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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.
***
The patient with newly diagnosed neuroendocrine tumor was
admitted to the ___ Surgical Service on ___ for elective
Whipple procedure. On ___, the patient underwent
pylorus-preserving pancreaticoduodenectomy (Whipple) with portal
vein resection and open cholecystectomy, which went well without
complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor NPO with an NG tube, on IV fluids,
with a foley catheter and a JP drain x 2 in place, and epidural
catheter for pain control. The patient was hemodynamically
stable.
The ___ hospital course was uneventful and followed the
Whipple Clinical Pathway without major deviation. Post-operative
pain was initially well controlled with epidural analgesia,
which was converted to oral pain medication when tolerating
clear liquids. The NG tube was discontinued on POD# 2, and the
foley catheter discontinued at midnight of POD# 4. The patient
subsequently voided without problem. The patient was started on
sips of clears on POD# 3, which was progressively advanced as
tolerated to a regular low fat diet by POD# 5. JP amylase was
sent in the evening of POD# 5; the JP 1 was discontinued on
POD# 6 as the output and amylase level were low; JP 2 was
discontinued on POD 8.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay, he was transitioned on prophylactic
Lovenox prior to discharge. The patient's blood sugar was
monitored regularly throughout the stay and was normal.
At the time of discharge on ___, the patient was doing
well, afebrile with stable vital signs. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and pain was well controlled. Staples were removed,
and steri-strips placed. The patient was discharged home without
services. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
***. | MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURE 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.
***
Ms. ___ was admitted to the ___ Spine Surgery Service on
___ and taken to the Operating Room for a L4-5 interbody
fusion through an anterior approach. Please 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
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#2 (___) she returned to the operating room
for a scheduled L4-5 decompression with PSIF as part of a staged
2-part procedure. Please refer to the dictated operative note
for further details. The second surgery was also without
complication and the patient was transferred to the PACU in a
stable condition. Postoperative HCT was low and she was
transfused PRBCs. A bupivicaine epidural pain catheter placed at
the time of the posterior surgery remained in place until postop
day one. She was kept NPO until bowel function returned then
diet was advanced as tolerated. The patient was transitioned to
oral pain medication when tolerating PO diet. Foley was removed
on POD#2 from the second procedure. She was fitted with a lumbar
warm-n-form brace for comfort. 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.
***. | COMBINED ANTERIOR/POSTERIOR SPINAL FUSION 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.
***
SUMMARY:
==========================================================
Mr. ___ is a ___ year old man with alcohol use disorder
complicated by withdrawal seizures, cirrhosis (Child ___ Class
B, MELD 15) ___ alcohol and HCV decompensated by varices s/p
TIPS, recurrent upper GI bleeding, ascites, hepatic
encephalopathy, and bipolar disorder. He presented after an
episode of hematemesis and melena as well as a witnessed seizure
in the setting of decreasing alcohol intake. He was treated for
alcohol withdrawal with phenobarbital and Ativan. He had no
further episodes of bleeding in the hospital and thus did not
undergo endoscopy.
ACUTE ISSUES:
==========================================================
# UGIB
The patient presented with 1 reported episode of hematemesis and
melena prior to admission. He had no further bleeding episodes
on admission and his Hb was stable (___) and unchanged compared
to his admission in early ___. The etiology was felt to be
most likely secondary to gastritis in the setting of alcohol
use, and less likely variceal bleed given his clinical stability
and history of TIPS, with last EGD in ___ showing grade 1
varices only. Furthermore, rectal exam was performed and there
was no evidence of melena or blood on exam despite a positive
guaiac test. Thus the decision was made to not perform endoscopy
at this time. He was initially treated with IV PPI, octreotide,
and CTX. The octreotide was subsequently discontinued given low
suspicion for varices. His PPI was switched to his home
omeprazole prior to discharge. He was continued on Bactrim DS
BID at discharge to complete a 7-day course of antibiotics for
SBP prophylaxis, ending ___. His home diuretics and beta
blocker were initially held, but re-started prior to discharge.
He remained hemodynamically stable throughout his stay. Despite
his TIPS, decision was made to continue his beta blocker given
persistent presence of varices and severe degree of cirrhosis.
# Decompensated EtOH/HCV cirrhosis
Child B/MELD-Na 15 on admission, previously decompensated by
grade I varices w/recurrent UGI bleed, ascites, and hepatic
encephalopathy. TIPS was performed at an outside hospital. On
admission, RUQUS showed patent TIPS without ascites. His home
Lasix, spironolactone, and propranolol were held initially, then
re-started prior to discharge. As above, his most recent EGD on
___ showed 1 cord of nonbleeding grade 1 varices. Endoscopy
was not repeated on this admission given no evidence of
continued bleeding and higher likelihood of
gastritis/esophagitis over varices as source of bleed in the
setting of heavy alcohol use.
# Alcohol use disorder with history of withdrawal seizures
In the ED, ETOH level was 347, with last drink on day of
admission. He received phenobarbital load in the ED and was then
monitored on CIWA scale Q4H initially. He required about 1 dose
of benzo daily and CIWA score remained <=10 throughout
admission. Social work was consulted but the patient deferred
services, saying that he works closely with a social worker as
an outpatient and preferred to continue this. He was given
folate, thiamine, and MVI daily.
CHRONIC ISSUES:
==========================================================
# Seizure disorder
Continued home Keppra 500mg BID
# Psoriasis
Continued clobetasol cream
# Bipolar disorder
Continued mirtazapine
# Insomnia
Held trazodone and hydroxyzine inpatient while on CIWA scale,
re-started at discharge.
TRANSITIONAL ISSUES:
==========================================================
[]Pt deferred alcohol cessation services at this time and was
determined to be pre-contemplative. The risk that he poses to
himself by continuing to drink, particularly in the setting of
complicated cirrhosis, was thoroughly discussed. If he does
attempt to stop drinking in the future, he will likely benefit
from IOP or similar program. He endorsed a plan of trying to get
into a program at ___ after the holiday.
[]Pt is homeless, per pt he is in contact with outpatient social
workers and working on finding a shelter. Would evaluate for
need for further social services as needed.
[]Pt had very low Mg on this admission, likely secondary to
combination of medications (PPI, diuretics) and alcohol use.
This should be monitored, consider further work-up such as Renal
consultation as renal wasting has not been ruled out in the
past. He is on PO magnesium. He had required IV Mg inpatient.
[]With regard to cirrhosis screening: last EGD in ___.
Last abdominal MRI in ___ so he is due for this.
Colonoscopy not indicated given his age.
***. | 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.
***
#. Fever. On arrival to the floor, patient had no localizing
symptoms of her fever. She had denied cough, dysuria, diarrhea.
Her dialysis catheter site was clean, dry, intact and non
tender. Patient refused influenza swab testing. Chest x-ray
was did not show evidence of an acute process. While in house,
she had one temperature of 101.1, and subsequently remained
afebrile. Lab testing demonstrated therapeutic levels of
vancomycin and gentamycin that were given during her last
session of HD. Repeat blood cultures were drawn and were
pending at the time of discharge. She was discharged with close
outpatient PCP follow up.
.
# ESRD on HD: Renal was consulted on arrival to ensure
continuation of her home dialysis regimen. She was continued on
her home doses of sensipar, folic acid and calcium acetate.
.
# Systemic lupus erythematosis: Symptoms were stable and she was
continued on her outpatient dose of prednisone 5mg daily.
.
# Chronic pain: While in house, she was continued on her home
dose of dilaudid 4mg PO q3hrs prn.
.
# Idiopathic thrombocytopenic purpura: Her platelet count
remained stable at 107, and she was continued on her home dose
of prednisone.
.
# History of seizure: She experienced no seizures while
hospitalized and was continued on her home doses of keppra and
topiramate.
.
# HTN: Patient remained normotensive throughout this
hospitalization.
.
# GERD: Her outpatient PPI was continued, without symptoms of
GERD.
.
***. | FEVER |
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 Trauma service. OMFS and Neurosurgery
Spine were consulted given his injuries. He underwent CT and MRI
imaging of his cervical spine; there was ligamentous injury
noted on MR imaging and it was recommended that he remain in a
hard cervical collar with follow up in 6 weeks after discharge
with Dr. ___.
