivered via Cesarean section and
was taken to the NICU. Please see the operative report for full
details. Postpartum course was notable for a persistent headache
in the setting of normal range blood pressures that was felt to
be musculoskeletal in etiology. Tizanidine was started and
titrated up, and her symptoms improved. She received magnesium
sulfate for 12 hours postpartum for seizure prophylaxis. On
discharge her headache had improved, and her blood pressures
were in a reasonable range without anti-hypertensive medication.
.
*)UTI
A 7 day course of Macrobid was continued while she was
hospitalized.
.
*)Asthma
She had one episode of shortness of breath postpartum that
improved with nebulized albuterol; her asthma was otherwise not
an active issue during this hospitalization, and her home
medications were continued.
***. | CESAREAN SECTION WITH CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with new diagnosis of NSCLC presented with left main-stem
bronchus obstruction.
# NSCLC, stage IV: New diagnosis, found to have mediastinal
lymphadenopathy and LMSB obstruction on CT along with RLL mass.
Patient is s/p bronchoscopy with cryodebriedment of obstructing
LMSB tumor and placement of Y stent. RLL mass had bleeding and
was injected with epinephrine. Patient will be undergoing
further management of cancer in NH.
# Paroxysmal atrial tachycardia: Patient has had increased heart
rates to the 150s consistent with atrial tachycardia v atrial
fibrillation that self-resolved. Was started on metoprolol.
# Dysphagia: The patient reports a sensation of food being stuck
above her stomach. This has been limiting her PO intake and she
has lost about 20 lbs in past few months. Evidence of
obstructing mass compressing the esophagus in OSH CT scan,
likely from lymphadenopathy or metastasis. Barium swallow showed
irregularity of the mid-esophagus, likely representing external
compression. Radiation oncology does not believe that there is
an urgent indication for intervention before full staging and
treatment plan is developed in ___. Was given nutrition
supplementation.
# Hyperthyroidism: Patient discovered to have a low TSH and
elevated T4 consistent with hyperthyroidism. Thyroid ultrasound
showed bilateral colloid cysts with no discrete solid nodule
identified. Further workup was deferred given acute illness and
malignancy. Should follow up with PCP for further evaluation and
management.
# Respiratory distress: Post procedure, patient experienced
severe respiratory distress that required intubation. Had
evidence of fluid in the lungs, likely due to alveolar
hemorrhage vs. pulmonary edmea. Was also started on antibiotics
for pneumonia. The patient improved and by discharge was satting
well on room air.
TRANSITIONAL ISSUES:
- The patient has follow up appointments with medical oncology,
radiation oncology, and radiology for a brain MRI. Appointments
on discharge summary. Should call ___ for further
instructions.
- Pt has evidence of hyperthyroidism with low TSH and high T4.
Should follow up with PCP.
- Patient is on antibiotics for post-obstructive pneumonia which
will be completed on ___
***. | RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ PMH dementia with Alzheimer's features, HTN, HLD, and DM2
who presented with acute encephalopathy in the setting of
hypothermia having been found down in his apartment, last
observed 24 hours prior. Patient appears to have opened his
closet which contained many boxes, tripped over theses boxes,
and was unable to rise from a prone position due to pain and
weakness. Found by his niece, who is his HCP.
ACTIVE ISSUES:
--------
# ACUTE METABOLIC ENCEPHALOPATHY: RESOLVED, RETURNED TO
BASELINE. Due to metabolic acidosis from lactate and due to
dehydration. Acute derangements resolved within 24 hours of
admission with rewarming and rehydration. Negative serum and
urine tox. No evidence of overt cardiac etiology with normal
trops and EKG. 24h EEG was negative. CSF from lumbar puncture
had elevated protein but was otherwise unremarkable. One blood
culture vial showed GPC (see below). Patient was started on
ceftriaxone with concern for bacterial meningitis, which was
stopped once apparent that this was not a contributing etiology.
# HYPOTHERMIA: RESOLVED. Moderate hypothermia given presenting
temperatures. Due to an extended period of on the ground in his
apartment without clothes. On the floor, patient was warmed with
bair hugger and eventually reached normothermia, at which time
his mental status greatly improved (see below).
# ENTEROCOCCAL BACTEREMIA: RESOLVED. Likely a contaminant. ___
bottles positive for coagulase-negative staph. ___ bottles
positive for enterococcus; however enterococcus was considered
uncomplicated without a clear source. Patient underwent TTE
that was without obvious evidence of endocarditis. Vancomycin
was continued for a total of 5d, in accordance with IDSA
guidelines. No further positive blood cultures.
# BACK PAIN: BASELINE. As patient's mental status improved,
patient began to complain of pain in his thoracolumbar back. In
addition, he appeared to have some weakness in his left leg. CT
of the T/L spine was performed and were neagtive for acute
fracture. In addition, patient's C spine was scanned in the ED
(negative) and he also did not have any tenderness when his MS
improved, so his C collar was cleared.
# MEDICATION NONADHERENCE: Patient was taking no medications in
the, at minimum, ___ years leading up to his current presentation.
This will no longer be at issue given that he will no longer be
living at home alone.
# RHABDOMYOLYSIS: RESOLVED. No evidence of acute kidney injury,
CK peaked at 3140. No evidence of oliguria.
# TRANSAMINITIS: RESOLVED. Due to acute muscle lysis in the
setting of extended period on the ground.
#HYPERNATREMIA: RESOLVED. Due to mild dehydration.
# DM2. STABLE. Patient's sugars were monitored and he was
started on ISS. His ___ remained in the 200s-300s on day prior
to discharge. He was started on glargine 11u daily in addition
to sliding scale.
CHRONIC ISSUES:
-----------
# DEMENTIA WITH ALZHEIMER FEATURES: MODERATE TO SEVERE.
Evidenced by bilateral ventricular enlargement, palmomental
reflex indicative of frontal release, and diffuse global
cerebral atrophy on CT imaging. Alternate endocrine, metabolic,
infectious etiologies are less likely, evidenced by negative RPR
for syphilis, normal B12, and TSH within normal limits.
Evaluated by Neurology, patient was felt not to be safe for
discharge home
# HTN. Patient's blood pressures were in low to normal range,
and so home BP meds were held.
TRANSITIONAL ISSUES
-------
# patient evaluated by ___ and felt dispo to rehab appropriate
# NO LONGER SAFE TO LIVE HOME ALONE. Ongoing discussion
regarding placement with his HCP.
# HYPERLIPIDEMIA: Discussion with PCP regarding the
risk:benefit of long term statin compared to poly-pharmacy.
# GOALS OF CARE / CODE STATUS.
***. | OTHER INJURY POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Patient found to have bilateral ureteral stones in ER on
___. As patient was making urine, renal function was at
baseline, and there were no occult signs of infection, she was
observed overnight on ___ to see if she would be able to pass
as least one of these stones. Repeat labs on HD2 remained
stable. Repeat renal US on HD2 showed persistent mild
hydronephrosis on both sides. Patient was additionally still
having intermittent flank pain, and was thus taken to OR on ___
for cystoscopy and placement of bilateral ureteral stents.
Procedure was uncomplicated and patient was transferred to the
recovery area in stable condition. She was observed in the
recovery area and was discharged after voiding. At the time of
discharge, she was ambulating on her own, tolerating diet, pain
was controlled with oral meds, and was voiding on her own.
***. | URINARY STONES WITHOUT ESW LITHOTRIPSY WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***rief Summary:
The patient was an active ___ year old male with several chronic
medical problems who presented to the emergency department with
hypotension. A central venous catheter and foley catheter were
placed. A chest xray showed a right upper lobe community
acquired pneumonia. The patient had a white count of 25.3 on
admission. He was started on intravenous ceftriaxone and oral
levofloxacin for the treatment of community acquired pneumonia.
He was fluid resuscitated and spent one night in the medical
intensive care unit, where he required a low dose of a
norepinephrine drip. The patient was weaned off of this pressor
on the morning of hospital day two and was transferred to the
medicine floor at that time. His right internal jugular central
venous catheter and foley catheter were removed. His intravenous
ceftriaxone was discontinued. He was continued on oral
levofloxacin and remained stable on this regimen until hospital
day three, when he was discharged home. He was afebrile for 48
hours upon discharge. His discharge WBC was 10.5 and he felt
generally well. The patient recieved subcutaneous heparin for
deep venous thrombosis prophylaxis.
The patient's problem list on the medicine floor was as follows:
Right upper lobe Community Acquired pneumonia: The patient was
discharged to continue a total 10 day course of oral
levofloxacin.
.
# Acute on Chronic Renal Failure: Resolved with fluid
resicitation. Creatinine improved from 3.0 on admission to 1.9
on the day of discharge (the patient's baseline is around 1.9).
.
# Elevated Troponin: The patient had a slightly elevated
troponin at .02 on admission. His second troponin was negative.
His EKG showed no changes that would indicate acute cardiac
ischemia.
.
# History of transient ischemic attack: The patient was
continued on his home dose of clopidogrel.
# HTN: The patient continued his home anti-hypertensive
medications on HD 3.
# HLD: The patient continued his home dose of statin.
# Communication: wife ___ is ___ ___
# Code: FULL
***. | SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year old man with history of R pelvic osteosarcoma s/p
3-cycles neo-adjuvant chemotherapy with cisplatin/doxorubicin,
XRT and R hemipelvectomy ___ with revision for hip
dislocation ___, admitted for adjuvant chemotherapy with
cisplatin and adriamycin (4 of 6 cycles total, first adjuvant).
#R pelvic osteosarcoma: Patient was admitted for planned
chemotherapy with cisplatin and adriamycin. This is his fourth
cycle of his chemo regimen, and first post surgery. He received
his chemo regimen ___ and tolerated it well. During his
hospitalization, CT chest on ___ (done for staging purposes)
showed stable multiple millimeter calcified nodules, and stable
subcm hypodensities in the liver. On day of discharge, his PORT
was evaluated with a flow study, and found to be working well.
He will need an echocardiogram during the next cycle to monitor
doxorubicin toxicity. Patient was given neulasta on day of
discharge.
#RLE swelling: He was found to have increased RLE edema due to
fluids with the chemo protocol, with net fluid positive status
and weight gain. RLE DVT was considered but given prior history
of same unilateral edema with weight gain on prior chemo
admissions, he was diuresed the same way (20mg IV lasix x 3)
with improvement of his edema. His weight on discharge was 151.2
lbs (68.7kg).
# Anemia: He was given 1 unit pRBC on ___ for HCT of 23.7 as
his counts will likely go lower by he following week. No
evidence of bleeding and HDS without symptoms.
#H/o enterobacter wound infection: He is s/p 6 weeks of IV abx
with amox and ciprofloxacin, and currently on PO abx. Per
patient and ___ notes, he was continued on home abx regimen amox
500mg po q8, and cipro 500mg sc q12.
TRANSITIONAL ISSUES:
-Pending results: PORT flow study showed working fine but final
report is pending.
-Patient was given one unit of pRBC ___, and his neulasta was
administered on day of discharge.
-Chest CT w/o contrast showed stable calcified nodules from
prior.
-He will need an echocardiogram during next chemo cycle (___)
for adriamycin tox monitoring.
***. | CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
TRANSITIONAL ISSUES:
======================
[ ] Per prior records, patient needs bone scan to assess for
mets
[ ] please follow up HCV viral load
[ ] please follow up on BP management, added Hydralazine during
hospitalization
[ ] patient should follow up with Dr. ___ HD fistula,
they are working on scheduling appointment
[ ] patient with systolic murmur and no prior TTE, please
schedule TTE
[ ] patient presented on DAPT, discontinued Plavix at discharge
due to bleeding but please follow up initial indication.
[ ] Per recent liver outpatient notes, they are considering EUS
with biopsy of periportal dominant lymp node. Would f/u to
coordinate EUS
[ ] Thyroid enlargement found on CT and TSH at 13. please follow
up with ultrasound, consider repeat TSH, and T4.
Discharge Hgb: 8.1
#CODE: full, presumed.
#CONTACT: None
PATIENT SUMMARY:
=================
Mr. ___ is a ___ year old man currently incarcerated with
liver cirrhosis and HCC 8.1cm biopsy proven on ___, T2DM
c/b neuropathy, ESRD on HD ___ HTN, DM), CAD (hx MI ___ and
___, treated medically) who was referred from ___ with anemia
of 8.5, melena x1 week and mild epigastric pain and new anemia
concerning for upper GI bleed. Now s/p EGD ___ with no active
signs of bleeding.
ACUTE ISSUES:
=============
# New onset anemia
Patient presents with approximately 1 week of black stools. No
hematemesis, remained HDS. Fe studies wnl. EDG ___ showing no
varices, however with erosions in antrum. He was placed on IV
PPI BID which was transitioned to PO PPI BID at discharge.
Aspirin and Plavix was reinitiated ___.
# Localized HCC (biopsy ___
8.1cm, seg7 biopsy proven and another 1cm seg6 suspicious but
does not meet criteria. There is periportal dominant LN. Per
recent liver outpatient notes, they are considering EUS with
biopsy of periportal dominant LN. If negative LN and good
response to Y90 (planned for in ___, then may become
resection candidate. Also needs bone scan to assess for mets. He
is scheduled for follow up with liver.
# RUQ pain: Pt with known large liver mass. RUQ U/S ___ with
patent vasculature. Pain likely ___ to mass from capsule
stretch. Oxy 5mg Q6H:PRN for pain. Tylenol for pain do not
exceed 2g in 24hr
# HCV Liver cirrhosis, well compensated. MELD-Na largely driven
by renal failure. HCV VL PND
VOLUME: volume management with HD, INFECTION: No known history
of ascites, no known history of SBP, BLEEDING: See EGD results
as above, ENCEPHALPATHY: No evidence of current or past
encephalopathy, SCREENING: EGD as above.
# ESRD: Via RUE fistula. ESRD thought to be due to HTN and DM;
has been on HD for ___ years. RUE fistula is large and likely
needs revision. s/p HD ___. He will follow up with vascular
surgery (Dr. ___ for potential revision. Continue sevelemer
# Systolic murmur: Likely iso anemia, no prior echo however.
Will need TTE as outpatient.
CHRONIC/STABLE ISSUES:
=======================
# Hypertension: SBPs in 200s on the floor, likely in setting of
no HD since ___. Added Hydral to regimen. Patient remains with
BPs in 140s and will need better control as outpatient. Continue
carvedilol, losartan, and amlodipine
# Diabetes: Pt says he 'no longer has diabetes' and is not on
insulin. Likely secondary to reduced insulin clearance from
ESRD.