He was taken to the operating room for repair of his fractured
mandible; his jaw was wired shut. There were no intraoperative
complications; postoperatively he did have pain control issues.
He initially required PCA; this was later changed to oral
narcotics with IV for breakthrough pain. He eventually no longer
required IV narcotics. He was given a full liquid diet for which
he tolerated. His home medications were restarted.
Because of his history of polysubstance abuse he was seen by
Social Work; per patient prior to the crash he was making plans
to enter into a drug/alcohol treatment program. He has expressed
interest to follow through on his original plan.
***. | DENTAL AND ORAL DISEASES 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.
***
On ___, the patient was admitted for elective left
stereotactic biopsy and insertion of arachnoid-ventricular shunt
with Dr. ___. After the procedure she was extubated and
transferred to the PACU for post-anesthesia care and monitoring.
The patient remained stable and she was transferred to the
floor. A routine NCHCT was performed and was stable and showed
the catheter in good position.
On ___ the patient remained neurologically stable. The
patient endorsed dizziness when out of bed, therefore a physical
therapy consult was ordered.
On ___ the patient remained neurologically stable. The patient
stated that her headaches were much improved and that she felt
safe for discharge to home. She was cleared for discharge home
by the Neurosurgery team. The patient was ambulating with the
nursing staff who felt she would not need a physical therapy
consult as she was steady on her feet. She was given follow up
instructions and was discharged home with prescriptions for pain
medication and a dexamethasone taper.
***. | CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL 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.
***
___ with DMII on insulin, asthma, multiple abscesses with prior
culture-proven staph infections presenting with scrotal abscess,
finger abscess, back abscess all s/p I&D, growing MSSA and
traumatic finger abscess growing MRSA.
# MSSA Scrotal abscess: S/p I&D ___ by urology with packing.
Initially on vancomycin, ultimately transitioned to Bactrim
monotherapy due to MRSA cultured ___ finger abscess. Discussed
with ID, antibiotic course as below
- 7 days Bactrim 1 tab DS BID
- repeat chem 10 with PCP next week to ensure K, Cr not
significantly elevated
- BCx without growth upon discharge, not yet finalized
- urology follow up next week
- daily dressing changes ___ clinic with wick replacement prn,
confirmed they will perform
# MRSA right ___ digit abscess: Traumatic ___ nature and
different evolution from his typical skin abscesses. Hand
consulted, s/p I&D and packing ___, wick removed ___.
Antibiotics as above.
- continue betadine soaks TID x 3 more days
- wound eval ___ clinic daily
- antibiotics as above
- ID follow up within ___ weeks
# MSSA Back abscess: s/p I&D ___ ED prior to admission. Daily
dressing changes done by RN while inpatient. HIV checked and was
negative, immunoglobulins normal. Clinicaly improved upon
discharge. ID consulted as above, recommended ___ week follow up
___ clinic.
- Bactrim 7 days as above
- Allergy/Immunology follow up for recurrent abscesses
- dressing dressing changes ___ clinic with packing
# Anemia: Likely of chronic inflammation. stable without signs
or symptoms of active bleeding while inpatient.
# DMII: Lantus and ISS, held metformin as inpatient and
restarted upon discharge.
# HTN/HLD: Continued home quinapril, atorvastatin
# Reactive Airway Disease: Continued home albuterol
Transitional issues:
- follow up with PCP, chem 10 at next visit
- Allergy/Immunology follow up for workup of possible immune
deficiency ___ setting of multiple recurrent abscesses
- follow up with ID
- follow up with urology
Medically stable for discharge home without services.
> 30 minutes spent on discharge day services, counseling and
coordination of care
***. | 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.
***
___ with hx cerebral aneurysm s/p coiling, OA, htn, anemia who
p/w BRBPR.
.
## BRBPR: Pt's history of rapid bleed, generally painless and
history of both diverticulosis and hemorrhoids is consistent
with either a diverticular bleed or hemorrhoidal bleed. No
evidence of infection in labs or inflammation on CT. Pt is
generally comfortable aside from mild TTP in the LLQ which
supports diverticular bleed. Anoscopy demonstrated blood in the
vault and int and ext hemorrhoids. HCT remained stable
throughout admission. Abdominal pain was decreased and bowel
movements were without blood at the time of discharge.
.
## HTN/cad: continued lisinopril, dilt, toprol
.
## Cerebral Aneurysm s/p coil: stable, continued aspirin
.
## Anemia: stable, actually slightly increased from baseline
.
## OA: continued home tylenol, tramadol
.
## Depression: continued home lexapro
.
## GERD: continued home nexium
.
## HL: continued lipitor 10mg daily
.
## Right renal cyst with indeterminate density by CT: Could f/u
with renal ultrasound as an outpt to further characterize if
clinically indicated.
.
## Prophylaxis: Heparin SC 5000 tid
.
## Dispo: Home
***. | G.I. HEMORRHAGE 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 F with GI motility disorder and multiple abdominal
surgeries with recent G-tube placement with ex-lap and GI
reconstruction at ___ in ___ and recent missed abortion
awaiting D&C on ___ admitted with two weeks of abdominal pain.
#Abdominal pain:
Given that pain was localized most to the LUQ, there was
initially concern for G-tube infection/malfunction. However, the
patient was seen by Surgery and the patient had a CT without any
abscess or fluid collection around the G-tube site and it was
not felt that the patient had any infection or G-tube
dysfunction as cause of the pain. Additionally, with normal labs
and unremarkable CT there was no other inflammatory pathology
suspected and there was no obstruction noted. It was felt that
the patient's pain may be related to her underlying
gastroparesis and her adhesions from her previous abdominal
surgeries. She was given pain control and antiemetics and
symptoms improved over course of hospitalization. The patient
was continued on her course of Keflex which was initiated prior
to admission and completed her course during hospitalization.
#Missed abortion:
Patient was scheduled to undgergo outpatient D&C day after
admission. In addition, there was difficulty obtaining IV access
and a foot IV and RIJ CVC were placed in the ER. Given
difficulties obtaining access and that she was scheduled to
undergo D&C soon, OB/GYN was consulted and the patient underwent
D&C during this hospitalization.
#Disposition:
The patient was discharged home to follow up with her GI
physician in ___, her surgeons at ___, and her usual
OB/GYN in ___.
***. | ABORTION WITH D&C ASPIRATION CURETTAGE OR HYSTEROTOMY |
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 ___ year old female with a recent diagnosis of
PE/DVT who was readmitted to ___ with multifocal
pneumonia and mediastinal/supraclavicular/axillary LAD
concerning for a possible underlying lymphadenopathy.
1. Multifocal Pneumonia: Outside hospital chest CT showed
multifocal consolidations and ground glass infiltrates, left
greater than right. Also with report of a sterile but exudative
effusion from ___. With her recent
hospitalization, she completed eight day course of Vancomycin
and cefepime for HCAP coverage (course completed on ___.
Patient had been on prednisone for unclear reasons at OSH, which
was stopped on admission to ___.
2. Left pleural effusion: Initial tap at OSH showed loculated
parapneumonic effusion with pH of 7.6 and negative gram stain.
Interventional pulmonology performed bedside thoracentesis on
___. They recommended CXR in 2 weeks and if she has
worsening of pleural effusion, she should be referred to them in
clinic.
3. Lymphadenopathy: Seen on CT chest, mediastinal
lymphadenopathy could be related to her current multifocal
pneumonia, however the axiallary and supraclavicular lymph nodes
are concerning for a potential underlying malignant process.
She has a current anemia without a clear cause which could be
due to an underlying malignancy. OSH images were loaded for our
radiologist. It was decided along with the patient that she
should have repeat CT chest in ___ weeks as outpatient for
evaluation of her lymphadenopathy. She should also have routine
age appropriate cancer screening with colonoscopy and
mammography.
4.Elevated LFT's: Have been stably mildly elevated at the OSH.
Patient had unremarkable RUQ ultrasound. Hepatitis serologies
were sent and were pending on discharge.
5 Anemia: HCT has continued to trend down and was low on
admission to the OSH, does not appear to be GI bleeding as per
GI evaluation at the OSH. Iron studies showed anemia of chronic
disease.
6. DVT/PE: Patient kept on heparin gtt in anticipation of
procedure. She was transitioned to coumadin with lovenox 80 mcg
SC BID bridge. She will follow her PCP in two days for INR
check.
7. Diabetes: Held home oral medications and kept patient on
humalog insulin sliding scale while in hospital. She was
discharged on her home oral medications.
8. Hypothyroidism: Continued home levoxyl 88mcg daily.
Follow up for PCP
1. RUQ ultrasound - Cholelithiasis and 7-mm gallbladder polyp
are noted. Followup imaging of the polyp is recommended in 12
months, due to size of 7 mm.
2. Mediastinal/supraclavicular/axillary lymphadneopathy: It was
decided along with the patient that she should have repeat CT
chest in ___ weeks as outpatient for evaluation of her
lymphadenopathy. She should also have routine age appropriate
cancer screening with colonoscopy and mammography.
3. Anticoagulation: She should have INR check on ___.
Please adjust coumadin dose and allow lovenox bridge for two
days after having therapeutic INR between ___.
4. Pleural effusion: Please obtain repeat CXR in two weeks. If
she has reaccumulation of her pleural effusion, consdier
refering her to interventional pulmonology for further
management.
***. | 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.
***
#) Bipolar I disorder, most recent episode manic: On admission,
the patient had signs and symptoms of a manic episode, including
rapid speech, decreased need for sleep, euphoric mood, and
grandiose delusions that his philosophy books "were written by
me and for me to discover." In the context of mania, he used
his skateboard to hit a police car, resulting in legal charges.
He reported medication compliance with Lamictal and Abilify.
His manic symptoms were preceded directly by a few months of
depressive symptoms, for which he had been started on Wellbutrin
and Zoloft, which may have played a role in precipitating this
manic episode. Wellbutrin and Zoloft were stopped two days
prior to admission. Following discussion with his outpatient
psychiatrist, the patient was started on Lithium, which was
titrated to a final dose of 300 mg qAM, 600 mg QHS. He was
discharged on this dose and will need a Lithium level checked on
___. Lamictal and Abilify were continued at his home
doses, with a likely plan to taper off Lamictal once the patient
is therapeutic on Lithium.
On admission, the patient showed good insight into his illness
and readily stated that he felt he was having a manic episode.
He continued to believe that his philosophy books were "written
by me for me to discover." He continued to sleep ___ hours a
night, for which he was started on Ativan 1 mg QHS. This was
quite effective; he slept 10+ hours after taking it. He will be
discharged with a seven-day prescription to continue Ativan to
continue to assist with sleep while he recovers from mania. On
the day of discharge, he had slept well, denied racing thoughts,
spoke at a normal rate, and appeared euthymic. He described
what had happened with reading his books as a "special
experience" that he knew did not make sense logically but that
the experience made sense to him on a spiritual level. In prior
discussion, he had attributed the experience to mania. Per
collateral, this is consistent with his baseline of being "very
spiritual."
The patient will return home with his parents for ___
and the following day and will begin a partial program at
___ next week. He will also follow up with his
outpatient psychiatrist and his therapist.
#) Asymptomatic UTI: An symptomatic urinary tract infection was
diagnosed in the emergency department, for which the patient was
started on Ciprofloxacin 250 mg BID x 7, with the final dose on
the morning of ___. He was discharged with a prescription
to complete this antibiotic course and outpatient follow up
#) Psychosocial: Social work was in contact with the patient's
family and school. The patient chose to take a medical leave of
absence. This was discussed in a family meeting on day of
discharge. His family remained closely invovled through his
admission, are supportive, and ___ a good understanding of his
illness.
#) Legal status: Conditional voluntary was signed and accepted
on admission.
#) Observation status: The patient was maintained on Q15 minute
safety checks without incident.
***. | 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.
***
___ is a ___ man with past medicla history
of high-grade CNS lymphoma, HIV presents with painful anal rash.
1. HSV Infection: Direct antigen from scrapings of base of
ulcers returned as positive for HSV. No evidence of disseminated
HSV infection. Pt reports he has had multiple infections with
HSV in the past ___ years that have been treated with acyclovir.
He was started on acyclovir with improvement in his symptoms and
rash. He will complete a treatment course of acyclovir followed
by continuing acyclovir at a prophylactic dose for continued
suppression.
2. Hyperlactatemia: Unknown etiology, did not respond to fluid
resuscitation. Likely type 2 lactic acidosis due to NRTIs, less
likely CNS lymphoma. Lack of evidence of hypoperfusion and
sepsis argues against type I lactic acidosis. Per ___
attending, HAART unlikely to be culprit as pt has been
stabilized on this regimen for awhile but unknown if lactate had
ever been checked. Will have this followed up as an outpatient.
3. Asymptomatic Bacteriuria: Urine culture grew e coli. Treated
with three days of antibiotics.
4. CNS Lymphoma: He is status post high-dose MTX, continues on
dexamethasone; no evidence of meningitis. He will follow up with
Dr. ___ continuing chemotherapy.
5. Hyponatremia: He appears euvolemic. Serum osmolality low,
urine sodium inappropriately high. This is most likely c/w
SIADH. Most likely related to underlying intracranial disease.
6. Thrombocytopenia: It is possibly due to MTX. no other new
medications. Stable but low.
7. HIV: He is well controlled, CD 4 count 245, suppressed viral
load. HAART re-started.
8. CAD: s/p remote PCI with BMS, stable, cont ASA, BB, ACEi
9. GERD: PPI
========================
transitional issues
========================
* Follow up Dr. ___ ___ for discussion about when
chemotherapy will continue
* Continue acyclovir at prophylactic dose after completing
treatment for HSV
***. | 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.
***
Mr. ___ was admitted on ___ with CLAUDICATION.
He agreed to have an elective surgery. Pre-operatively, he was
consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were
obtained, all other preparations were made.
It was decided that she would undergo a Right common femoral to
below-knee popliteal
artery bypass with nonreversed saphenous vein and angioscopy.
He was prepped, and brought down to the operating room for
surgery. Intra-operatively, he was closely monitored and
remained hemodynamically stable. He tolerated the procedure well
without any difficulty or complication.
Post-operatively, he was extubated and transferred to the PACU
for further stabilization and monitoring.
He was then transferred to the VICU for further recovery. While
in the VICU he received monitored care. When stable he was
delined. His diet was advanced. A ___ consult was obtained. When
he was stabilized from the acute setting of post operative care,
he was transferred to floor status
On the floor, /he remained hemodynamically stable with his pain
controlled. He progressed with physical therapy to improve her
strength and mobility. He continues to make steady progress
without any incidents. He was discharged home with ___ to a in
stable condition.
To note he was discharged on dicloxacillin for superficial
cellulitis around wound edge in groin
***. | OTHER VASCULAR 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.
***
Ms. ___ is a ___ y/o F w/ chronic urinary retention, OA,
and depression who p/w subacute worsening and new abdominal pain
on a background of chronic abdominal pain with associated
worsening PO intake and weight loss due to pain with eating. CT
scan revealed pancreatic head mass with possible metastatic
lesions in the liver and peritoneum as well as acute sigmoid
diverticulitis vs. metastasis. Pathology now confirms carcinoma.
#stage IV metastatic pancreatic cancer-mets to liver, near
uterus, ?sigmoid, with ascites
#malnutrition, other protein calorie
#nausea
#abdominal pain
#constipation
#on background of IBS
Chronic, going on since ___ per her report. Likely due to
her pancreatic mass. Limiting her ability to take in PO, causing
weight loss and malnutrition. CT with metastatic
pancreatic cancer, now s/p biopsy umbilical mass confirming
cancer from pancreaticobiliary origin. Pt with ongoing nausea,
abdominal cramping and generally not tolerating good PO. Pt not
in favor
of enteral feeds or TPN an is not in favor of chemotherapy at
this time.