# CAD: Pt is on dual antiplatelet therapy with ASA and Plavix -
unclear why. Had medically managed myocardial infarctions, most
recently ___. He was not on statin, so this was started during
hospitalization. Cirrhosis is not a contraindication to statin.
Discontinued Plavix at discharge due to bleeding risk, however
please follow up initial indication.
***. | G.I. HEMORRHAGE WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Brief Hospital Course:
============================================================
___ PMH of pAF (s/p ablation), HTN, AI, who presents for
elective dofetilide administration for AFib rhythm control, s/p
first dose on ___.
Acute Issues:
=
=
=
=
=
=
================================================================
#AFib: Mr. ___ was admitted for elective initiation of
dofetilide. He tolerated initiation well and then underwent DCCV
on ___ with return to sinus rhythm. He was slightly
subtherapeutic in terms of INR on admission, but was therapeutic
on discharge. He said was taking 2.5mg 5x/week and 5mg 2x/week,
but OMR note said he should be taking 5mg 5x/week and 2.5mg
2x/week. His QTc was monitored during intiation and due to QTc
of 489 on last day, he was sent stabilized at a dose of 375 mg
bid.
Transitional Issues:
=============
-Monitor patient on dofetilide, follow up with EP in one month
-Check INR in one week ___. Please verify dosing with pt.
CODE: Full (Confirmed)
# CONTACT: Wife- ___: ___
***. | CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ hx ___ Disease, L THR (___) at OSH, who presents
for recurrent hallucinations and delirium after being discharged
to rehab.
# Delirium:
-- Summary of prior hospitalization: After L hip orthopedic
surgery, the patient had hallucinations and altered mental
status. At the time, CXR and UA was negative, and delirium was
attributed to strong narcotics, disorientation, and underlying
___ disease. The patient improved with weaning of
narcotics, and was discharge to rehab.
-- Immediately upon discharge to rehab, the patient became
delirious again, hallucinating that his roommate was a sexual
predator. He became so scared that his family brought him back
to the hospital for re-admission. At the hospital, he was
hallucinating on admission, seeing small animals dressed as
people walking around the hospital. He also had delusions about
being part of a hospital experiment. The patient was
re-oriented, and given a private room to help re-orient him. His
wife stayed at bedside. Narcotics were mostly weaned off, and
the patient had very little pain. Several days into
hospitalization, the patient had a low grade fever of 99, and
his white count increased to 20. Repeat CXR showed ___
acquired PNA. The patient was treated for PNA (see below).
Concurrently, Neurology was consulted, and recommended
decreasing the dose of Mirapex. With initiation of Abx and
weaning of Mirapex, the patient improved and no longer suffered
from hallucinations or anxiety.
# Hospital acquired pneumonia:
The patient complained of persistent non-productive cough after
surgery. Several days in, the patient's WBC count jumped to 20,
and the patient had some soft BPs and a temp of 99. CXR showed
consolidation in LUL. Urine legionella antigen was checked
which was negative. The patient was treated with IV Cefepime,
for a course of 10 days. A PICC line was placed before
discharge.
# bright red blood per rectum:
The patient was initially complaining of constipation, and
requested several enemas. The next day, he had profuse diarrhea
with some episodes of incontinence. C diff was negative. All
laxatives were stopped, and the patient improved. The next day,
the patient had 1 episode of bright red blood per rectum.
Hemodynamics were stable, repeat Hct was stable. Review of
records revealed that prior colonoscopy demonstrated internal
hemorrhoids. Rectal exam revealed internal hemorrhoids and scant
bright red blood on the glove. The patient stool was wnl after
this isolated episode.
# ___ disease:
Neurology was consulted, and recommended decreasing the dose of
Mirapex. The patient did not experience worsening of his
___ Sx on the decreased dose of Mirapex. This was done
around the same time as Abx were initiated, and the patient's
delirium improved clinically around that time. Thus, the
patient's Mirapex dose was continued at the decreased dose, and
can be increased in the future per the outpatient Neurology.
# S/P L hip surgery: after recent ortho hip surgery, the patient
was started on Coumadin 1 daily with INR 1.1, unclear reasoning.
The OSH surgeon was attempted to be contacted via email without
reply. Since appropriate DVT ppx post orthopedic hip surgery
requires stronger A/C, the patient's Coumadin was stopped and he
was switched to Lovenox for a total of ___fter
surgery after extensive discussions with the patient and family.
# CV:
ASA was switched from 325 to 81 mg daily, since the patient has
no indication for full strength ASA.
# Polyuria: The patient has complained of polyuria since hip
surgery, and was told at that time it was from getting a large
volume of IVF. The patient continued to have some episodes of
polyuria in house, which was exacerbated when he got IVF for ___
days for soft BPs. His polyuria improved during hospitalization
when he stopped requiring IVF. Recommend following up with PCP
for ___ for possible BPH or other etiologies. Patient also has
an outpatient Urologist who can help with this issues is this
persists after the hospitalization.
TRANSITIONAL ISSUES
- The patient will F/U with PCP to monitor improvement after hip
surgery and monitor recovery from PNA, and to evaluate for
continuing polyuria
- The patient will F/U with neurology for further management of
Parkinsons.
-The patient has two pending blood cultures from ___ which
need follow up
.
***. | OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year old with multiple medical problems including cad, htn,
dm, CKD stage IV, diastolic heart failure admitted with one week
of cough and fevers:
1. Cough/Fevers: History consistent with viral pneumonia/flu.
Husband with similar symptoms of late. CXRAY without evidence
pneumonia. Flu negative. Started on ceftriaxone/azithro in
emergency room and continued on floor ___ (had received
azithro at home from PCP). IVF support given fevers,
dehydration.
With ongoing fevers in house, unclear etiology, chest CT
obtained ___ and demonstrated no pneumonia, left pleural
effusion. Ceftriaxone and azithromycin were discontinued.
U/A and culture, blood cultures negative.
*********Patient had last fever AM of ___ to 102. She then
defervesced.
Likely secondary to viral
pneuomonia/bronchitis********************
2. Chronic blood loss anemia
3. Fe deficiency anemia
4. Anemia chronic kidney disease
5. Vitamin B12 deficiency.
Patient with hematocrit in mid ___ on admit which decreased to
19 in house. Baseline anemia likely multifactorial including
kidney disease, possible GI source/Fe deficiency, b12 def.
Patient has refused to see GI for possible endoscopy/colonoscopy
as outpatient, despite PCP ___. Acute drop in house likely
due to acute illness and dilutional.
B12 borderline low by assay (functionally deficient) Given 2
units on ___ with bump to 29 from 19. B12 replacement
initiated. Folate initiated. Iron continued. Stable
throughout rest of course. Again recommended GI eval as an
outpatient. Should also consider epogen as outpatient.
SPEP/UPEP sent and were negative.
6. Acute renal failure:
7. Chronic Kidney Disease Stage IV:
hypovolemic from fevers, poor PO at home. Creatinine on admit
to 3.6, returned to baseline of low to mid 2's with IVF's.
Enalapril initially held and then restarted on ___ given
multiple indications. Chronic lasix, given prn in house as
below. Given patient on lasix and multiple bp meds, will need
weekly or twice weekly monitoring of electrolytes/renal function
while at rehab. Could consider repeat renal U/S if renal
function were to worsen. Renal Prot/Cr checked and were as
above.
.
8. Acute on chronic diastolic heart failure
9. coronary Artery Disease
10. Hypertension:
Continued Amlodipine, Labetalol, imdur, aspirin, ___,
throughout
Held Enalapril until re-start ___. On ___ pulm edema with two
units inspite of IV lasix. On ___, again pulm edema with resp
distress. Resolved with further IV lasix (40) and nitropaste.
Subsequently, respiratory status improved and patient
transitioned back to home Lasix dose of 40mg daily.
.
11. DM, type 2, controlled: followed by ___ Lantus 18 units bedtime ans SSI with good control of
sugars.
.
12. Conjuncitivitis: Given polymixin ointment in house with
resolution. This can likely be discontinued if patient remains
asymptomatic.
.
13. Tachycardia w/ episode of A-fib w/ RVR
On ___ morning, the patient was tachycardic to the 140s while
sitting in chair. Patient was asymptomatic (no chest
pain/sob/LH/dizziness/blurry vision/palpitations). ECG showed
A-fib w/ RVR. She was given Lopressor 5mg IV x 1 and regular
bp/cardiac meds. HR subsequently went back to ___ in sinus
rhythm. She was monitored on telemetry and did not have any
further episodes of A-fib w/ RVR, though she was noted to have
PVCs at times.
.
14. Multi-Nodular Goiter
Pt w/ h/o multi-nodular goiter and had previously been followed
by endocrine. CT of chest as above showed continued evidence of
thyroid nodule. TSH WNL. Pt should have outpt endocrine f/u
and consideration of repeat thyroid U/S. These findings were
communicated to her PCP.
.
Disposition - The patient was seen by physical therapy who
recommended rehab given patient's deconditioning. Patient and
family were initially very opposed to rehab and wanted patient
to go home. Ultimately, patient's husband and son agreed with
decision to d/c to rehab, however patient was very reluctant.
After extensive conversations with family, physicians, and
social work, patient ultimately agreed to go to rehab. She is
being discharged to ___.
.
Full code throughout.
***. | SIMPLE PNEUMONIA AND PLEURISY WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ ___ man with HFpEF, pulmonary hypertension,
atrial fibrillation, hypothyroidism, hyperlipidemia, anxiety,
gout, colon cancer s/p colectomy, recent admission to ___ with
PPM placement and ongoing hematuria, who presented to ___
with sepsis and Ecoli bacteremia as well as coag neg bacteremia,
transferred to ___ for drainage of possible prostatic abscess
found to likely be BPH only. Ruled out for endocarditis/ppm
infection in setting of recent coag negative staph bacteremia.
Patient discharged to rehab with expected < 30 day stay.
ACUTE/ACTIVE PROBLEMS:
# Prostatitis
# Ecoli bacteremia: Patient with persistent prostate gland
enlargement while on treatment for prostatitis and E.coli
bacteremia prompting transfer to ___ due to concern for
prostatic abscess. ___ biopsy attempted but found to have solid
tissue and no fluid obtained. He had a prostate ultrasound done
which showed solid prostate consistent with BPH without evidence
of abscess. ID consulted and recommended completion of total of
4 weeks of antibiotics. He received 3 weeks of ceftriaxone and
was transitioned to ciprofloxacin to be completed ___. He
continues to have an ___ catheter in place (as below) which
was exchanged by urology on ___. He was also noted to have
some discharge from his urethra (milky/yellow) which per urology
is likely just related to the catheter as patient has no
leukocytosis or other signs of infection currently.
# Coag negative staph bacteremia
# Concern for PPM infection
Patient was noted to have two separate blood cultures from OSH
with coag negative staph aureus concerning for possible true
infection. Given recent implantation of
pacemaker (with evidence of fluid collection surrounding on US),
there was concern for possible device infection. He was started
on IV vancomycin. Repeat cultures at ___ negative and TTE and
TEE both negative for vegetations on valve or PPM leads and thus
vancomycin was stopped. Patient will f/u with ID after discharge
to ensure stability and for likely surveillance blood cultures.
# Decreased breath sounds on right:
Noted on TTE to have right sided effusion which was corroborated
on exam. CXR with only small right pleural effusion and exam
improving at time of discharge. Would benefit from repeat CXR as
outpatient in ___ weeks to ensure resolution of effusion.
# Chronic HFpEF
# Cardiac Amyloidosis:
No current evidence of heart failure exacerbation this
admission. EF on TTE 45% on TTE this admission, stable from
___. Patient was continued on daily Lasix, rosuvastatin and
metoprolol. Discharge weight: 61.92 kg (136.5 lb).
# Paroxysmal atrial fibrillation:
# Tachybrady syndrome s/p PPM: Patient with recent admission for
asystole x 3 requiring < 1 min CPR with ROSC, now s/p PPM.
Previously on apixaban which was held last admission due to
hematuria however this was restarted this admission following
prostate biopsy given no evidence of ongoing bleeding. Will need
to monitor closely for s/s of bleeding and if recurrent major
bleeding, would stop apixaban as risks likely outweigh benefits.
Continued metoprolol succinate 12.5 mg PO daily.
# C. diff positive at ___: Patient was found to be c. diff
positive on ___ and received therapy with IV flagyl. He
initially had diarrhea and then had formed stools. Per ___, they felt that this was possibly a carrier status given lack
of diarrhea and a history of c. diff colitis in ___. C diff
negative here.
# Hematuria: Occurred on most recent ___,
thought to be due to traumatic ___ placement, requiring CBI
and blood transfusion. Per urology at ___, the patient had
a paraphimosis which was reduced with resolution of hematuria.
Apixaban restarted as above without recurrent hematuria.
#Sacral wound: Patient with unstageable wound on coccyx which
was followed by wound care this admission. No evidence of
superinfection. Nutrition recommended sending Vitamin A, C, zinc
and CRP which were pending at discharge.
CHRONIC/STABLE PROBLEMS:
# Gout: continued home allopurinol ___ daily
# Hypothyroidism: Continued home levothyroxine 25mcg daily.
Please repeat TSH as outpatient when through acute illness as
mildly elevated this admission.
# Urinary rentention: Has had ___ for almost 2 months now.
Unclear etiology of retention though likely in large part due to
BPH. Discussed with urology and given prior failed trials, plan
is for outpatient f/u with urology for voiding trial. Tamsulosin
continued this admission.
# Anemia: Continued ferrous gluconate 324 mg daily.
Transitional Issues
=====================
[ ]Please ensure f/u with urology for voiding trial
[ ]Please repeat CXR in ___ weeks to ensure resolution of small
right pleural effusion
[ ] Discharge weight: 61.92 kg (136.5 lb)
[ ]monitor for hematuria on apixaban (had during prior
hospitalization)
[ ]Repeat TSH in 6 weeks (mildly elevated this admission)
[ ]Continue ciprofloxacin through ___ for prostatitis
[ ]Follow-up Vitamin A, C, zinc and CRP levels
>30 mins spent coordinating discharge planning.
***. | INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ presented to the ___ on ___ after afer a fall.
She was initially admitted to the ICU for management of low
blood pressures, which were stable. She went to the OR on
___, and underwent repair of her periprosthetic fracture.The
rest of her hospital stay was uneventful. SHe worked with ___ and
needs rehab.
***. | HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ w/ presumed stage IV pancreatic cancer with hep;atic mets
admitted for hyperbilirubinemia. Bile duct was normal on ERCP,
so no stent was placed. Underwent EUS-guided biopsies and has
follow up with oncology (Dr. ___ at ___ in 5 days to
start treatment. His post-procedure course was complicated by
acute urinary retention.
# Hyperbilirubinemia
# Pancreatic cancer
Patient with hyperbilirubinemia and transaminitis that was
concerning for biliary obstruction in the setting of presumed
pancreatic cancer. Patient underwent ERCP evaluation with EUS
with FNB of his pancreatic mass and liver lesions. Bile duct
was patent, so per Dr. ___ hyperbilirubinemia is likely
___ infiltrating metastatic disease in the peripheral liver and
main bile duct and CHD are decompressed. Per the ERCP team,
there is no role for further ERCP intervention and there is no
great target for PTC as well. They anticipate that with
palliative chemo, his bilirubin will stabilize/improve. He will
follow up with ___ oncology on ___ to start
treatment.
#ACUTE URINARY RETENTION
Patient had acute urinary retention after his procedure. Given
the patient's age and the use of anesthetics, cause is presumed
to be medication effect on presumed underlying BPH. A foley was
placed and he was started on tamsulosin and finasteride. He
passed a spontaneous void trial two-days after his procedure He
was told to limit meds that will worsen urinary retention: he
will use opiate analgesics sparingly and stop using Tylenol ___.
# ___.
Cr mildly elevated to 1.4 from baseline 1.1-1.2. Resolved to
1.0 with 3L IVF. His blood pressure was consistently <140/90 on
this admission and he is at risk for poor PO intake and
resultant pre-renal ___ going forward, so his lisinopril was
stopped.
# SIADH
The patient was given aggressive fluids (despite appearing
euvolemic) to help him make urine for a spontaneous voiding
trial; after this, Na dropped to 129. Given underlying cancer,
this is presumed to represent SIADH. He was recommended to avoid
excessive free water intake, although a rigid fluid restriction
was not initiated since he will be at risk for poor PO intake
generally.
# HLD.
Atorvastatin was stopped in the setting of transaminitis.
#CODE: Full (confirmed)
#CONTACT: ___ (patient's son) ___
#CONSULTS: ERCP
#DISPO: Medicine for now
*******************
TRANSITIONAL ISSUES:
1) Oncology will follow up biopsy results and start chemo as
appropriate.
2) Ensure he is voiding well.
3) Patient found to have SIADH and is discharged with a Na of
129. This will need to be rechecked at his next doctor's
appointment (likely his Oncology visit on ___ to make sure
it is better not worse.
2) Keep an eye on his BP after stopping lisinopril.
3) Started on Mirtazapine for sleep (so that he won't have to
take diphenhydramine). If he tolerates this well, consider
uptitrating to 15 or 30 mg for the appetite stimulating effect.
***. | HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L tibial plateau and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for L tibial plateau external fixation, and then on
___ for ORIF L tibial plateau, both of which the patient
tolerated well. For full details of the procedures please see
the separately dictated operative reports. The patient was taken
from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
TDWB in the left lower extremity, and will be discharged on
lovenox for DVT prophylaxis. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
***. | LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP FOOT AND FEMUR WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year old male with history of paraplegia secondary to
cervical stenosis surgery in ___ complicated by postoperative
hematoma, chronic indwelling foley, colostomy bag, poorly
healing stage IV sacral decubitus ulcer c/b osteomyelitis found
to have acute on subacute ___ and FTT. His course was notable
for discontinuation of antibiotics as his wound was felt to be
not infected. He was deemed a poor candidate for surgery by
plastic surgery given his poor nutritional status and concern
for appropriate post-surgical wound care. He expressed wishes to
return home to ___. He was arranged to have a med-flight
home, and extensive teaching was performed with the patient's
family regarding wound care. He will need follow up with
urology, infectious disease, and a surgeon to consider flap
surgery for his decubitus ulcer.
# ___:
Baseline Cr 0.8 in ___ at discharge on ___. Now
elevated at 2.5 on admission. Possibly pre-renal in setting of
poor oral intake. Other etiologies include ATN vs AIN (esp given
recent piperacillin-tazobactam, current esosinophils and
positive urine eosinophils). Renal US ___ with no evidence of
hydronephrosis. Urine microscopy ___ showed very celluar
specimen, no casts seen. Patient was initiated on mIVF given
concern for poor po intake with additional boluses of IVF as
well. ___ has been improving without intervention after
antibiotics discontinued. Last Cr prior to discharge was 1.7.
# Stage IV sacral decubitus ulcer:
# Osteomyelitis
Admitted in ___ and found to have osteomyelitis with some
Pseudomonal growth. On Zosyn (planned end date ___ with
transition to Cefepime per ___ clinic. Wound showed no acute
signs of infection however bone is still exposed. Given
downtrending CRP, Cefepime discontinued ___ per ID
recommendations. Patient was continued on wound care with with
weight offloading and q2H position change. No plan for flap
placement by plastics given albumin <3.5 and unreliability of
patient being able to not put pressure on sacral area when not
in the hospital. We performed teaching with his wife and
daughter regarding his wound care. He will need to follow up
with an infectious disease doctor to assess for infection, as
well as a surgeon (plastic surgeon) to consider flap surgery.
#Failure To Thrive
#Hypoalbuminemia
#Severe protein caloric malnutrition
Pt with poor PO intake due to post-prandial nausea and early
satiety. Very low albumin (2.4) on admission, possibly related
to urinary losses iso high urine protein/cr ratio. CT A/P showed
no evidence of acute intraabdominal process to explain early
satiety, though does demonstrate liver features suggestive of
cirrhosis. His home mirtazapine was uptitrated, metoclopramide
and daily MVI. Ondansetron timing changed to TID prior to meals.
His appetite significantly improved over his hospitalization.
#Troponemia
From prior notes, pt with presumed CAD given ?hypokinesis in
inferobasal segment on TTE. Patient without any cardiopulmonary
symptoms, EKG stable compared to baseline.
#Cirrhotic morphology of liver
#Splenomegaly
LFTs, PLTs WNL, no known history of cirrhosis or splenomegaly.
Per patient he has never drank alcohol and he has no know
history of liver disease. He does not have PCP. Hepatitis
serologies (Hep B and C) negative. He should be considered for
HBV vaccine.
# Normocytic Anemia: Chronic, stable. Possibly anemia of chronic
disease with component of occult GIB as guiac positive. Patient
will likely benefit from outpatient upper and lower endoscopies.
Most recent hemoglobin prior to discharge was on ___,
and was 8.4.
# RUE DVT:
Diagnosed last admission (___) with right upper extremity
DVT, on 3 month course of warfarin, due to end ___. Home
lovenox initially held in setting of ___, pt w/ lower risk of
thrombosis given location of clot and no indications to bridge
with heparin ggt at this time. Warfarin was continued with daily
INR monitoring. He should continue on his current regimen of 8
mg daily until ___. His INR on discharge was 3.0
# Thyroid nodules:
On prior admission concerned for hyperthyroidism given TSH 0.08
with plan for further outpatient workup with radioactive iodine
study but did not undergo the test due to elevated urine
iodine/creatinine ratio. TSH, free T4, and T3 all WNL this
admission. Thyroid US ___ shows Large heterogenous thyroid
gland with two dominant nodules in the right lobe, with the
nodule in the right upper pole demonstrating a focal
calcification. Patient may benefit from outpaient follow up US
and repeat thyroid function testing.
# Eosinophilia: Patient with mild eosinophilia outpatient prior
to recent admissions, with increase in eosinophilia thought
likely due to Zosyn; abx course changed to cefepime with
interval slight improvement in eosinophilia.
# Depression: Per chart bx. pt has had depressed mood since
surgery which led to his paraplegia. He was continued and
uptitrated on his mirtazapine.
# Hx urinary retention/ obstruction- Pt has required foley since
surgery. Patient prefers foley to suprapubic catheter per chart
review. He needs foley exchange every 4 weeks. Foley exchanged
___ given positive UA. Next foley change ___. Patient
should follow up w/ urology for urodynamic testing.
CHRONIC ISSUES
===============
# Insulin dependent diabetes. Started on glipiride 2.5 mg BID
with good blood sugar control, not requiring any sliding scale
insulin.
# Colostomy
- Continued bowel regimen with miralax, senna, and docusate
standing and bisacodyl and fleet enemas PRN.
#Hyperlipidemia: Continued home aspirin and atorvastatin
#Hypertension: Continued home amlodipine
TRANSITIONAL ISSUES:
===================
[ ] Follow up with infectious disease, urology, surgery (ideally
plastics, although any wound care specialist would be fine).
[ ] Monitor wound for signs of infection and appropriate
continued wound care
[ ] EGD to monitor for guaiac positive stools and anemia
[ ] Hep B nonimmune, please consider vaccinating
[ ] Large heterogenous thyroid gland with two dominant nodules
in the right lobe, with the nodule in the right upper pole
demonstrating a focal calcification. RECOMMENDATION(S):
Ultrasound follow up recommended. ___ College of Radiology
guidelines recommend further evaluation for incidental thyroid
nodules of 1.0 cm or larger in patients under age ___ or 1.5 cm
in patients age ___ or ___, or with suspicious findings.
[ ] Liver findings on CT suggestive of cirrhosis, consider
hepatology referral
[ ] Gastric empyting study for persistent post-prandial nausea
[ ] Urinary retention, exchange foley every 4 weeks (exchanged
last on ___
[ ] F/u cardiology re: focal WMA on TTE ___
[ ] Repeat protein/Cr ratio, albumin
# CODE: full (presumed)
# CONTACT: ___ (___)
***. | RENAL FAILURE WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
#Shaking Spells: Patient was admitted for recurrent paroxysmal,
whole body, asynchronous shaking events and multiple other
neurologic symptoms, including numbness and tingling in her
hands, neck pain, headache, gait abnormality, urinary retention,
and memory problems, beginning shortly after lumbar surgery.
Her typical paroxysmal events involve dyssynchronous limb
flailing and alteration of consciousness. Several of these were
captured on continuous EEG monitoring and did not have an ictal
EEG correlate. Clinically and electrographically, these
episodes were most consistent with nonepileptic psychogenic
events.
Patient was evaluated by Psychiatry team (Dr. ___, who
noted patient did not have clear risk factors for nonepileptic
events, but this is difficult to assess in a single interview.
The team recommended neuropsychological testing to assess
effort in cognitive tasks and determine if there is any organic
nature of her symptoms. Given that patient has multiple
neurologic complaints which are likely to be psychogenic in
origin, she remains at high risk for continued and new
functional symptoms without adequate psychiatric follow up.
Over the weekend of ___, patient developed significant
frustration with staff and with being in the hospital. She had
typical events captured as detailed above without an ictal EEG
correlate. In particular, on ___, she became progressively more
agitated, refused to stay in bed, and insisted on multiple
physicians to enter her room nearly every hour to discuss her
condition. She also displayed verbally aggressive behavior,
where at times she yelled at nurses and other staff.
Ultimately, patient took off her EEG electrodes at 5 AM on the
day of discharge (___). Given that she had an adequate enough
monitoring where events were captured, this was not replaced.
#Headaches: Patient reported acute on chronic headaches during
the admission. Many medication options were proposed and
discussed with the patient. She declined many of these options,
including nortriptyline, propranolol and lidocaine patch. She
felt that the diagnostic testing was not being completed fast
enough, and that we were not providing answers to explain her
symptoms fast enough.
#Dysphagia: Patient reported subjective choking episodes. She
had a formal speech/language pathology swallowing evaluation for
complaints of dysphagia. Video swallowing study showed delayed
swallowing, but no clear pattern of dysphagia. Outpatient ENT
evaluation was recommended. Patient voiced wishes for this to be
addressed by PCP on hospital follow up first.
#Parathesias: Patient reported significant numbness and tingling
in her hands and arms. This was associated with neck pain and
spasm. Her examination had numerous functional signs. For
further evaluation, she underwent MRI cervical spine, which was
notable for evidence of prior surgery at C6-7, disc bulging at
C5-6 without cord signal abnormality, narrowing of spinal canal
due to ligamentum flavum thickening. It did also reveal
incidentally, a 17 mm cystic structure in the region of the left
thyroid lobe, incompletely evaluated on this exam. We
recommended continued tramadol, cyclobenzaprine, and a soft
cervical collar. Overall, the cervical disc disease did not
explain her functional gait, and is unlikely to explain her
urinary symptoms.
#Subjective Memory Loss: Patient was evaluted by
neuropsychiatry/cognitive neurology as an inpatient. We
attempted, but were not able to complete, comprehensive
neuropsychological testing during her inpatient stay. She was
arranged for outpatient Neuropsychological testing.
#Urinary Retention: An extensive review of medical records was
sought. We were unable to find results of any prior urodynamic
testing (this was only alluded to on prior discharge paperwork).
Moving forward, it would be important to clarify if there is an
organic cause of her urinary symptoms. She will follow-up with
her primary care physician to discuss urology follow-up.
TRANSITIONAL ISSUES:
[ ] Follow up with Psychiatry, Dr. ___, for treatment of
nonepileptic events
[ ] Neuropsychiatric testing as outpatient
[ ] Soft cervical collar, tramadol, and cyclobenzaprine for
neck spasm.
[ ] Follow-up in spine clinic for treatment options.
[ ] Recommend Outpatient ENT evaluation for swallowing
complaints if deemed appropriate by PCP.
[ ] Recommend Outpatient urology appointment for
urodynamics/evaluation of urinary retention.
[ ] When seen by PCP, ___ up cystic lesion in thyroid lobe,
with further workup per PCP if not already performed
***. | HEADACHES WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
=========
SUMMARY
=========
Ms. ___ is a ___ female with history of
asthma, IgA nephropathy, Nash cirrhosis, left side pleural
effusion with a Pleur-evac in place, presented with Pleur-evac
malfunction which has been fixed. Hospital course complicated by
hepatic encephalopathy started empirically on CTX for possible
SBP. Had diagnostic paracentesis which ruled out SBP and was
consistent with chylous ascites. Patient's mental status
improved with lactulose and rifaximin to baseline.