Symptoms were managed with prn oxycodone, compazine, bowel
regimen and PPI. Encouraged to liberalize her PO diet as much as
possible. Oncology and palliative care evaluated the patient. Pt
not in favor of chemotherapy at this time but was provided with
the oncology office clinic number should she change her mind.
Palliative care consulted to assist with ongoing symptom
management of pain, nausea and constipation. She was referred to
outpatient hospcie which was set up prior to discharge.
# Acute sigmoid diverticulitis: Adjacent hyperenhancing lesions
may be intramural abscesses or drop metastatic deposits, and
therefore acute diverticulitis may be secondary in the setting
of
malignancy. s/p course of cipro/flagyl.
# Transaminitis: mild, mixed type, stable
Suspect likely ___ hepatic mets. No elevation in bilirubin to
suggest biliary obstruction and biliary ducts not dilated on
___
CT a/p
# Coagulopathy: mild, INR peak 1.3, likely nutritional
s/p dx/tx dose of IV vitamin K 10 mg x1 on ___
# MDD:Continue home Welbutrin and sertraline
# Insomnia:
Held home PRN oxazepam and amitriptyline during admission.
OK to restart upon DC. Pt warned of black box warning of taking
benzodiazepines and opiates.
# Urinary retention
[home] Intermittent catheterization ordered
------------
Contacts: ___, ___
Code status:
-DNR/DNI (confirmed w/ patient on ___
-Okay with reversal for procedure(s)
***. | MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS 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 Dr. ___ service
after his transurethral resection of prostate. No concerning
intraoperative events occurred; please see dictated operative
note for details. The patient received ___ antibiotic
prophylaxis. Patient's postoperative course was uncomplicated.
He received intravenous antibiotics and continuous bladder
irrigation overnight. On POD1, the CBI and foley catheter were
discontinued, and he passed a voiding trial. His urine was
clear yellow without clots. He remained a-febrile throughout his
hospital stay. At discharge, patient's pain well controlled
with oral pain medications, tolerating regular diet, ambulating
without assistance, and voiding without difficulty. He is given
pyridium and oral pain medications on discharge, without
antibiotics. He is given explicit instructions to f/u with Dr.
___ ___ days or as otherwise scheduled after
discharge. I spoke with He and his wife prior to discharge and
answered all questions.
***. | TRANSURETHRAL PROSTATECTOMY 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.
***
___ y/o F with PMHx of HTN and DM who p/w BRBPR, acute blood loss
anemia and had a brief episode of SVT/Atrial tachycardia that
resolved with
metoprolol.
Acute blood loss anemia/Lower GI Bleed: Pt had significant BRBPR
on admission with tachycardia but no hypotension. She received
a total of 5units prbcs during the admission for presumed
diverticular bleed. Bleeding stopped while undergoing a bowel
prep and no active bleeding was seen on colonoscopy. Pt had
grade 1 hemorrhoids and diverticulosis. She was monitored for
an additional 24hrs without any bleeding and hgb was ___ by the
time of discharge. She was instructed to hold Aspirin until she
is seen by her PCP.
Paroxysmal SVT vs Atrial Tachycardia: pt had tachycardia to 150s
on the first night of admission while having significant lower
GIB that was narrow complex and regular but did not appear
sinus. She was treated with blood transfusions and low dose
metoprolol with resolution back to normal sinus rhythm. Pt
remained HD stable and was monitored on telemetry without any
symptomatic tachycardia. She was discharged on Toprol 50mg
daily. Pt may benefit from outpatient referral to cardiology if
she has any recurrent episodes of symptomatic tachycardia.
HTN: Pt was hypertensive after resolution of the bleeding
despite Toprol and was restarted on Lisinopril. HCTZ was
stopped at discharge given the addition of Toprol with room for
titration of both agents.
DM: Metformin was restarted at discharge, no insulin coverage
needed while inpt.
Hx of CVA: Pt was instructed to hold Aspirin until she is seen
by her PCP next week given the significant lower GIB.
Cataract and macular hole: recent left eye surgery. Continued
home prednisolone, bacitracin/polymyxin and atropine in L eye
TRANSITION ISSUES:
- Discuss restarting Aspirin when seen by PCP
- ___ referral to Cardiology for possible SVT
- pt/family interested in getting a lifeline
> 30min spent on clinical care on the day of discharge including
> 50% of time spent at bedside with patient and family on
education, anticipatory guidance for recurrent bleeding and
coordinating home health referral for home safety evaluation.
***. | 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.
***
BRIEF HOSPTIAL SUMMARY:
=======================
___ man with a history of abdominal aortic aneurysm
status post repair now c/b type II endoleak around ___, CKD
stage III, dementia, who presented to the ___ for N/V and
abdominal pain. He underwent a CTA which showed acute
pancreatitis and was found to have elevated lipase levels of 291
with leukocytosis to 21K. The CTA also revealed a type II
endoleak of his AAA, and a stone in the pancreatic duct.
Patient's presenting symptoms quickly improved however he was
also noted to have an acute kidney injury and uptrending lactate
despite stable blood pressures. This was attributed to
inadequate fluid rescussitation in the setting of likely ___
spacing being caused by his pancreatitis and he was given
multiple boluses of IVF as well as maintenance fluids while
taking in minimal po. His kidney injury and lactic acidosis
resolved with administration of IVF. He was able to gradually
increase his po intake to normal over the course of the
hospitalization. Vascular surgery was consulted given the
findings of possibly increased size of endoleak around AAA graft
from prior scans. They felt that things were stable at this time
and no surgical intervention was required. Advanced Endoscopy
team was also consulted to evaluate for possible procedure to
remove pancreatic duct stone. They felt that there was no role
for intervention in the acute setting but would like patient to
follow up as an outpatient to discuss possible interventions.
Physical therapy also evaluated patient while admitted and
recommended discharge to rehab.
TRANSITIONAL ISSUES:
====================
-Follow up with advanced endoscopy team to discuss possible
procedures to remove pancreatic duct stone and prevent further
episodes of pancreatitis
-Follow up with Vascular Surgery to ongoing management of
AAA/Endoleak
-Repeat CBC within 2 weeks of discharge to ensure leukocytosis
continues to downtrend/has normalized and anemia is stable to
improving. Discharge WBC 14.4, Hgb 8.9
-Discharge Creatinine 1.3
ACUTE MEDICAL ISSUES
=====================
#Acute on Chronic Pancreatits
#Abdominal Pain
#Nausea/Vomiting
Patient presents with acute onset abdominal pain, nausea,
vomiting with work-up significant for lipase greater than 3x the
upper limit of normal as well as CT imaging findings consistent
with acute on chronic pancreatitis. Of note, patient was again
demonstrated to have a stone in their pancreatic duct which had
been seen on imaging in the past. No other clear cause of his
pancreatitis was identified, as he does not drink alcohol, was
not exposed to any drugs, etc. Diet was gradually advanced per
the patients tolerance. Advanced endoscopy team was consulted
who felt there was no role for intervention in the acute setting
however would like patient to follow up with them in clinic for
further evaluation.
___ on CKD:
Cr elevated on admission to 1.5 from baseline ___. Felt to
most likely represent a pre-renal injury from hypovolemia in the
setting of vomiting, diarrhea and poor po prior to admission as
well as likely ___ spacing from his pancreatitis. The patients
creatinine trended down to baseline with administration of IVF.
#Anion Gap Metabolic Acidosis
#Elevated Lactate
Patient noted to have developed an anion gap metabolic acidosis
on the day of admission. Lactate checked and found to be
elevated despite normal blood pressures. This was felt to most
likely represent poor GI perfusion in the setting of hypovolemia
due to ___ spacing from his acute pancreatitis. He was bolused
IV fluids with normalization of his lactate and acidosis.
#Abdominal Aortic Aneusym
#Type II Endoleak
CTA on admission demonstrated his known AAA, with ongoing type
II endoleak with change in the aneurysm sac contour and slight
sac enlargement. In the ___, the patient was evaluated by
vascular surgery who noted that overall the endoleak was stable
and there was no surgical indication at this time
CHRONIC ISSUES:
===============
# Chronic HFpEF:
No evidence of exacerbation during admission. Home dose of Lasix
20mg daily was held on admission then restarted as patient
became more stable.
# Gout:
Patient was continued on home allopurinol, colchicine
# CAD:
Patient continued with his home aspirin and pravastatin.
[x]>30 minutes spent on discharge planning and care coordination
on day of discharge
***. | DISORDERS OF PANCREAS EXCEPT MALIGNANCY 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 was admitted to the Orthopaedic Arthroplasty
surgical service on ___ and taken to the OR for right total
knee arthroplasty. Please see separately dictated operative
note by Dr. ___ details of this procedure.
Postoperatively, pt was extubated and transferred to the PACU,
and remained afebrile and hemodynamically stable. The patient
was transferred to the floor later that day, and underwent an
unremarkable postoperative course.
N: Pain appropriately controlled, initially with IV and then
transition to PO pain medications. Patient followed by Chronic
Pain service. Plans for increased dose MS ___ (60 TID) and
gabapentin (600TID); patient will wean back to pre-operative
doses at 2 weeks after surgery.
CV: Vital signs were routinely monitored; the patient remained
hemodynamically stable.
P: There were no pulmonary issues. Patient did have CXR on POD3
which was read as possible consolidation, but also possible
atelectasis per d/w rads. Given absence of productive cough,
fever, or rales/crackles, it was decided that did not need to be
tx'd for PNA.
GI: The patient tolerated a regular diet postoperatively
GU: Foley catheter was removed POD2, and the patient voided
without issues postoperatively. Home lisinopril, HCTZ continued.
ID: The patient received perioperative antibiotics and remained
afebrile. As noted above, pt noted to have WBC to 14 post-op;
however, no fever, urinary sx's, or productive cough; likely
postoperative inflammation.
Heme: The patient received lovenox for DVT prophylaxis starting
POD1, and will complete a 4 week course postoperatively.
MSk: The patient was made weight-bearing as tolerated on the
operative extremity with range of motion as tolerated. The
overlying surgical dressing was changed on POD#2 and the
Silverlon dressing was found to be clean and intact without
erythema or abnormal drainage. The patient worked with Physical
Therapy daily postoperatively, with recommendations for
discharge to home c home ___.
At the time of discharge, the patient was afebrile with stable
vital signs and good pain control; the operative extremity was
neurovascularly intact. The patient will follow-up in
___ clinic.
***. | MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY 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.
***
___ PMHx refractory afib on warfarin s/p ablation ___
diastolic CHF; ESRD ___ PCKD s/p bilateral nephrectomy, s/p
failed renal transplant now on HD MWF who presents with fever,
myalgias and headaches due to Klebsiella bacteremia.
ACUTE ISSUES:
------------------
# KLEBSIELLA BACTEREMIA - RESOLVED. Blood cultures without
growth in the 96 hours preceding discharge. Unknown source -
CTAP revealed no clues despite extensive review with radiology.
Considered GI sources, which were less likely in the absence
collection or mesh entanglement on CTAP. Considered UTI, which
was lessl likely given anuric at baseline. Considered recent
dental crown procedure, which was less likely given Klebsiella
would be atypical oral flora.
- Initiated on cefepime (___), transitioned to cefazolin
given sensitivities.
- She is to complete 2 weeks of cefazolin 1 gram, dosed after
each HD session through ___.
- Close ___ clinic followup, seen by Dr. ___.
- Repeat blood cultures after completion of antibiotic course,
to confirm clearance.
- TTE without evidence of vegetations.
# LIGHTHEADEDNESS - Due to deconditioning. Orthostatics
negative. BP stable at 126/80 on discharge.
# ABNORMAL COAGULATION STUDIES: RESOLVING. Due to
antibiotic-induced destruction of native GI flora with
associated loss of vitamin K processing.
- Warfarin held initially, then restarted at 1mg DAILY.
- Will need close followup on ___ for repeat INR check,
followed by PCP ___.
# MODERATE AORTIC STENOSIS: NEW DIAGNOSIS. ___ 1.0-1.2cm^2.
- Transitional issue.
- Dr. ___, aware.
# HISTORY OF HYPOTENSION: STABLE. Patients runs SBP 110-120
baseline.
- continue midodrine prior to HD
CHRONIC ISSUES:
---------------
# ATRIAL FIBRILLATION: STABLE. Anticoagulated with coumadin.
- Anticoagulation as above.
- Continued digoxin
# MODERATE TO SEVERE AORTIC REGURGITATION: STABLE.
# BACK PAIN - STABLE, BASELINE. Patient complains of chronic,
band like back pain.
# ESRD on HD MWF:
- continue sevelamer, nephrocaps, and cinicalcet
- renally dose all meds
# Hypothyroidism:
- continue levothyroxine
# Chronic diastolic CHF: EF >55% on echo in ___. Appears
euvolemic currently
- monitor volume status while giving maintenance fluids
- low Na diet
- continue metoprolol, digoxin
# SECONDARY HYPERCALCEMIA: STABLE. Due to hyperparathyroidism
___ hyperphosphatemia in the setting of ESRD.
# Reactive airway disease:
- continue home ipratropium and advair
- Note that the patient states she has a "allergy" to albuterol
- induces tachycardia.
- continue montelukast
TRANSITIONAL ISSUES:
----------
# KLEBSIELLA BACTEREMIA: Continue Cefazolin 1gm post
hemodialysis ___ THROUGH ___. *** TO BE ADMINISTERED BY ___
CLINIC AFTER DIALYSIS RUN*** No vegetations on TTE. Followed by
ID while inpatient. Will require followup in 2 weeks after
completion of Abx with repeat blood cultures and seen in ___
clinic.
# MODERATE MITRAL STENOSIS - Noted incidentally on TTE.
# LIGHTHEADEDNESS - Due to deconditioning. Orthostatics
negative. BP stable at 126/80 on discharge.
# ANTICOAGULATION - For Afib. Adjusted (smaller) dosing in the
setting of antibiotic administration. Will require followup on
___ with Dr. ___, where her
anticoagulation is managed.
***. | 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.
***
Mr. ___ is a ___ gentleman who was admitted for
workup of three months of progressive upper extremity weakness
to the point that the patient cannot lift up his arms or open
any jars, gait instability and falls.
His neurologic examination on admission was notable for
significant upper extremity weakness right greater than left
weakness in the supraspinatus, deltoids, biceps, triceps, wrist
extensors, finger extensors and flexors. He also had prominent
fasiculations in the upper extremities, as well as diffuse
hyperreflexia.
Diagnostic workup was notable for MRI Brain, Cervical and
Thoracic spine which were unremarkable for cord abnormality. He
underwent an EMG that was consistent with a diagnosis of
amyotrophic lateral sclerosis.
Transitional Issues:
- start Riluzole 50mg BID
- trend liver function enzymes (normal on admission)
- get baseline pulmonary function tests
- CT torso to rule out possibility of paraneoplastic etiology
(low suspicion)
- video swallow test as outpatient setting
- follow-up with ___ Neurology, ___ Neuromuscular/ALS group,
___ Neurology as indicated
***. | DEGENERATIVE NERVOUS SYSTEM DISORDERS 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. ___ was admitted to the Orthopaedic Surgery service on
___ to undergo Right knee patellar tendon repair. Please
see Operative Report for full details. He underwent
preoperative nerve block for pain control. The patient
tolerated the procedure well, and there were no complications.
Post-operatively, the patient was taken to the recovery room
prior to being transferred to the floor. He underwent repeat
peripheral nerve block to postoperative pain, which improved his
discomfort considerably. On the evening of surgery, a Foley
catheter was placed due to inability to void. The patient was
able to void spontaneously following discontinuation of this
catheter on POD#1.
The patient's hospitalization course was otherwise uneventful.
He was transitioned to a long-leg bivalved cast in full
extension on POD#1 with instructions to be weightbearing as
tolerated. He worked with the Physical Therapy service and made
steady progress. On the day of discharge, his pain was
well-controlled on oral pain medications, he was tolerating a
regular diet, he was able to void spontaneously, and he was
deemed safe for home with crutches by the Physical Therapy
service. He expressed readiness for discharge and was
discharged home in stable condition with detailed precautionary
instructions and instructions regarding appropriate follow-up
care.