==============================
ACUTE MEDICAL ISSUES ADDRESSED
==============================
# Hepatic encephalopathy
Patient presented with pleur-evac site pain and dysfunction but
on further evaluation was found to be confused and disoriented
and with Asterixis. Per patient's PCA, she has noticed patient
has become increasingly sleepy and confused over the last week.
She was guaiac negative, no portal vein thrombosis on abd US,
but with massive ascites and vague complaint of abdominal
discomfort. Due to concern for SBP, she was empirically started
on IV ceftriaxone and was started on lactulose and rifaximin for
hepatic encephalopathy. Had diagnostic paracentesis that was
negative for SBP. CTX was discontinued. Mental status improved
with lactulose and rifaximin. Will be discharged on lactulose
30mL TID titrated to three bowel movements daily and rifaximin
550mg BID.
# NASH Cirrhosis: MELD 18, MELD-Na 19, Mortality 3 month: 6%
# Portal HTN
Admission MELD 18, MELD-Na 19, Mortality 3 month: 6%. Presented
with acute decompensation with hepatic encephalopathy treated as
above. Also noted to have large-volume ascites and portal HTN
via US. Patient had a diagnostic paracentesis which showed a
SAAG >1.1 and chylous ascites. No varices per EGD done at OSH
___. No HCC on Liver US ___.
In terms of etiology, NASH cirrhosis diagnosed in ___ via
biopsy done with outside provider. Lab evaluation for other
cirrhosis etiologies was largely unrevealing. AIH studies were
not suggestive of autoimmune hepatitis (low titer smooth
positivity), negative hepatitis markers (prior HAV infection and
non-immune hepatitis B). HIV negative. Ferritin WNL. AST>ALT but
patient without alcohol history. Patient does have mildly
elevated ALP concerning for biliary pathology but no abdominal
pain. Patient was seen by hepatology who felt findings most
consistent with NASH cirrhosis. She was continued on PO
furosemide 40mg BID and spironolactone 50mg PO BID for portal
hypertension and ascites and was arranged for follow-up with
___.
# Transudative Chylothorax:
Discovered in ___. Pleural fluid from ___ done on admission
showed transudative process. Interventional pulmonology
restiched tube and discomfort improved. Hepatology was consulted
to aid in optimizing medication management of portal HTN and
whether TIPS may be an option. Recommended optimizing with
diuretics. Not candidate for TIPS given renal function and age.
Recommended continued medical management with furosemide and
spironolactone as above and low fat diet. Nutrition was
consulted and provided information to patient and PCA.
Chylothorax reaccumulates very quickly and plan per IP is to
drain for a maximum of 1 liter, 4 days a week and will continue
to follow as outpatient.
In terms of the etiology of transudative chylothorax, includes
amyloidosis, cirrhosis, nephrotic syndrome, superior vena cava
obstruction, heart failure, and chylous ascites that has crossed
the diaphragm into the pleural space. Etiology is presumed to be
due to NASH cirrhosis with chylous ascites crossing the
diaphragm. It is certainly strange that develops left sided
pleural effusion if truly is crossing diaphragm. Malignancy
workup has been negative (planned to get PET but denied for
insurance reasons). TTE in ___ without evidence of ___
normal and AFB negative x1 so TB less likely. Had CT chest
without any evidence of lymphatic obstruction. Not likely to be
amyloid.
# IGA Nephropathy:
# CKD
Patient with recent renal biopsy ___ showing basement
membrane disease and IgA nephropathy but minimal glomerular
pathology on light microscopy, no evidence of diffuse FP
effacement on EM, and only low grade proteinuria. Per renal, no
indication for immunosuppression and no indication for ___
given no proteinuria. Baseline creatinine appears between
1.9-2.2. UA showed some hyaline casts and 9 RBCs but no RBC
casts. Continued lasix and spironolactone at discharge as above.
# Hypoalbuminemia:
Patient with albumin of 1.8. Could be secondary to renal disease
given UA of 30 protein and underlying cirrhosis. Nutrition
consulted as above, added ensure clear TID w/ meals given PO
intake.
CHRONIC ISSUES:
================
#PAML: Confirmed pAML with PCA. Notably was not taking
spironolactone, midodrine, ranitidine, loratadine, ferrous
sulfate, citalopram, fluticasone at home.
# Moderate persistent Asthma:
Will continue home inhalers at discharge
# DM2:
Discharged on diabetic diet and home lantus 15U QAM
# Depression:
Discontinued mirtazapine as per PCA making her more confused at
home
# Hypertension:
Continued metoprolol 25mg PO BID
# GERD:
Continued home PPI
#insomnia:
Discontinued mirtazapine as seems to be worsening mental status
per PCA.
====================
TRANSITIONAL ISSUES
====================
[] Chylothorax management: Pleur-evac to be drained four days a
week (___) for a maximum amount
of 1 liter each day. Please look at drain closely when draining
as can fill up to 1 liter very quickly
[] Diet: Patient discharged on a low fat, medium chain fatty
acid diet to reduce chylothorax accumulation. Patient was
provided materials in ___ and educated by nutrition services
on diet.
[] ___ Cirrhosis: Continued on PO furosemide 40mg BID and
spironolactone 50mg PO BID for portal hypertension and ascites
and was arranged for follow-up with ___.
[] Risk of hepatic encephalopathy: Will be discharged on
lactulose 30mL TID titrated to three bowel movements daily and
rifaximin 550mg BID.
[] Discontinued mirtazapine as seems to be worsening mental
status per PCA.
[] Medication list: Discontinued ranitidine, loratadine, ferrous
sulfate, citalopram, fluticasone as not on home medication list
provided by PCA. If these medications were prescribed as
outpatient please be advised they were discontinued and should
be added back if felt to be necessary as outpatient.
[] Stopped aspirin as risk outweighed benefit given cirrhosis
and on for primary prevention.
# CODE: full
# CONTACT: ___ ___
Patient's PCA ___ ___
***. | COMPLICATIONS OF TREATMENT WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient is a ___ year-old gentleman with an extensive
surgical history including necrotizing pancreatitis with
compromise of the transverse colon requiring an open abdomen and
skin grafting in the past. He underwent staged reconstruction
of the abdominal wall. The patient was admitted to the hospital
this admission to undergo reversal of the loop ileostomy and
perform a fascial repair with component separation and placement
of biologic versus prolene mesh as feasible. Two ___ drains
were placed at the close of the procedure.
The patient was taken to the operating room and underwent
ventral hernia repair with component separation and ileostomy
takedown as a joint Plastics/ACS case. The procedure was lengthy
due to prior dense adhesions and extensive need for
adhesiolysis. There was also a bladder injury with primary
repair. Prolene mesh was placed in the retro-rectus space as
well as inlay mesh. EBL 600cc and patient received 5L of
crystalloid and 500cc albumin. He was extubated afterwards and
monitored in the intensive care unit. He did not require any
pressors. A NGT was left in place. An epidural placement was
attempted by Acute Pain Service, but this was unsuccessful. He
received a 500 cc LR bolus for an epidural associated headache.
On POD #2, the NGT was removed and he was advanced to clears. On
POD #5, the patient passed flatus, had a fleet enema which
resulted in 2 bowel movements and he received toast and
crackers. On POD #6, the patient had another bowel movement and
he was started on senna. The prevena VAC was replaced by
Plastic Surgery because initial cannester not holding suction.
The patient was discharged home with ___ services on HD 11. His
vital signs were stable and he was afebrile. He was tolerating
a regular diet and voiding without difficulty. His Prevena vac
dressing was changed by Plastic surgery and replaced because it
was not holding seal with discharge canister. Discharge
instructions were reviewed and a follow-up appointment was made
with the Plastic surgery service and acute care surgery.
=================================================
At time of discharge, c.diff returned +, patient started on 10
day course of oral vancomycin
***. | MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Assessment/Plan: Patient is a ___ year old female with history of
recently diagnosed Chronic Eosinophilic Pneumonia on Prednisone
and Atovaquone who now presents with symptoms of chills, sweats
and hypotension.
.
#. UTI with hypotension, likely early sepsis: She was admitted
with hypotension and chills, as well as sweats. She received IV
fluids in the emergency room and was rehydrated. She was
diagnosed with a urinary tract infection with Ecoli, and was
treated with levofloxacin. She defervesced, and her blood
pressure improved. She was treated with stress dose steroids
until her adrenal function was evaluated.
.
#. Early Adrenal Insufficiency: She has been on high dose
steroids for approximately 4 weeks, and given the hypotension,
there was concern for adrenal insufficiency. She was started on
stress dose decadron and had a cortisol stimulation test
performed. This showed a baseline low cortisol at 5.4, but with
cosyntropin, she had an appropriate response to 17 and then to
21 (after 30 and 60 minutes respectively). The stress dose
steroids were stopped and she was restarted on prednisone.
.
#. Chronic Eosinophilic Pneumonia, pulmonary eosinophilia:
Patient's symptoms per report appear to be improving. Her CXR
showed no improvement in her infiltrates.
She was treated with steroids and atovaquone, and will follow up
with Dr. ___ further evaluation and treatment regardint
the CEP, given her poor xray response
.
#. Benign Hypertension: Given hypotension, her atenolol was
held. She was advised to follow her blood pressure with her
home cuff, and to restart her atenolol when her blood pressure
became consistently higher than 140/80.
.
#. Hypothyroidism: She was continued on Levothyroxine 112mcg per
outpatient regimen. Her TSH was suppressed at 0.23, but her T4
was normal at 1.1. She will follow up with her PCP for repeat
___ in ___ weeks. It is possible that her steroids and
intercurrent illness have affected her thyroid function.
***. | SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year old man with DM2, chronic recurrent foot osteo admitted
with increased foot pain and foul smelling drainage in setting
of nonhealing ulcer likley secondary to known osteo
.
# Left foot osteomyelitis: Patient presented with increased pain
and drainage in the setting of leukocytosis and reactive
thrombocytosis, was found on foot XR to have osteomyelitis and
midfoot dislocation. Podiatry was consulted and recommended
BKA. Vascular surgery evaluated patient, who underwent left BKA
- he tolerated the procedure well with no complications. ID was
also consulted, and given pt has had multiple resistance
organisms and polymicrobial infections in the past, recommended
covering broadly with Vanco/Cipro/Flagyl, with plan to broaden
coverage to Meropenem if pt decompensates. Anesthesia was
contacted to evaluate pt pre-op given his ___ and
h/o MG crisis. Blood cultures grew ___ bottles of GPC in
pairs/clusters from initial admission cultures.
# DM2: Hyperglycemic in ED, most likely secondary to poor
medical compliance at home, given ___ were well controlled
in-house subsequently on home regimen. HgbA1C high, evidencing
poorly controlled DM. Infection was also likely contributing to
hyperglycemia prior to administration of antibiotics, given
leukocytosis (though this is possibly from steroids) and GPC in
pairs/clusters on bcx. Continued home lantus 60 units qhs as
well as SSI.
.
# MG: No active issues. Had recent MG crisis 3 weeeks prior and
was treated with multiple courses of IVIG. Anesthesia was asked
to evaluate pt pre-op in the setting of recent crisis. Home
prednisone and pyridostigmine were continued.
- stress dose steroids perio-op
.
# Hyponatremia: Likely secondary to dehydration and
hyperglycemia given elevated Cr and hemoconcentration. Patient
was given NS x1L, with resolution of hyponatremia.
.
# ARF: Cr. 1.4 from baseline 1.1-1.2. Likely ___ prerenal
azotemia given HCT is above baseline and has hyperglycemia,
likely osmotic diuresis resulting in dehydration. On Dc back to
base line
.
# HTN: Currently well controlled. Patient reports he does not
take Atenolol, and this was discontinued. Home Lisinopril was
held given elevated Cr and well controlled BP without Lisinopril
in the setting of current osteo/infection and upcoming surgery.
.
# GERD:Continue PPI
.
# Hyperlipidemia: Continue statin
.
# Anemia: HCT 31 from baseline 27, likely hemoconcentrated.
.
# Code: full (confirmed)
***. | AMPUTATION OF LOWER LIMB FOR ENDOCRINE NUTRITIONAL AND METABOLIC DISORDERS WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ was admitted to the Urology Service after
undergoing robotic assisted laparoscopic prostatectomy. No
concerning intra-operative events occurred; please see dictated
operative note for full details. The patient received
___ antibiotic prophylaxis. At the end of the
procedure the patient was extubated and transported to the PACU
for further recovery before being transferred to the floor. He
was transferred from the PACU in stable condition. On POD0, pain
was well controlled on PCA, hydrated with intravenous fluids for
urine output >30cc/hour, provided with pneumoboots and incentive
spirometry for prophylaxis, and he ambulated once. On POD1, the
patient was restarted on home medications, basic metabolic panel
and complete blood count were checked, pain control was
transitioned from PCA to oral analgesics, diet was advanced to a
clears/toast and crackers diet for breakfast and lunch. Diet
was advanced to regular after lunch and with further ambulation,
the JP drain was removed. Foley catheter care and leg bag
teaching was provided by nursing. The remainder of the hospital
course was unremarkable. Mr. ___ was discharged in stable
condition, eating well, ambulating independently, and with pain
control on oral analgesics. On exam, incision was clean, dry,
and intact, with no evidence of hematoma collection or
infection. The patient was given explicit instructions to
follow-up in one week for post-operative evaluation and trial of
voiding.
***. | MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ w/ MS, h/o PE, thoracoabdominal aortic aneurysm (6.3cm),
centrilobular emphysema, recent admission for DVT/PE now on
pradaxa, who was admitted for weakness and was found to have b/l
pleural effusions (R>L) s/p thoracentesis by IP.
#Bilateral Pleural Effusions (R>L): Patient initially presented
to the hospital with weakness and cough. She reports that she
has been having some nasal congestion and a predominantly
non-productive cough (occasionally coughs up yellow sputum). A
CT scan demonstrated that patient had bilateral pleural
effusions (R>L), and pulmonary emboli at the origin of the right
upper lobe and right middle lobe pulmonary arteries.
Interventional pulmonology was consulted and performed a
thoracentesis of her R side, draining 700ccs of light pink
fluid. Patient tolerated the procedure well and a post-procedure
CXR was negative for pneumothorax. The pleural fluid results are
as follows: RBC 7800, WBC 436, 76 poly, 1.4 protein, 123 LDH,
albumin <1, serum LDH 183, serum protein 4.2. Gram stain was
notable for 3 PMNs and no organisms. The pleural culture is
pending at the time of discharge. This was likely due to her
recent PE. Cytology analysis was negative for malignant cells.