***. | SOFT TISSUE 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.
***
Mr. ___ underwent amputation of his left ___ toe for left
___ toe gangrene on ___. The procedure was without
complications and the patient tolerated the procedure well. The
wound was initially packed wet-to-dry. After a brief uneventful
stay in the post-operative care unit, he was admitted to the
vascular surgery service for post-operative care. Wound dressing
were taking down on POD1 and a VAC was placed. On POD1 he was
started on Lovenox bridge to coumadin. At time of discharge his
INR level was 1.2. He was discharged on Lovenox bridge to
coumadin with close follow-up with his PCP for anticoagulation
management. Physical therapy worked closely with patient and
deemed him safe for discharge home. Home ___ was arranged for
home wound VAC. Close follow-up with Dr. ___ was also
arranged. He was discharged with a 1 week course of augmentin
875 BID. At time of discharge, patient was tolerating a regular
diet and pain was well controlled. Discharge instructions were
communicated with the patient and he was in agreement with
discharge plan.
***. | UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM 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.
***
She was admitted for evaluation of inability to speak that
improved completely without any residual deficits. It was not
associated with any other neurological manifestation. The
initial diagnostic possibility was of stroke hence she underwent
CT scan of her head which did not show any acute intracranial
abn. She was evaluated by MRI of brain with MRA of blood vessels
to evaluate for any possible infarct or vessel abn, both of
which did not show any evidence of acute infarct. Her Ethanol
level was found to be very high and she was explained about ill
effects of alcohol and advised to avoid alcohol use in future.
She was started on IV fluids, multivitamins , thiamine and
folate and was advised to continue as an outpatient.
She underwent HbA1C ( 6.4 ), lipid panel ( LDL 104) work up as a
part of stroke evaluation and secondary risk factor prevention.
we did not start her on any meds for blood sugar and lipids, she
was advised for lifestyle modification, healthy eating habits
and regular physical activity. Her primary care doctor was
contacted and follow up arranged for follow up and further plan
of care.
***. | 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.
***
The patient was admitted to the podiatric surgery service
post-operatively on ___ after undergoing surgery for left
foot charcot deformity. Patient was taking to the OR for left
foot External Fixation and ORIF Left foot Charcot deformity. Pt
was evaluated by anesthesia and taken to the operating room.
There were no adverse events in the operating room; please see
the operative note for details. Afterwards, pt was taken to the
PACU in stable condition, then
transferred to the ward for observation.
Post-operatively, the patient remained afebrile with stable
vital signs; pain was well controlled oral pain medication on a
PRN basis. The patient remained stable from both a
cardiovascular and pulmonary standpoint. He was placed on 24
hours antibiotics. His intake and output were closely monitored
and noted to be adequate. The patient received subcutaneous
heparin throughout admission; early and frequent
ambulation were strongly encouraged. Patient was evaluated by a
member of the physical therapy team who cleared the patient to
return home.
The patient was subsequently discharged to home on POD 2 with
all vital signs stable and vascular status intact to left foot..
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
***. | EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 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 CAD s/p PCI to the LMCA-LAD and POBA of the LCx, dCHF,
mild-moderate AS (___), HTN, HLD, CKD with NSTEMI, now
s/p DES to L main ostium extending into LAD and LCx.
# NSTEMI: Patient presented with chest pressure and dyspnea. The
patient had been recently admitted for NSTEMI and had declined
cardiac cath at that time due to renal failure and opted for
medical management. Troponins on this admission 0.08, 0.23,
0.43. EKG with ST depressions consistent with global ischemia.
After discussion of goals of care, patient opted to proceed with
cardiac cath. Cardiac cath performed ___ showed severe left
main and 2 vessel CAD with in-stent restenosis, no intervention
performed at this time due to risk. Patient evaluted by cardiac
surgery who felt he was not a candidate for bypass given
comorbidities. Results discussed with patient and family
including possible need for dialysis with dye load. Patient seen
and evaluated by renal who discussed risks and benefits of
dialysis. Patient chose to go ahead with cardiac cath which was
performed on ___ with successfull PCI of left main and left
circumflex with DES. Patient tolerated the procedure well.
Medications optimized and patient discharged on atorvastatin,
plavix, aspirin, imdur, nifedipine and carvedilol.
# Acute on chronic diastolic CHF (EF>60%): Patient presented
with dyspnea consistent with flash pulmonary edema, possibly
secondary to aortic stensosis and ischemia. BNP elevated to
11,000 with no prior values for comparison. CXR on arrival with
mild pulmonary edema, however on day two of admission patient
became acutely dyspneic and desaturated. CXR at that time
consistent with acute pulmonary edema. Cardiac cath on ___
with elevated biventricular filling pressures. Patient diuresed
and improved.with only mild pulm edema and this seems less
likely.
Discharged on home dose of Lasix 20 mg daily. Patient not on
ace-inhibitor ___ due to renal failure.
# Moderate AS: Patient has moderate aortic stenosis with mean
gradient on cath of 20.26 and calculated valve area 0.97 cm2.
Symptoms more likely secondary to ischemia and congestive heart
failure than aortic stenosis, although AS contributing.
# CKD: Cr baseline 4.0. Patient was seen and evaluated by
nephrology due to risk of cardiac cath dye causing more renal
failure. The risks and benefits of dialysis were discussed with
the patient and family who chose to proceed with cardiac cath.
There was no urgent indication for dialysis during
hospitalization. He was continued on calcitriol and bicarbonate.
Creatinine on discharge of 4.1, which is very close to
baseline. Patient will follow up with PCP to trend creatinine.
# HTN: Patient continued on home clonidine, nifedipine, and
imdur. Carvedilol increased for better control of morning blood
pressure which was occasional high prior to medication
administration.
Transitional Issues:
- Creatinine to be checked
- Follow up with renal and cardiology
***. | PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ VESSELS OR STENTS |
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 Summary:
================
___ year old with history of vascular dementia who presents with
low appetite and failure to thrive. She was found to have a UTI
and presented with significant hypernatremia. She was minimally
responsive on arrival, although not far from her baseline
according to SNF and family. We treated her UTI and electrolyte
abnormalities with slight improvement in level of arousal. After
___ discussion with family, she will be DNR/DNI but wants to
continue to be hospitalized if needed. She was discharged in
stable condition to her nursing home.
Transitional Issues:
================
[] Please have ongoing goals of care discussions with family and
HCP. Patient has end stage vascular dementia and has lost thirst
drive. She will likely have many similar repeat admissions if
transfer to hospital is within goals of care.
[] Please try to keep patient hydrated. She has no thirst drive
and will need fluids offered frequently by spoon.
[] Please see speech and swallow recommendations as patient was
noted to have oropharyngeal dysphagia on their evaluation
Acute Issues:
==============
#Hypernatremia
This was likely a major contributor to patient's AMS. She became
hypernatremic due to lack of thirst drive leading to
dehydration. She was fluid resuscitated. Her sodium was normal
on the day of discharge at 145.
#UTI
Patient came in with AMS and suprapubic pain and UA consistent
with UTI. She was treated with 3 days of ceftriaxone. She later
again had suprapubic discomfort and a fever, and was treated
with another 3-day course of CTX. Her urine cultures were
negative.
# ___, resolved
Cr elevated to 1.2 on admission from baseline of 0.9. Likely
pre-renal in the setting of decreased PO intake which improved
with IV fluids. Discharge cr was 0.7.
#Vascular dementia (end stage)
Patient will not be able to recover thirst drive or appetite.
She will likely re-present with similar issues given how far her
dementia has progressed. Please continue to have goals of care
discussion with the family.
#Dysphagia
Evaluated by speech and swallow and found to have oropharyngeal
dysphagia. Please see below for their recommendations that were
also communicated to patients daughter.