Please follow-up on the final pleural fluid results. This was
communicated via telephone communication with Dr. ___. At
the time of discharge, patient was breathing well on RA. Patient
will follow-up with her primary care physician in the outpatient
setting.
#Pulmonary Embolism/DVT: Patient was recently hospitalized for
DVT (left popliteal vein thrombus)/PE (right pulmonary artery
and extending into the right upper lobe). A CT scan demonstrated
pulmonary emboli at the origin of the right upper lobe and right
middle lobe pulmonary arteries, consistent with recent findings.
___ pradaxa was initially held and she was placed on
heparin gtt in preparation for the thoracentesis. After the
procedure, a discussion was held with Dr. ___
primary care physician), who recommended to continue patient on
Pradaxa 75mg BID due to a possible family history of clots
concerning for an inherited disorder. Per inpatient pharmacy as
well as ___ guidelines, patient does not need to be bridged
with lovenox. ___ heparin drip was discontinued and
pradaxa was restarted prior to discharge. She tolerated this
well without any evidence of bleeding. Patient will follow-up
with Dr. ___ in the outpatient setting.
#Weakness/URI: Patient initially presented with weakness and URI
symptoms. Patient reports that she had been feeling weak since
being discharged from the hospital and never regained her
strength. Physical therapy evaluated Ms. ___ and
recommended rehab. Patient likely never recovered from her
recent deconditioning and in the setting of the URI/decreased
oral intake became more fatigued. She was discharged to rehab
where she will continue physical therapy treatments. ___
rehab stay is expected to be below 30 days.
#Thoracoabdominal aneurysm: Patient has a history of a stable,
6.3 cm thoracoabdominal aneurysm. A CT scan demonstrated it was
stable with a small dissection. Patient remained hemodynamically
stable without any abdominal pain throughout this
hospitalization. Vascular surgery was consulted and recommended
no surgical intervention during this admission, and to have
patient follow-up with Dr. ___ in the outpatient
setting to determine optimal management.
#Poor nutrition: Patient is thin although she endorses having
"ok" PO intake and is able to cook for herself sometimes. On
clinical exam, she is thin and very frail. Nutrition was
consulted and recommended continuing ground regular diet as well
as ensure supplementation TID.
#Macrocytic Anemia: Patient has a chronic history of macrocytic
anemia. Hgb was stable between ___, MCV 101-103. Iron studies
notable for Fe 48, ferritin 128, low TIBC and TRF. B12 and
folate are normal. There is a suspicion as to whether patient
may have MDS, although she is not neutropenic. Patient was not
started on any new medications recently that are known to cause
macrocytic anemia. Please follow-up on this in the outpatient
setting if clinically warranted.
#Severe COPD: Patient has a history of severe COPD. Per Dr.
___ has not had any PFT studying over the past
several years. We continued her on home Spiriva and her
respiratory status remained stable. She may benefit from
outpatient PFT testing.
# MS: Clinically stable. ___ weakness had started since
recent hospitalization and is unlikely to be due to MS. ___ did
not have any worsening sensory changes. Patient will continue
home ampyra in the outpatient setting.
# Spinal stenosis: Patient was continued on home MS ___ and
Percocet.
# Depression: Patient was continued on home fluoxetine.
=
=
=
================================================================
Transitional Issues:
1. Please follow-up on pending pleural fluid culture results.
Follow-up on ___ respiratory status s/p thoracentesis.
2. Please note that we continued patient on home pradaxa at 75mg
BID per recommendations from Dr. ___.
3. Please follow-up regarding her macrocytic anemia. Hgb was
stable at 10.6. Iron studies unrevealing except for low TIBC and
TRF. B12 and folate are normal. There is a suspicion as to
whether patient may have MDS, although she is not neutropenic.
4. Please follow-up on ___ mobility and strength recovery.
5. please follow-up on ___ thoracoabdominal aneurysm.
Patient will follow-up with Dr. ___ in the outpatient
setting.
6. Please follow-up regarding severe COPD. Patient may benefit
from outpatient PFT testing.
7. Please note that ___ home Lasix 20mg and potassium were
held on discharge due to her poor PO intake status, borderline
UOP and electrolyte fluctuations. Please consider restarting
this in the outpatient setting if clinically warranted.
8. Please follow-up on final blood culture results (pending at
time of discharge).
9. Please consider obtaining a TTE in the outpatient setting.
Pleural fluid BNP was 1100.
# CODE: DNR/DNI
# CONTACT: ___ (son) ___
***. | PLEURAL EFFUSION WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with PMH of ETOH cirrhosis c/b ascites, grade 1 varices,
h/o HE, PVT s/p tPA thrombectomy (___), recurrent
pancreatitis, T2DM, seizures, CVA, melanoma, bipolar disorder,
presenting with increasing abdominal distension and dyspnea,
likely secondary to ascites accumulation and missing recent
paracentesis (last one ~3 weeks ago, generally receiving them
every ___ weeks). Now s/p para, but required transfusion due to
anemia, as well as episodes of orthostasis.
# ETOH CIRRHOSIS (MELD- NA 16)
# RECURRENT ASCITES
He has been seen multiple times over last few months for
worsening
ascites. Last therapeutic para ___ per report. Patient has been
working on having low sodium diet. RUQUS without occlusive PVT.
No evidence of SBP. s/p para on ___ while on floor with
7L removed and received 75mg albumin. Patient will require
outpatient paras every ___ weeks, preferable near ___
(___) as this is where patient is near. His outpatient
diuretic regimen is lasix 160 mg PO and spironolactone 300mg.
His spironolactone was increased to 400mg this admission.
# ANEMIA
Patient with Hgb <7 after para. No signs of bleeding during
para. ___ be dilutional from albumin. Discharge Hgb was 7.2
# ORTHOSTASIS
Patient with episodes of lightheadedness upon standing, thought
to be secondary to anemia and fluid shifts s/p para.
# H/O HEPATIC ENCEPHALOPATHY:
Mild asterixis, but AAOx3. Has hsiotry of acute encephalotpyh.
- continued Lactulose 30mL TID and titrate to ___ BM daily
- Continued Rifaximin 550mg BID
- Infectious work-up was negative
# VARICES:
Last EGD in ___ with grade A esophagitis in distal esophagus
and
2 cords of grade 1 varices without intervention. ___ for
which
he required banding of medium sized varices.
- Continued PPI
- not on nadolol due to significant ascites
TRANSITIONAL ISSUES:
- please recheck CBC in one week. discharge Hgb was 7.2, likely
will require semi-frequent transfusions.
- Increased patient's spironolactone from 300mg to 400mg daily.
- patient had leaking from site of paracentesis requiring a
single suture. He will require removal of this suture 7 days
from discharge.
Name of health care proxy: ___
Relationship: Father
Phone number: ___
***. | CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. . Diet was
advanced as tolerated. The patient was transitioned to oral
pain medication when tolerating ___ diet. Physical therapy was
consulted for mobilization OOB to ambulate. Hospital course was
otherwise unremarkable. On the day of discharge the patient was
afebrile with stable vital signs, comfortable on oral pain
control and tolerating a regular diet.
Incisional vac was placed and was removed on POD#2. ID was
consulted and recommended discharge on oral ciprofloxacin. They
will see the patient in follow up.
***. | POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURE WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ h/o lung cancer with known mets to her spleen, adrenals, and
brain (no known bone mets) presented with L sided pain. Multiple
metabolic abnormalities.
# Nausea/Poor PO intake: Possible viral in etiology vs
exacerbation of her chronic nausea. LFTs/Lipase normal. Resolved
with IVF and bowel regimen.
#. Left side pain/L hip pain: DDx includes rib fracture d/t
potential bone mets, pain from adrenal mets, less likely splenic
rupture. After hydration wtih dilutional effect, underlying
anemia was revealed--worrisome for bleeding as a cause for the
pain. CT A/P negative for lytic lesion in iliac crest or bleed
but demonstrated worsening nodal disease which could be the
source of her pain. ___ left rib fracture seen on imagining was
not in area of pain. Her methadone was increased 40 mg am, pm
and 35 mg at noon and Oxycodone switched to dilaudid ___ mg q2h
PRN (___). A Lidocaine patch and standing Tylenol were used
for additional relief. Gabapentin was started in house at 300 mg
TID which can be uptitrated as an outpatient.
# ANEMIA: Bleeding (very possible with concurrent
thrombocytosis) vs. inflammatory block from malignancy were
considered. Iron panel was more consistent with the latter. She
was transfused 1 unit in house and Hct was stable. There was no
signs of bleeding on CT A/P.
#. Lung cancer: patient has chosen not to pursue chemotherapy or
radiation therapy in the past. Has hospice but currently living
at home alone. On admission she was planning to transition to an
___ facility but over the course of the hospital
stay had decided to return home to prior living situation with
home hospice. There was a family meeting with the team, the
patient, her sister ___ and ___ husband the day before
discharge
#. ___: Resolved
#. Hyperkalemia: Resolved
#. Hyponatremia: likely hypovolemic hyponatremia. Improved with
fluids although persistant.
Transitional issues:
--------------------
[ ] continued monitoring and titration of pain medication as an
outpatient
***. | RENAL FAILURE WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
PRINCIPLE REASON FOR ADMISSION
Ms. ___ is a ___ with h/o aplastic anemia and ITP with
development of myelodysplastic syndrome presenting for her
matched unrelated allogeneic stem cell transplant on Protocol
___ ___, a reduced intensity conditioning with
Clofarabine, ATG and TLI followed by Allogeneic Stem Cell
Transplantation, Cohort 3.
ACTIVE ISSUES:
# MDS/Allogenic SCT. Ms. ___ has a h/o aplastic anemia and ITP
with development of MDS; she had no evidence for transformation
to leukemia but she has had progressive anemias and it was felt
that allogeneic transplant offers her the best chance for cure.
She had an unrelated ___ match. She is enrolled on Protocol
___ ___, a reduced intensity conditioning with
Clofarabine, ATG and TLI followed by Allogeneic SCT. She had all
eligibility testing done and has adequate cardiac and pulmonary
function prior to transplant. She had no other active medical
issues. She had been on Neoral and Prednisone at a low dose
(d/'d on day of admission).
During this admission, she received TLI for a total dose of
80cGy on Days -11 through Day -7 and Day -4 to 0. She received
ATG 1.5mg/kg on days -11 to -7 and Clofarabine 30 mg/m2 on Days
-6 to -2. On ___ she had T101.2 and chills from the ATG,
which resolved with decreasing the infusion rate and APAP; as of
___, her Sx during ATG infusions were much improved and
remained benign for other infusions thereafter. Acyclovir ppx
was started on day-2. Cyclosporin was started day -1. On ___
she received her stem cell transplant, and developed fever with
rigors shortly after infusion, which was treated with APAP and
demerol. MMF, fluconazole and GSCF was started on day+1. She
required multiple pRBC and platelet transfusions in the days
following the transfusion. On D+10 her ANC began to recover. She
was discharged with a WBC of 8.8, HGB of 9.3, HCT of 26.9, and
Plt of 36.
# Neutropenic fever: Her first spike was to 101.5 on ___
ciprofloxacin was discontinued per protocol and vancomycin and
cefepime were started o/n. When the pt received cell infusion on
___ she also had fevers which may have been ___ cell
infusion/engraftment. Multiple blood and urine cultures were
negative and patient defevervesced. All antibiotics were stopped
on ___ and patient had no recurrence of fever prior to
discharge.
# GVH: On D+8 patient noted to have mild, ___
___ rash over abdomen and back. Thought to be grade I
acute GVH of skin. Rash did not progress over the following 2
days prior to discharge. Tacrolimus and cyclosporin were
continued per protocol.
# Hyponatremia: Patient noted to have Na 128 on ___. Urine
sodium and osmolality was consistent with SIADH. Patient was
placed on 2L fluid restriction with improvement in Na. She was
discharged with Na of 137 and no longer on fluid restriction.
# Drug Rash: Developed rash on ___, likely drug rash due to
clofarabine. Resolved by ___. Icepacks were applied prn, and
the pruritus was controlled with atarax and benadryl prn. The
rash improved after several days.
# Transaminitis: ALT and AST slowly increased from ___ to ___.
Initially there was no elevation in Alk phos or Tbili, and
patient was asymptomatic; was likely due to drug effect or
ATG/chemo. AST and ALT then downtrended during rest of
admission. However, ALP then began to rise from ___ to ___ with
normal ALT and AST. Unclear clinical significance and had
started to downtrend by discharge.
#. Preceding Infection Risks. ___ has a h/o mild
inflammation of a stone in her salivary gland which acts up on
occasion. Dr. ___ this with Dr. ___ ENT.
Because of the size, the stone is unlikely to pass on its own.
It is encapsulated and is felt to be a minimal risk of
developing systemic infection and may not bother her at all
during her transplant. The surgery would be more extensive and
would require further delay of her transplant. It was felt she
could proceed forward with her allogeneic transplant.
TRANSITIONS OF CARE:
- Will need close follow up of fluid intake in ___ clinic
following discharge
- Please obtain cyclosporin level in clinic following discharge
and adjust dosage per ___ attending
- Please continue magnesium sulfate IV repletion in clinic for
at least one week following discharge prior to initiation of Mg
Oxide oral repletion to help prevent complicating immediate post
discharge time with possible diarrheal side effects of Mg Oxide.
***. | ALLOGENEIC BONE MARROW TRANSPLANT |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ yo M with PMH of bipolar disorder, factor V leiden defiency,
presenting to ED approximately 8 hours after taking up to 18 g
of lithium.
# LITHIUM OVERDOSE
Patient with history of bipolar disorder, ingested 18g of
Lithium ER 300mg tablets. Lithium peaked at 2.7. Had episode of
vomiting after ingestion. Afterwards he was asymptomatic with
unremarkable labs. EKGs showed no QTc prolongation, flat T
waves, bradycardia. He had no ataxia, AMS, nystagmus, clonus,
tremor. Toxicology was consulted and recommended Golytlely until
stools clear and IV fluids. He was admitted to the ICU for close
monitoring and his lithium was checked every ___ hours and
down-trended. Lithium was in the subtherapeutic range (0.3) at
the time of discharge.