1. Diet: puree solids, thin liquids VIA TSP ONLY
2. Medications: crushed in puree
3. Safe Swallowing Strategies:
-Supervision: strict 1:1
-Liquids VIA TSP ONLY
-Reduce distractions
-Ensure patient has swallowed prior to providing more PO
-Low threshold to make NPO with any s/sx c/f aspiration and/or
discomfort, decline in mental status, and decline in respiratory
status
4. General Safety: HOB at 30 degrees at all times and fully
upright for meals; Feed only when alert and attentive; Eat
slowly
and carefully; Remain upright for ___ minutes after meals
5. Frequent oral care (Q4)
Chronic Issues:
==============
# Depression
- Continued mirtazapine and trazodone
#CODE: DNR/DNI per records from ___, ___ not with
chart
#CONTACT: health care proxy: ___
___ number: ___
***. | KIDNEY AND URINARY TRACT INFECTIONS 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.
***
GLOBAL ASSESSMENT:
___ year old ___ unemployed mother of two with reported hx of
bipolar disorder and alcohol use disorder who presented to the
ED via EMS after being assaulted by her abusive and controlling
boyfriend. Admitted to inpatient psychiatry d/t depression with
psychotic features (i.e. paranoia), in the setting of relapse on
alcohol and medication noncompliance x ___ year. She responded
remarkably well to reinitiation of psychotropic meds (i.e.
Risperdal) becoming future oriented, optimistic, motivated to
improve her life circumstances. She was deemed ready for
discharge after a 1 week stay.
SAFETY: The pt. was initially placed on 5 minute checks and
advanced to 15 minute checks the second day of hospitalization
and remained on that level of observation throughout. She was
unit-restricted. There were no acute safety issues or
behavioral problems during this hospitalization.
LEGAL: ___
PSYCHIATRIC:
# Depression with psychotic features.
Per patient, OMR and OSH records, Ms. ___ has had multiple
psychiatric admissions for similar presentation of worsening
depression, with poor self care, hopelessness, anhedonia and sx
of psychosis in the setting alcohol relapse and/or medication.
She presented to ___ with ___ year of worsening depression and
paranoid delusions that something bad would happen to her or her
children if she went outside, or cleaned her home. Since
relapsing on alcohol and stopping her medications nearly ___ year
ago. She also presented in the context of an abusive
relationship as she did in ___. On admission, patient was very
quiet/mute, tearful, isolative and had significant PMR. There
was some concern for catatonia, though is seemed she was
actually selectively mute. She was started on ___ 1mg BID
d/t hx of psychotic depression, patient very quickly showed
stark improvement in mood and endorsed partial remittance of
paranoid symptoms (intermittently fearful of being around
people). Risperdal was increased to 1mg daily and 2mg qhs to
further address ongoing paranoia. Patient tolerated medication
and improvement was quick and dramatic. She was discharged with
instructions to f/u with therapist, ___ of ___ at
___ the next day who would also refer her to the ___'s
psychiatrist, Dr ___ medication management.
# PTSD
Patient presented acutely decompensated, very depressed,
experiencing a trauma reaction. She was selectively mute and
withdrawn. She was started on ___ 1mg BID and Ativan 0.5mg
BID as it was thought ativan may help her relax and engage with
team and bc there was some question of catatonia. Patient
responded well to medications and soon started smiling and
engaging with team. Ativan was dc'd prior to discharge given
pt's hx of alcohol abuse.
Patient initially very reluctant to discuss abusive relationship
only to say she injured her hand and head during a "slight
argument" with a "person." Patient says she wanted this
individual to leave because of "weird things" happening to her
that she "couldn't explain" and thought this person may adding
to her stress. Some days later she revealed she was in an
abusive and controlling relationship with a male boyfriend who
kept her hostage in the house, and prohibited her from speaking
with her children or family. She was able to escape this person
by sneaking a cell phone to call an ambulance after their last
fight. Prior to admission, patient arranged to move to ___
with her cousin and filed a restraining order against her ex
partner.
___ met with patient during admission to provide counseling and
support. They agreed to follow her after discharge.
#Substance use disorder (alcohol and marijuana)
Patient has several year history of alcohol use disorder with
very heavy drinking. She presented after relapsing on Etoh one
year ago and stopping meds which resulted in a series of
psychiatric admissions for decompensation of mental illness and
losing custody of her children. She reported drinking "a few
beers" daily over the past year. She denied hx of withdrawal sz,
DTs or ICU admission for alcohol withdrawal management. No BAL
obtained in the ED. Patient monitored on CIWAs which remained
flat x2 days and then CIWA discontinued. She was started on
Thiamine 250 mg PO QD, MVI 1 tab PO QD and Folate 1 mg PO QD.
Motivated to get her children back, patient vowed to stay away
from alcohol after discharge. She was encouraged to seek support
for substance use issues.
GENERAL MEDICAL CONDITIONS:
# Chronic PE:
Patient has hx of chronic PEs, and was supposed to be on
life-long anticoagulation. She reported being off all meds ___
years d/t relapse on alcohol. She was started on heparin upon
arrival to the inpatient unit. Medicine was consulted after
medical trigger called d/t pt complaining of chest pain and
concern for PE. Medical workup reassuring (i.e. VSS, EKG normal
sinus rythmn, troponin flat and ddimer non significant). Patient
resumed Xaralto on ___ as recommended by medicine consult
service. She was discharged and scheduled to meet her PCP the
following day for anticoagulation rx.
# R hand laceration:
Patient had stitches placed in the ED on ___ d/t small R hand
laceration obtained during a fight with her boyfriend. ___
were removed on ___. She complained of numbness and pain in
her right hand distal to the lac in digits ___. She was assessed
by the rotating neurology resident who felt her symptoms were
attributable to traumatic neuropraxia and should improve with
time. She was prescribed gabapentin 100mg TID for pain which
provided some relief. PCP follow up was scheduled for ___ at
___ with an NP, ___ was advised she could
discuss this issue further with her PCP.
PSYCHOSOCIAL:
#) GROUPS/MILIEU:
___ was initially placed in the quiet room on 5 minute checks
d/t her very concerning presentation. She was tearful,
selectively mute and would not engage with her treatment team.
She was med compliant, but did not care for her ADLs. However,
after hospital day 2 this changed and she appearing much
brighter and very involved in her treatment. She was consistent
with her group ___ and group ___
per OT report. She was visible on the unit socializing with
peers, but spent much of her time journaling and planning around
improving her life circumstances. She made lists of action items
and contacted various people to assist her in filing a
restraining order against her abuser, and collecting her things
from his home. Speaking with housing authority around her sec 8
housing voucher, applying for various community resources, and
working towards regaining custody of her children.
#) COLLATERAL CONTACTS:
SW contacted patient's father.
Primary team spoke with patient's ex husband and father of her
two sons.
Attempted to contact her prior therapist and PCP, but was
unsuccessful at reaching them.
Obtained records from patient's most recent psychiatric
hospitalization at ___.
#) FAMILY INVOLVEMENT:
Patient's father and cousin were involved and seemed invested in
patient's treatment. They were very supportive, visiting
frequently and assisted in helping ___ to resolve issues
around housing, child custody and cutting ties with her abusive
boyfriend.
#) INTERVENTIONS:
___ Referral: The team submitted a DMH application for the
patient to receive services, specifically requesting PREP
program participation and community-based support.
INFORMED CONSENT:
___-
The team discussed the indications for, intended benefits of,
and possible side effects and risks of starting this medication,
and risks and benefits of possible alternatives, including not
taking the medication, with this patient. We discussed the
patient's right to decide whether to take this medication as
well as the importance of the patient's actively participating
in the treatment and discussing any questions about medications
with the treatment team, and I answered the patient's
questions. The patient appeared able to understand and
consented to begin the medication.
RISK ASSESSMENT:
#) Chronic/Static Risk Factors:
Chronic mental illness
History of trauma
Hx of suicide attempt
#) Modifiable Risk Factors:
Alcohol use disorder
Depression w. psychotic features
Abusive relationship
Housing issues
Child custody issues
Lack of outpatient treaters
#) Protective Factors:
Offspring
Family support
Gender
Age
Ethnicity
PROGNOSIS:
Ms. ___ prognosis is good if she can maintain sobriety
from alcohol and drugs, continue to be compliant with
medications and engage regularly with her outpatient mental
health treaters. However, she has several risk factors for self
harm and decompensation as well as a history of recurrent
hospitalizations in the context of alcohol use, and medication
non compliance. Fortunately, many of her risk factors are
modifiable.