# BIPOLAR DISORDER
# SUICIDE ATTEMPT
Patient with suicide attempt as above. On ___. He had a
1:1 sitter and psychiatry was consulted, recommended inpatient
psychiatric stay once medically cleared. Outpatient psychiatrist
Dr. ___ ___. Lithium was held while
inpatient.
# STE V2/V3
Patient with ST elevations in V2/V3. Given lack of chest pain,
age and negative Tn x 3, unlikely to represent ACS. Given
concern for Brugada pattern, cardiac electrophysiology was
consulted. Assessment as per cardiac electrophysiology: "ECGs
not classic for Brugada although clinical context ___ toxicity
could be compatible with a sodium channel interaction. No
personal or family history of syncope/presyncope. No need for
urgent cardiac testing or a change of therapy at this
time, as clearly the goals of his current acute care are more
focused on his psychiatric health. As he is covered in the MIT
health network, which generally
refers subspecialty care to ___, I would recommend that he be
connected with the cardiac genetics ___ clinic there with
Dr. ___, whom I will notify via email. Long-term
follow-up of his ECGs, with further testing as needed, can be
coordinated there. This may also be useful for consideration of
his psychiatric regimen going forward."
# FACTOR V LEIDEN DEFICIENCY: With history rt calf, ___ dvt. S/p
3 months of Xarelto, now not on AC. No clinical evidence of VTE
during admission, and he was maintained on heparin SQ ppx.
TRANSITIONAL ISSUES:
- The patient should follow up with cardiology as above.
***. | POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Patient is a ___ year old woman who presented urgently to the
clinic after being ___ by her PCP for ___ right
temporoparietal mass. Her only neurologic deficit is left sided
vision loss. She is otherwise neurologically intact. She
underwent an MRI for surgical planning. She had a
chest/abd/pelvis CT which was negative for any malignancy. She
is being discharged home to return on ___ for a sterotactic
biopsy. She is aware of her follow up times and to return if her
visual symptoms worsen.
***. | NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Patient was called in as a STAT trauma and brought to the trauma
bay for management. He had been intubated on scene and had a gcs
of 4t on arrival. He was admitted to the TSICU for management of
his neurological injuries and a bolt was placed by the
neurosurgical service until the patient could be taken to the
operating room for a hemicraniectomy.
___: Pt admitted to TSICU, bolt placed and ICP noted to be in
the ___. Pt taken to the OR for emergent RIGHT craniotomy for
elevated ICP (40s) noted after bolt placed at bedside. Intra-op
EBL estimated to be 4000 mL. Pt received 2100 mL pRBC, 1668 mL
FFP, and 4700 mL crystalloid. Factor 7A also given. Required
pressure support with phenylephrine bolus and gtt, epinephrine
bolus, and norepinephrine gtt. Post-op pt with tachycardia and
stable b/p. Lopressor given to decrease hr with good effect. Pt
ICPs post-op have ranged from mid-teens to ___. Neuro exam
stable.
___ patient continues to be unresponsive, though neuro exam
waxes and wanes with decorticate posturing and occasional
withdrawal to pain. Started on Keppra and continued mannitol.
Patient undergoing video EEG. Had slowly falling hematocrit and
recieved 2 units pRBCs.
___ Unchanged neuro exam, occasional posturing. Fever > 101,
arctic sun was applied, after couple of hours patient developed
shivering, arctic sun was discontinued. Temperature remained
less 101. New L SCV CVL placed, femoral CVL removed. EEG
continued for another 24 hours. Pan cultured.
___ Unchanged neuro exam. Fever to 102.6, cultures sent,
antibiotics started, arctic sun applied. Pt with shivering,
propfol not sufficient, cisatracurium gtt added.
___ Decreased oxygen saturations in the morning. Obtained CXR
that showed RLL infiltrate/collapse. Bronchoscopy was performed
with copious thick secretions in right mainstem and down. BAL
sent. Started on PCV ventilation.
___ - OR for trach/ PEG/ IVC filter, off paralysis in am,
bronched - lots of thick yellow secretions, CT head, febrile at
night, on arctic sun again, after an hour shivering, paralyzed
now
___ cisatracurium changed to vecuronium IV bolus PRN for
shivering
___ paralytics were discontinued.
___ Pt was hypertensive into the 170's on triple therapy
therefore a nipride gtt was initiated. Staples were removed and
an MRI was obtained which revealed extensive ___ and hemorrhagic
contusions.
___ Pt was stable off ventilator and nipride gtt.
___ Neurologically and medically stable. Cleared for transfer
to stepdown unit. TLSO and Helmet ordered.
___ Pt remained stable. ___ and OT consulted pending
helmet/brace arrival. ___ ordered for routine screening were
negative.
___ cipro/vaco/ceftaz course for PNA completed.
___ febrile 102.6 overnight, central line d/ced tip cx, pan cx,
ID CONSULT, increased MSO4/Labetalol for poss PAID syndrome,
autonomics consult, removed sutures at crani site
___ vanc 22.7 held pm dose /UA NEG
___ Autonomia team eval/ LP by ___
___ Med Consult.
___ LFT's increasing,per ID-> dc'd all antibxs
___ afebrile, LFT's improved.
___ febrile. sent blood cx, u/a, sputum. Baclofen started for
spasm
___ febrile.
___ R direct tap of epidural space 20cc which finalized as no
growth.
___ Infectious Disease determined there was no infectious
process and fevers were central vs. secondary to an autonomic
disorder
___ Rehab screening started
___ Repeat Head CT to eval for cranioplasty planning: Return to
clinic in 4 wks w/head CT then schedule day.
**** Patient shows what appears to be an autonomic disorder such
as PAID: becomes hypertensive, tachycardia, increased
respirations, increased temps (99-100 ax), diaphoretic, extensor
posturing. We have been using Morphine/Baclofen/Clonidine to
help with symptom management. A Autonomic Disorder consult was
done but a the diagnosis of PAID could not be given as it is a
diagnosis of exclusion and they felt that all medical work-up
would need to be repeated in order for a formal diagnosis.
Infectious Disease has cleared patient of an infectious
etiology. Medicine was also consulted and could not find a
medical reason for symptoms. He is currently managed on the
above medications.
He was sent to rehab on ___
***. | ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PDX EXCEPT FACE MOUTH AND NECK WITH MAJOR O.R. PROCEDURE |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
#sepsis
#cellulitis
#tender inguinal lymphadenopathy:
He presented with ___ SIRS criteria (fever, tachycardia,
leukocytosis) with likely source of infection from cellulitis
and likely lymphangitic spread from right knee to hip. CT was
negative for forniers, abscess, or nec fasc. ID was consulted
and he was started on vancomycin and ceftriaxone with
improvement of symptoms. On discharge he was afebrile >48hrs and
leukocytosis had resolved. He was discharged on Keflex ___ QID
to complete 14 day total course of antibiotics through ___.
#cystic lesion, prostate: not concerning radiographically for
abscess.
#thrombocytopenia: mildly lowered; hb is reassuing no MAHA or
other consumptive process; low likelihood for viral or
rickettsial infectious etiologies that may cause
thrombocytopenia a/w infection. Likely due to underlying sepsis
___- Found to have rising creatinine to 1.4 in the setting of
sepsis. Likely pre-renal, resolved with IVF.
Transitional Issues:
[] consider repeat CBC in ___ weeks to ensure platelets
normalize
[] consider further outpatient evaluation of cystic prostate
lesion
Greater than 30 min spent on discharge planning.
PCP is ___ at ___
***. | SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year old M w/HCC metastatic to lung and abdominal wall,
presenting with weakness and hypotension, found to have
significant anemia thought ___ hemorrhage into tumor, as well as
acute kidney injury.
ACTIVE ISSUES
=============
#Hematemesis: ___ Patient with increasing nausea/emesis
previously controlled with antiemetics. Patient with emesis
initially with ?feculent material. NGT placed with noted BRB
return and continued hematemesis. Patient with worsening
tachypnea, transferred to the FICU where both ICU and hepatology
attendings made the decision that the risks of EGD requiring
intubation were too great given patient's abdominal mass. After
speaking with Mr. ___, patient decided to become DNR/DNI, CMO.
patient expired ___ at 8pm.
# HCC
Large tumor with associated portal vein tumor thrombus, s/p Y90
embolization to the right liver ___ and DEB-TACE to the
right liver ___. He was planned for initiation of FOLFOX
on ___ but was found to be hypotensive and therefore
admitted. Ultimately FOLFOX was initiated on ___. However,
pt decompensated on ___, and after discussion with ICU
attending and hepatology attending, patient decided to become
DNR/DNI, CMO. patient expired ___ at 8pm.
# Anemia
Patient admitted with severe acute on chronic anemia with
hemoglobin 4.7. Patient was guiac negative and hemolysis labs
not suggestive of hemolysis; however, CT and pelvis concerning
for hemorrhage into tumor. He received 3 units pRBCs while in
the ICU with appropriate bump in H/H and stabilization. He
received another unit on ___ while on the oncology floor.
Ultimately bleed into tumor felt to most likely be a slow bleed
and patient did not require ___ embolization. However, pt
decompensated on ___, and after discussion with ICU attending
and hepatology attending, patient decided to become DNR/DNI,
CMO. patient expired ___ at 8pm.
***. | MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ yo G2P0 with cHTN and labile BP and chronic HA admitted for
BP monitoring
*) cHTN, labile BP
- Lytes wnl, TSH 1.5
- 24 hour urine for protein 189 (___)
- ___ +barbituates (fioricet)
- no evidence of preeclampsia
*) chronic HA
- s/p neuro w/w with neg MRV and neg optho eval for papilledema
- cont home meds compazine, cyclobenaprine, cyproheptadine,
benadryl, tylenol, fioricet
- neuro consult if no improvement in HA w/ recommended
medications (deferred for now with outpatient follow up)
* Cyproheptadine IS covered by her insurance, spoke to her
pharmacy to clarify and they are processing the prescription-
will call pt when ready
.
*) anemia: continue Fe supplements
***. | OTHER ANTEPARTUM DIAGNOSES WITH MEDICAL COMPLICATIONS |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mrs. ___ was evaluated by the Trauma team in the Emergency
Room and admitted to the hospital for further management of her
rib fractures and small pneumothorax. Her cervical collar was
removed on ___ after a normal exam and negative CT C spine.
She had full ROM without pain.
Her pain was controlled initially with a Dilaudid PCA and
eventually oral Ultram , Tylenol around the clock and Oxycodone
as needed. She was able to maintain adequate oxygenation on
room air and she was using her incentive spirometer to 1000 cc.
A chest xray was done 24 hours post accident to evaluate her
pneumothorax. She had a tiny right effusion but no evidence of
pneumothorax. Her diet was gradually advanced and she was up and
walking independently.
She had some soft tissue swelling on the right side of her neck
but no C spine tenderness and full ROM without pain. Her right
elbow wounds were dry and healing without cellulitis.
After an ___ hospital stay she was discharged to home
on ___ and will follow up in the ___ clinic in ___ weeks.
***. | PNEUMOTHORAX WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ yo F with HTN, HLD, RA, PAD, significant tobacco history, p/w
new lung mass and ___ masses discovered on w/u of her ataxia,
now confirmed to have metastatic small cell lung cancer.
.
# Bowel incontinence: This is a new symptom, although patient
reportedly was brought in from home covered in feces. Currently
without any other focal neuro findings on exam, and has intact
rectal tone, but given this new symptom, and risk for spinal
mets, did obtain MRI of the entire spine to evaluate for spinal
lesions. She is already on systemic steroids for her ___
lesions. MRI spine without spine mets and no cord compression.
Suspect that her incontinence may be due to weakness limiting
her ability to get to the commode / BR in a timely fashion.
.
# Small cell lung cancer with ___ mets, with ataxia
Patient was started on systemic steroids for her ataxia, likely
from her ___ metastases. She had an MRI ___ (see above)
that did not show any clear spinal lesions concerning for spinal
mets. Her neurologic symptoms remained stable, although without
significant improvement. She underwent bronchoscopy with
biopsy, with pathology concerning small cell lung cancer. She
was seen by Radiation-Oncology and started on whole ___ XRT,
with 2 sessions received as an inpatient, and will continue 3
more sessions (___) to complete a total of 5 sessions.
Following completion of her XRT sessions, her decadron can be
tapered, reducing the dose by half every 3 days. She will
follow-up with Dr. ___ of ___ Oncology for
discussion and likely initiation of chemotherapy on ___.
.
# Hyperglycemia: no history of DM. Currently elevated BS likely
steroid-induced. Her blood sugars have been mainly in the
200's. Given that she has no history of DM2, is insulin naive
and will be weaned off her steroids soon, will use just gentle
PRN units of short-acting insulin for BS >300.
.
.
# HTN: BP suboptimal, but likely due to high dose steroids, will
continue home dose lisinopril for now. Can uptitrate lisinopril
as needed.
# HLD: continue home statin
# RA: She is on weekly methotrexate (25mg IM qweek) and
leucovoroin at baseline. Per d/w her ___, since she
is currently on dexamethasone, which will control her RA
symptoms, can hold off on continuing methotrexate at this time.
Furthermore, if she is to initiate chemotherapy for her lung
cancer, MTX can also continue to be held. .
# PAD, s/p bypass: continue full dose ASA
.
# FEN: Regular diet
# DVT PPx: HSQ
# Code: Full Code (confirmed)
# Contact: ___, HCP / nephew, ___ (cell),
___
.
TRANSITIONAL ISSUES:
1. Complete WBXRT sessions #3 - #5, scheduled for ___
2. Steroid taper after completing XRT sessions, can reduce dose
by half every 3 days
3. follow-up with Dr. ___ on ___ for discussion and
likely initiation of chemotherapy
4. Consider resuming methotrexate and leuocovorin once she
completes her steroid taper
***. | NERVOUS SYSTEM NEOPLASMS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year-old man with metastatic pancreatic CA with liver
involvement receiving palliative chemo (last chemo mid ___ was
found to have liver abscess. He had ___ percutaneous
drainage and pigtail catheter placement on ___. The drainage
was noted to be frank pus. He was started on Zosyn. Cultures
grew Proteus and antibiotics tapered to Ceftriaxone and Flagyl.
When drainage from the pigtail catheter was at a minimum, he
underwent repeat abdominal imaging with a CT. The liver abscess
had been successfully drained, but another large fluid
collection had formed during the interval. Another drainage was
performed on ___. Drain output decreased to 30 cc for the
day prior to discharge. Due to ongoing drainage will need to
keep drain in place at the time of discharge. Pt underwent MRCP
to eval biliary drainage, to ensure biliary obstruction was not
etiology of formation of liver abscesses. Per discussion with
Radiology, MRCP without e/o clinically significant obstruction,
and abscesses unlikely result of biliary obstruction/bilomas.
.
.
# Liver abscess with Proteus:
ID consulted during the admission. Ceftriaxone recommended to be
continued for at least 1 week after the drainage catheters are
removed. Flagyl should be continued for at least 1 week after
catheter removal or until all wound anaerobic cultures are
negative. Home IV antibiotics were arranged for discharge, and
Dr. ___ will continue to follow and manage his liver
abscesses. Recommend maintaining abscess drain until drainage
<10cc per day for 2 days. Consider clamping drain for ___ days
and reimage liver for resolution of abscess before
Interventional Radiology discontinues drain.
.
# Pancreatic CA: last CA ___ rising (mid ___ suggestive of
progressive disease. Patient is on narcotic pain medications for
pain from the cancer at baseline. Pain currently well
controlled.
.
# Right pleural effusion: IP consulted on ___ and found too
little fluid to drain after performing bedside ultrasound.
.
# Anemia: likely chronic disease and iron deficiency (iron level
9). Stable. Started oral iron.
.
# GERD: Continued PPI.
.
# Tobacco abuse: continue nicotine patch.
.
CODE: FULL
DISP: Discharged to home with ___ services and home IV
antibiotics.
***. | DISORDERS OF LIVER EXCEPT MALIGNANCY CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year old female with biliary stent placed for Mirizzi
syndrome ___, now with acute cholecystitis and concern
regarding infected stent. Patient had ERCP and stent
replacement. She also had a percutaneous cholecystotomy tube
placed and she was treated with IV antibiotics. By the time of
discharge she was tolerating regular diet, afebrile and adequate
pain control. She will follow up as an outpatient with ERCP for
stent removal and with Dr. ___. Her drain will remain in
place until follow up and she will be placed on PO antibiotics.
.
# Acute cholecystitis: The patient was treated with unasyn for
her acute cholecysistis. She underwent ERCP due to concern for
acute cholangitis given the fact that she has had a previous
stent. ERCP showed that the patient's bile duct stent was
working properly and there was no pus in the bile duct. Again
noted was the stone in the cystic duct, which was felt to be
intermittently compressing the common bile duct. For this
reason, a stent was again placed in the common bile duct. It
was felt that the patient's symptoms were primarily related to
acute cholecystitis rather than cholangitis. Drain to be left
in place until follow up with antibiotics
.
# Anemia: microcytic, likely blood loss, either GI or GU or
hemolysis/DIC, unclear chronicitiy, at least partially acute
(HCT 33 at OSH). Pt did report lightheadedness prior to this
event. Guaiac negative, denies blood in vomit, report mentrual
cycles not particularly heavy. No prior baseline.
- blood smear, fibrinogin, hapto, INR, FDP, D bili
- q8h HCT
.
# ___: The patient's kidney fuction improved from the
presentation to OSH to the time of admission to ___. It
improved with fluid resuscitation.
.
# Non-gap metabolic acidosis: Most likely related to fluid
resuscitation and gastric losses from vomiting. The patient was
given lactated ringers for further volume resusciation and her
acidosis resolved.
.
# Urinary tract infection: Treated with unasyn as above.
.
# Left Black Eye: The patient was noted to have a black eye on
admission. The patient reported it occurred as an injury
related to falling down the stairs. The was concern about
physical abuse. Social work was consulted
***. | DISORDERS OF THE BILIARY TRACT WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
He was admitted to the ACS service and evaluated by neurosurgery
for his traumatic brain injury. He was loaded with Dilantin and
remained on this for approximately 1 week. He was stabilized in
the ICU and transferred to the regular nursing unit. There were
no observed or reported seizure activity during his stay.
There was no evidence of seizure activity throughout his
hospital stay. He was intermittently agitated during his stay
and sustained falls out of bed x2 without any apparent injuries.
He was started on Olanzapine with marked improvement in his
behaviors. His mental status currently is alert and oriented
x1-2, he is cooperative with his care.
His home antiretroviral medications were restarted.
He was evaluated by Physical and Occupational therapy and is
being recommended for traumatic brain injury rehab after his
acute hospital stay.
***. | TRAUMATIC STUPOR AND COMA COMA <1 HOUR WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ is a ___ woman with HTN, HLD, chronic neck
pain who presented with two weeks of left neck pain radiating to
head, L ptosis, and anisocoria that was found to be ___ to L ICA
dissection with L ICA clot. Pt was treated with heparin gtt
before being transitioned to Coumadin (goal INR ___ with
lovenox bridge.
# Left ICA Dissection and thrombosis
Pt presented to the ED on ___ with left-sided neck and
associated HA accompanied by left ptosis, for the past two
weeks. Exam showed left-sided ptosis and miosis (Horner
syndrome). Patient received CTA head and neck, which showed
occlusion of left internal carotid artery with distal
reconstitution. MRA head and neck confirmed left ICA dissection
with distal recanalization of flow with no evidence of stroke.
Pt was treated with heparin gtt before being transitioned to
Coumadin (goal INR ___ with lovenox bridge. At discharge,
patient continues to have left ptosis and miosis (anisocoria),
with no new deficits.
There was no obvious etiology of the dissection identified - no
trauma, neck manipulation. She was counseled on avoiding this in
the future. She will be discharged with ___ for neck range of
motion and help with pain relief as below.
# Migraine
Pt reported headache for the past two weeks prior to
presentation, pulsatile in nature and worse behind the left eye
that remained stable during this admission. On ___ she noticed
a "floater" in her left eye that was described as a squiggly
black-red line with another line underneath it in her L temporal
visual field that moves with EOMI. This floater is associated
with a warmth spreading over her head prior to worsening
headache. Reports this floater with HA intermittently with
otherwise stable neurologic exam. Likely migraine with aura ___
to trapezius spasm (below). Pt was started on nortriptyline for
headache prophylaxis and HA was acutely treated with Tylenol,
valium and tramadol PRN.
# Left trapezius spasm
Patient has chronic neck pain that had worsened in the last two
weeks prior to presentation. During this admission she L
trapezius muscle spasm treated with cyclobenzaprine 5 mg TID.
Transitional Issues
=====================
[] INR subtherapeutic (1.1) at discharge, continue to monitor
until goal INR ___ achieved.
[] Please, dc ___ once patient has therapeutic INR.
[] will need repeat MRA at 3 months to evaluate dissection for
resolution
***. | PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is a ___ year old male with a hx of ___
disease who presented to the hospital on ___ for elective
surgery. An MRI was completed pre-operatively for operative
planning. The patient was taken to the OR for stage one of a DBS
stimulator placement. A left subthalamic DBS lead was placed in
the OR. The patient tolerated the procedure well. For more
details of the operation please refer to the op note in OMR.
Immediately after surgery the patient was taken back to MRI and
the study revealed good placement of the DBS and no hemorrhage.
The patient was taken to the PACU for recovery. The patient
remained stable and was transfered to the floor.
On ___, the patient was tolerating a regular diet. On exam
he was slightly confused to place. The patient exhibited full
strength and no pronator drift. The patients face was symetric
and pupils were equal and reactive. The patient dressing was
clean dry and intact. The daughter noted that the patient's
baseline confusion, paranoia, and impulsiveness was exaggerated.
Dr ___ neurology came by to assess the patient and found
him to be close to his neurological baseline noting that he may
be less confused in his home environment and felt that he was
ready for discharge as long as his family would be able to
provide 24 hour supervision. The daughter agreed to supervising
the patient at home. The patient was given written discharge
instructions and all questions were answered.
***. | PERIPHERAL CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with PMHx ischemic cardiomyopathy (EF 20%) s/p CABG in ___
w/ICD (replaced in ___, recently admitted for a CHF
exacerbations thought in part related to cardiac
desyncronization w/ recent BiV-CRT, who presents for hemoptysis,
SOB found to have PE
# Acute Pulmonary Embolism with pulmonary infarct: Patient
presented with hemoptysis, increased SOB with CTA revealing
posterior embolism. ECG was not remarkable for heart strain and
he was hemodynamically stable. Troponin was negative. He
started on heparin drip initially then switched to Lovenox as a
bridge to Coumadin. Goal INR ___, indefinite. Lovenox bridge.
# Chronic CHF secondary to Ischemic cardiomyopathy: (most recent
echo ___ shows EF of ___. He has been feeling well
since his CRT upgrade. He was at his dry weight on admission and
showed no signs of his volume overload on exam. He was kept on
his home dose of furosemide.
Transitional issues
- Patient will be bridged to Coumadin with Lovenox. Next INR
check will be on ___
- Full code
***. | PULMONARY EMBOLISM WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
On ___, the patient was electively admitted for a
pipeline embolization of right ICA aneurysm and PComm aneurysm.
She underwent this procedure with Dr. ___, without
complication, and subsequently transferred to the PACU for post
anesthesia care and monitoring. She was later transferred to the
___ for continued management. Patient was noted to be
hypotensive overnight and received 1L of NS bolus with
resolution of the hypotension. On POD#1 Patient remained
neurologically intact. She complained of headache which was
relieved by fioricet. She was tolerating a diet, ambulating and
voiding independently. She was discharged home in good condition
with instructions for follow up on daily aspirin and Plavix.
***. | CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
*** s/p aortic mass resection & replacement of ascending aorta
w/ gelweave graft, was discharged to home on ___. Please
refer to discharge summary for further details of his previous
hospital course. He returns to ___ on ___ with persistent
fevers postop, and now with leukocytosis. He was admitted to
Cardiac Surgery for further workup. Repeat blood and urine
cultures were drawn. Follow up cultures from ___
were all negative or No growth to date. He was placed
empirically on vanc/Zosyn given presence of graft. CXR done was
concerning for right lower lobe pneumonia. Over the next few
days he slowly progressed. He remained afebrile with a
decreasing white blood cell count. Blood and urine cultures were
negative, as well as CDiff. CXR on ___ shows slight improvement
of right lower lobe opacity. He was placed on oral antibiotics
for discharge to home. On hospital day 7 he was afebrile,
feeling better, ambulating freely and reports increased
appetite. He was discharged to home with follow up appointments
advised.
*Of note, Lupus anticoagulant was drawn. Results are pending at
the time of discharge. If this returns positive, he will
follow-up with heme.*
***. | SIMPLE PNEUMONIA AND PLEURISY WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year old male with a hx of seizures and chronic hyponatremia,
as well as paraplegia secondary to a T4 injury presenting with
seizures in the setting of hyponatremia.
ACTIVE ISSUES:
#Hyponatremia: Pt presented to the ED following a seizure at
home and was found to be hyponatremic to 120. Pt is chronically
low at baseline (mid-high 120s). On exam found to be clinically
euvolemic. With elevated urinary sodium and osmolality thought
to be secondary to SIADH. AM cortisol and TSH wnl so adrenal
insufficiency and hypothyroidism unlikely. On prior admissions,
also thought that "reset osmostat" could be contributing to
hyponatremia, as observed in paraplegics due to venous pooling
in legs. Evaluated by renal during admission, and pt was fluid
restricted 1L, with improvement of sodium to 127 at time of
discharge.
#Seizures: Pt presented following a seizure at home.
Subsequently had another ___ min seizure while in the ED and was
given Keppra and ativan, with resolution of symptoms. Described
as partial complex seizure with secondary generalization. CT
___ was obtained which demonstrated no acute findings, although
had a hypodensity in the left frontal lobe thought to be sequela
of chronic small vessel disease. An MRI was also performed which
showed brain parenchymal volume loss and sequelae of chronic
small vessel disease. EEG without any acute findings on
preliminary read. Pt was evaluated by Neurology who felt that
seizures were likely were due to a structural epileptogenic
focus (although this was not visualized on imaging),
precipitated or promoted in the context of severe hyponatremia.
He was started on Keppra 1g po BID prior to discharge, although
pt was reluctant to take any medications, he agreed to remain on
Keppra at home.
#Hyperglycemia with glucosuria: On presentation with elevated
serum glucose to 170s and glucosuria. No known diagnosis of
diabetes in the past, and A1c was wnl at 5.3.
TRANSITIONAL ISSUES:
# Need to follow up for 6-month CT Chest to evaluate right hilar
CXR finding
# Follow-up on official EEG final read
# Blood cultures still pending from ___: No growth to date
# Follow-up with Neurology
***. | SEIZURES WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
A/P: ___ yr old male with Parkinsons s/p fall with compression
fracture and E.Coli UTI.
# s/p fall/ L1 compression fx: It appeared that the patient
tripped and fell secondary to gait abnormality in the setting of
Parkinsons. Could be in the setting of UTI. Neurosurgery
followed, and since the patient tolerated TLSO brace without
pain, neurosurgery did not recommend kyphoplasty. The patient
should wear TLSO when out of bed or head of bed greater than 45
degrees. If HOB<45, he may take the TLSO off. Pain was
controlled with Tylenol and ibuprofen. He should continue
working with ___ at the rehab and f/u with Dr. ___ in 6 weeks
after discharge (___).
# E.Coli UTI: sensitive to Cipro. Pt initially had leukocytosis
and fever which all resolved. Pt was started on Cipro at the
time of admission on ___ and should finish a 7 day course (Last
day ___.
# Sacral Decubitus Ulcers: Wound care was consulted and there
were no signs of infection. The followings were the
recommendations:
Please turn and reposition the patient every ___ hours and prn
off back. Please have heels off bed surface at all times.
Moisturize bilateral lower extremities and feet BID with Aloe
Vesta Moisture Barrier Ointment. Secure external condom cath
with Flexiseal tube stailizing device to prevent trauma. Please
use foam cleanser to gluteal tissue and pat the tissue dry.
Apply a thin layer of Critic Aid Clear Moiture Barrier Ointment
to both gluteals over irregular tissue, daily and prn or every
time cleansing.
.
# CAD: He has a significant history of CAD but was stable during
this admission. We continued all his home regimen
.
# ___: Continued his Sinemet
.
# HTN: continued home meds
.
# Hypothyroid: Continued levothyroxine at home dose.
.
# Constipation: senna, colace, MOM/as needed.
#FEN: regular diet, replete lytes PRN
PPX: SC Heparin, bowel regimen
Code: full
***. | MEDICAL BACK PROBLEMS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is an ___ yo AAM with PMH B iliac artery/aneurysm s/p
coiling ___, Chronic systolic CHF EF 45-50%, atrial
fibrillation on Coumadin, T2DM on lantus, htn, hld, h/o CAD
without PCI presented to ___ ED with BRBPR.
#Acute Blood Loss Anemia/Lower GI Bleed: Patient with multiple
episodes of BRBPR. Hb 9.8 initially with unclear baseline but
dropped to 7.9. Initial mild tachycardia improved with fluids
and
BP has been stable in 130s since arrival though pt had syncopal
event on toilet when arrived at room with 200-400mL of dark red
stool. INR ___ s/p 1U FFP and po vitK in ED so administer FFP
and
additional vit K in addition to 1 u pRBC. s/p ___ ___, found to
have diverticulum with clot which was endoclipped as well as
small polyps which were not removed. Received 2nd unit pRBC in
___
___. His H/H was monitored and remained stable for 4 checks. His
Coumadin was restarted without a bridge per GI recommendations.
# Syncope: Occurred in room while defecating in the setting of
acute blood loss. BP and HR largely stable. No further episodes.
Telemetry unremarkable.
# Persistent atrial fibrillation: on Coumadin, CHADSVASC 6, but
given risk of bleeding much greater than stroke INR was reversed
with FFP and po vitamin K. INR now 1.2, per GI ok to restart
warfarin. Did have one episode of atrial fibrillation with RVR
in the setting of holding his nodal blockade. These were
restarted and HR was well controlled without issue. He is now
back on his Coumadin without a bridge and will need his INR
monitored.
# T2DM: On Lantus 14U qhs at home
# Chronic Systolic Heart Failure - mild EF 45-50%.
-Cont Coreg 25 BID today
-Cont Losartan 100 qd, Lasix 40
TRANSITIONAL ISSUES:
-Will need close monitoring of INR/warfarin dosing
***. | MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ female with history significant for scleroderma
skin, gastroparesis, reflux, Raynaud's), stage IIA NSCLC/p RUL
lobectomy, RML wedge resection and lymphadenectomy
___ (deferred chemotherapy), who has since been 02
dependent; is also in the midst of an evaluation for PAH (likely
related pulmonary disease, but possibly ___), who presented with
chest
pain, found to have pulmonary embolism on CTPA.
# ACUTE LEFT LOBAR and SEGMENTAL PULMOMARY EMBOLISM:
No proximal risk factor aside from prior NSCLC. Worrisome for
harbinger of recurrence. Patient was started on heparin gtt,
which was held only for chest tube placement. She was ultimately
discharged on lovenox.
# LOCULATED RIGHT PLEURAL EFFUSION,
# POSSIBLE NSCLC RECURRENCE:
Patient received antibiotics int he ED. However, she had no
signs/symptoms to suggest pneumonia and was non-toxic appearing,
therefore, antibiotic therapy was discontinued on admission.
Chest CT findings concerning for possible disease recurrence. IP
was consulted, who placed a chest tube finding an exudative
effusion. They were only able to obtain 20cc of serosanguinous
fluid. Culture was negative and not enough fluid was available
for cytology. Thoracics was consulted who did not feel a VATS
washout was indicated. Given concern for recurrence, oncology
was consulted, who recommended CT torso to evaluate for
metastatic disease. Pleural fluid returned positive for
malignant cells, and patient was to followup with IP and
oncology regarding next steps.
# SCLERODERMA:
Stable
# HYPERTENSION:
Stable, continued ___ and ___
# FIBROMYALGIA:
Amitriptyline HS and Tramadol PRN
# HYPOTHYROIDISM:
Continued synthroid
TRANSITIONAL ISSUES:
***. | PULMONARY EMBOLISM WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is a ___ with PMHx DM, PVD s/p multiple toe
amputations (last on ___ and right BKA, CKD, HCV, h/o IVDU,
and recent admission for osteomyelitis, hyperkalemia and MRSA
bacteremia who was admitted with hyperkalemia and due to
inability to find a safe and suitable post-discharge plan.
====Key points from long hospitalization====
***Consult Case Management if presents to Emergency room***
(Patient is unable to be placed in a Rehab)
- Baseline Cr 2.4-2.8.
- Hyperkalemia stablized with lasix/chlorthalidone.
- No need to treat unless K > 6.
- Fingersticks often run high and vary in setting of dietary
noncompliance. Fasting Fingersticks are controlled.
**Please check chem-10 at next appointment and then weekly
therafter**
- Needs chronic narcotic agreement.
=========================================================
ACTIVE ISSUES
# DISPOSITION- Patient was admitted for placement, but
subsequently declined from all rehabs. He was initially
transferred from rehab after an asymptomatic hyperantremia to
154 at rehab. At recheck a few hours later he was found to be
140 in the ED and still asymptomatic. It was thought that this
value was a lab error. The ED attempted to have him return to
his rehab, but they refused for unclear reasons. The patient was
admitted for placement.
.
For a variety of reasons, stemming mostly due to past behavior
problems, we had extreme challenges finding a rehab or care
facility that would accept him (throughout ___. He was
also not accepted at nearly all methadone clinics in ___. We
had several blunt conversations with the patient about his
behavior, and over his long hospitalizations there were some
marked improvements noted.
.
During his stay, patient was challenging to manage, including
reports of inappropriate conduct towards nurses and staff. He
required a multidisciplinary approach to his care.
.
Final plan was to discharge him to intake appointment at the
___ clinic and a short term post-hospital stay at
the ___, with transition to the shelter system
until he can find more permanent housing. However on day he
finally was able to get a methadone intake appointment with
transition to ___, the patient decided he would rather
go stay with his cousin in ___. Patient was provided
with a ride to the methadone appointment and a taxi voucher to
his cousin's thereafter. He was discharged with all his
prescriptions until a followup appointment in ___
clinic.
# LEFT FOOT OSTEOMYELITIS: Resolved. Patient with recent left
toe amputation in ___ with OR cultures positive for MRSA.
Completed a previously started course of antibiotics on ___.
No fevers. Repeat imaging not consistent with osteo. Area of
erythema around wound consistent with post-inflammatory change
and not cellulitic appearing at present. His PICC was removed
after his antibiotic course was finished.
# HYPERKALEMIA: Resolved. Nephrology evaluated and thought there
may be a type IV RTA, recommended treatment only if K > 6. He
had multiple EKGs with peaked T-waves. Treated multiple times
with insulin, kayexalate and furosemide, low K diet. Refused
kayexelate for potassium below 6.0. He refused to wear
telemetry. His max potassium was 7.3, but his potassium was
better controlled with standing daily lasix 40mg. After addition
of chlorthaldione to the lasix, his hyperkalemia never recurred.
# CHRONIC KIDNEY INJURY: Baseline Cr 2.4-2.8. Likely secondary
to poorly controlled diabetes. Initially his Lasix was held for
concern for worsening his renal function. Eventually lasix as
well as chlorthalidone were restarted with stable renal function
with just mild fluctuations. He remained euvolemic on exam.
# METHADONE MAINTENANCE: Patient initially came in on dose of
80mg methadone in AM, with 10mg in early afternoon, and 20mg in
___. He had episodes of confusion, lethargy, and jitteriness. It
was felt high doses of methadone were doing him harm, and he
wanted to reduce them, so dose was gradually decreased to 30mg
over a few weeks. Mild withdrawal symptoms eventually subsided.
His breakthrough pain was managed with oxycodone, for which
he'll likely need to set up a chronic opioid agreement, as he
adamantly declined increasing the methadone dosing again.
# TYPE 1 DIABETES: Last HbA1c 6.6 in ___. Initially his
glucose levels were well controlled but they became elevated
throughout his hospital stay despite maintaining him on a
diabetic diet. He often was seen eating sugary foods.
Fingersticks often run high and vary in setting of dietary
noncompliance. Fasting Fingersticks are controlled. His insulin
requirements were uptitrated for better glucose control. His
lantus had been increased to 30U QHS plus sliding scale
***Anticipate fingersticks will be better controlled once he is
out of the hospital setting and into shelters***
# RASH: During his admission he developed a maculopapular rash
over his groin, legs, and flanks. The etiology was unclear. He
was given topical steroids and his rash improved. He was
discontinued from his antibiotics as previously planned which
may have been contributing. He was not discharged with topical
steroids.
# DIARRHEA: Patient with several week history of diarrhea. Cdiff
negative here and at rehab. Stool cultures negative last
hospitalization. Most likely antibiotics assoiciated diarrhea
vs. intermittent kayexalate. His diarrhea improved and
eventually flipped to constipation which was treated with a
bowel regimen.
# HISTORY OF R BKA - Patient was fitted with a prosthetic leg
for which he can continue outpatient physical therapy. Please
keep his stump wrapped with ACE-Bandages per ___ recs to reduce
edema and ensure good fit.
# HYPERTENSION: He was hypertensive on initial presentation to
170/90s. He was started on hydralazine and given amlodipine. As
his methadone was decreased he continued to remain hypertensive
so his hydralazing was increased. He was primarily in the
140-160s sysotlic prior to discharge. It was thought that a
large component of his disease was due to his diabetic renal
disease.
# HYPERPHOSPHATEMIA- Likely secondary to renal failure. He was
started on calcium acetate and a low phos diet, and his phos
improved.
=========================================================
CHRONIC ISSUES
# CHRONIC PAIN DUE TO DIABETIC NEUROPATHY: His pain was stable.
His methadone was decreased as detailed above. He was given
lyrica with oxycodone for breakthrough pain.
# LOW T - Patient requested "his testosterone" injections as he
was previously diagnosed with "low T." He did receive two doses
during his hospitalization, though we recommend further
discussion regarding the mounting evidence of potential harms of
this treatment.
# CHRONC NONHEALING LLE WOUNDS- Appeared noninfected as
discharge with standard wound care.
# CHRONIC NORMOCYTIC ANEMIA: His hemoglobin remained stable
during his admission.
# COPD: Respiratory status at baseline. He was continued on
albuterol and ipratropium he had no complaints.
# DEPRESSION: He was stable throughout his hospitalization. He
was continued on sertraline. He was anxious about discharge
given his multiple medical conditions. He was concerned about
his ability to care for himself.
# ADHD: Stable. He was continued with Adderall.
=========================================================
TRANSITIONAL ISSUES
**Please check chem-10 at followup appointment
1) Baseline Cr 2.4-2.8.
2) Hyperkalemia stablized with lasix/chlorthalidone. No need to
treat unless K > 6 per nephrology.
3) Patient will need to initiate chronic narcotic agreement with
his PCP if remains on oxycodone
4) Please initiate outpatient ___ as patient is still getting
used to his new prosthetic leg.
***. | MISCELLANEOUS DISORDERS OF NUTRITION METABOLISM FLUIDS AND ELECTROLYTES WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year-old female with history of asthma and allergies
presented with shortness of breath, admitted for further
evaluation and treatment of severe asthma exacerbation.
.
ACTIVE ISSUES
-------------
#. Asthma exacerbation: Given patient's history of cough and
fever, the likely trigger of her exacerbation was an infection,
probably viral. Patient failed initial observation in the
emergency department, but symptoms improved with nebulizer
treatments and magnesium sulfate. Chest tightness was worse with
coughing and wheezing, thus was likely secondary to asthma
exacerbation. She was treated with albuterol and ipratropium
nebulizers and started on a prednisone burst of 40 mg which was
continued for five days. She was also continued on her home
fluticasone-salmeterol diskus, which she had not been using
daily. She did not tolerate attempts to space out her nebulizer
treatments initially. She continued to become dyspneic with
exertion, and she was started on azithromycin to treat for
possible bronchitis as well. Her nebulizer treatments were then
gradually spaced out and she was deemed ready for discharge once
she was able to tolerate stair-climbing without becoming
dyspneic. During her course, she was given education about how
to use her asthma medications to optimize their effectiveness.
She was discharged on home nebulizer treatments,
fluticasone-salmeterol diskus, and albuterol inhaler. Predisone
burst was completed during inpatient stay. Follow-up appointment
with her PCP was scheduled for the day after discharge. There
are no pending results to follow up. In terms of her
medications, she requested that any long-term medications her
PCP wants her to take be faxed to her pharmacy at ___
so they can be delivered to her regularly; phone number is ___.
.
#. Headache: Patient's symptoms were most consistent with a
tension headache, in that it began in the occipital region and
radiated bilaterally forward. She had no photophobia, nausea,
vomiting, or aura. There was no meningismus or meningeal signs
on exam, and she had been afebrile in house. Based on history
and exam, etiology was most likely tension headache. Her pain
remained well controlled on acetaminophen as needed throughout
the course of her hospitalization.
.
# Chest pain: On Day 2 of admission, the patient complained of a
new pressing, squeezing chest pain associated with dyspnea,
nausea, and dry heaving. There was low concern for cardiac
etiology but EKG was obtained (which showed no changes from
prior) and cardiac enzymes were sent to rule out myocardial
infarction (three sets of enzymes were negative). The chest pain
was thought to be secondary to her asthma exacerbation and
cough, and her pain improved over the course of her
hospitalization and had largely resolved at the time of
discharge.
.
# Abdominal/pelvic pain: The patient complained of mild
abdominal/pelvic pain that had been present for several months.
She described the pain as crampy, localized it to her right
lower quadrant and pelvic region, and noted that it was not
associated with or alleviated by eating or having bowel
movements. It was not associated with nausea, diarrhea, or
fevers. Her abdominal exam was benign and patient stated that
her PCP had been planning on sending her for outpatient
abdominal ultrasound to work up this pain further. On Day 4 of
admission, she complained of acute worsening of this pain. The
intensity had increased but the character was unchanged; she had
no new nausea, vomiting, or diarrhea, but did note some dysuria.
She was afebrile and her exam remained unchanged. Urinalysis and
urine beta-hCG were negative. Her pain improved with ibuprofen
and had largely resolved by the time of discharge.
.
CHRONIC ISSUES
---------------
# Allergies: the patient was continued on her home fluticasone
nasal spray as needed.
.
TRANSITION OF CARE:
Follow-up: There are no pending results to follow up. The
patient will follow up with her primary care provider. Please
follow up with the patient regarding her request to have any
long-term prescriptions faxed to her pharmacy so they can be
delivered to her at regular intervals.
.
CODE STATUS: full code
.
CONTACT INFORMATION: no health care proxy chosen
***. | BRONCHITIS AND ASTHMA WITHOUT CC/MCC |
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