***. | 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.
***
Mr. ___ was admitted to the ___ Spine Surgery Service on
___ and taken to the Operating Room for L3-S1 interbody
fusion through an anterior approach. Please 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
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#2 he returned to the operating room for a
scheduled L3-S1 decompression with PSIF as part of a staged
2-part procedure. Please refer to the dictated operative note
for further details. The second surgery was also without
complication and the patient was transferred to the PACU in a
stable condition. Postoperative HCT was low and he was
transfused PRBCs. A bupivicaine epidural pain catheter placed at
the time of the posterior surgery remained in place until postop
day one. He was kept NPO until bowel function returned then diet
was advanced as tolerated. The patient was transitioned to oral
pain medication when tolerating PO diet. Foley was removed on
POD#2 from the second procedure, however he developed urinary
retention and had it replaced. He was fitted with a lumbar
warm-n-form brace for comfort. 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. He became confused and slipped on the
floor sustaining a skin abrasion on his right buttock. The
confusion resolved spontaneously. He moved his bowels with the
use of magnesium citrate.
***. | COMBINED ANTERIOR/POSTERIOR SPINAL FUSION 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.
***
Ms. ___ presented with 90% stenosis of her left carotid
artery. She underwent a left carotid endarterectomy on ___.
She tolerated the procedure well with no complications, was
neurologically intact and was transferred to the PACU in stable
condition. Her diet was advanced as tolerated; she was voiding
although incontinent and her pain was controlled on oral pain
meds. On POD#1, ___ worked with her and she was found to be very
unsteady so she was hospitalized for another day. She was then
febrile to 102.7 so a fever workup was performed. Given that she
had a foley placed in the OR, the working theory was a UTI. Her
UA showed few bacteria, no nitrites or leukocyte esterase so the
decision was made to not treat. She was deemed stable for
discharge on POD#2 on aspirin and atorvastatin with follow up
instructions in vascualr surgery clinic.
***. | EXTRACRANIAL 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/ frailty, chronic compression fractures coming with back
pain in setting of deconditioning and increased activity. Had
hospitalization in ___ at ___ for back pain after
over-straining (attempted to pull a trash can), then went to
___, then home with ___. ___nded, patient again
tried over-exerting herself with 3 days of cooking in
preparation for ___. Also not sleeping (~3 hours/night) and
eating poorly. Came in with recurrent back pain to ___,
where CT showed what were initially thought to be new
compression fractures at T9-10, and she was transferred here.
Neurosurgery evaluated and thought that her fractures were
chronic in nature and pain was unrelated. Pain is spastic in
T9-10 distribution in paraspinal muscles, coming in waves.
Suspect muscular spasm from compensating after injury.
#Back pain, right sided flank pain
Thought to be ___ muscular strain from compensating after
compression fractures, in setting of deconditioning (due to
weight loss) and significant exertion. Significant pain over
right side, rib series negative for fracture, CT A/P showing ___
acute abnormalities. She was put on standing Tylenol, PRN
Tramadol, lidocaine patches, baclofen and gabapentin. Pain
service consulted and due to frailty they did not recommend any
further adjustments in regimen at this time. Concern there is
an anxiety component to her symptoms as her son reports whenever
she is getting ready to leave the hospital her symptoms worsen.
- Appreciate pain service recs
- Continue Tylenol, Tramadol, lidocaine patch, baclofen,
gabapentin
- Continue working with ___ on discharge
- Social work consult
#COMPRESSION FRACTURES
#Vitamin D deficiency
- Started on calcium
- Replete with high dose vitamin D
- consider DEXA scan and bisphosphonate infusion (unlikely to
tolerate PO bisphosphonate due to GI issues) as an outpatient,
discussed recommendation with PCP
#COPD
___ signs of exacerbation
-Continue Advair, Spiriva
#Severe protein calorie malnutrition
Patient reports decreased PO intake for years after abdominal
surgery for perforate ulcer and whipple. Extensive counseling
of patient on importance of increasing her PO intake and trying
small frequent meals throughout the day.
-Encourage PO intake
-Appreciate nutrition recs
#FEN/PPX: regular diet, heparin SC
Dispo: home ___ and given scripts, PMP reviewed ___ active scripts
for pain medications.
PCP ___ on discharge.
Full code
Transitional issues:
-Repeat CBC, chemistries as outpatient.
-Encouraged PO intake
-___ with ___
-___ with PCP as outpatient
-___ with neurosurgery as outpatient
***. | PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY 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.
***
Ms. ___ is a ___ with CAD s/p LCx DES ___ for angina), PAD
s/p failed revascularization, HFpEF, hx of syncope w/AV
conduction delay and IV conduction delay s/p permanent
pacemaker, T2DM, chronic knee pain s/p R TKR and inability to
use RLE, and ___ disease who presented to the ED after
experiencing chest pressure iso worsening anxiety, insomnia, and
constipation.
# ___ Disease medication titration: Patient is followed
by Dr. ___ was last seen in ___. He had
instructed her to increase her carbidopa and levodopa to 3 tabs
in ___, but she only increased to 2 tabs because she was
unsure if the medications were helping, and notes feeling dizzy
after taking the medication. Was noted to have ongoing
bradykinesia and rigidity, worse on R>L, resting tremor R>L at
last outpatient visit. In the ED she complained that
levodopa-carbidopa had not improved her bradykinesia, rigidity,
or her ability to ambulate, or complete ADLs. She feels instead
that the increased dose causes her to have worsening anxiety and
associated insomnia, accompanied by episodes of crying out in
her sleep, as well as constipation. Neuro saw her in the ED, and
noted that she continued to have ongoing bradykinesia, rigidity
and tremor R>L, but no dyskinesia, and felt that she would
benefit from continuing to take levodopa-carbidopa. Per neuro,
she was started on ___ tablet ___ of carbidopa ER 25
mg-levodopa 100 mg, with a plan to increase by ___ tablet qweek
(i.e., 1 ___ tab next week) as tolerated to help
with stiffness and bradykinesia. It was also discovered that
patient had run out of her nortriptyline 25 mg qhs capsules for
mood and sleep, which was restarted and patient was given a
script for these.
# Hypotensive episodes:
# Concern for autonomic dysfunction
Patient became acutely hypotensive with SBPs in the ___ shortly
after standing up after using the commode on ___ AM. She was
observed to have a blank facies and did not respond to questions
or commands. She was returned to bed in a supine position and
bolused with 500cc D5W and also given 1 tab of sinemet given
concern for possible exacerbation of Parkinsonian symptoms.
Patient was not hypoglycemic, CBC was stable, EKG was unchanged,
and no evidence of bleed on exam. Patient's responsiveness
returned to baseline with these interventions. Neurology was
called to evaluate the patient and per their exam, the patient
did not appear to have worsening of her Parkinsonian symptoms-
tone, rigidity, and tremor were at baseline. Appeared that
episode was vasovagal, perhaps exacerbated by patient's recent
poor PO intake. Orthostatics were negative. Patient's home
valsartan and furosemide were held in the setting of hypotension
and ___, as below. Patient remained normotensive for 48hrs, and
then on ___ AM, patient had an additional, similar episode when
she felt "dizzy and like I am going to faint" and then became
hypotensive with SBPs in the ___ and unresponsive while sitting
in a chair, eating breakfast, and talking with her daughter.
SBPs increased to ___ w/reverse Trendelenberg and into the low
100s w/500cc NS bolus. Once again, this was deemed unlikely to
be a Parkinsonian "freezing" episode given hypotension and
prodrome. Patient did complain of some head and neck pain
(reminiscent of her known cervicogenic headache pain); NCHCT was
negative for acute bleed and CT c-spine was w/o fracture. EKG
was unchanged. Telemetry was notable for a few PVCs/fusion
beats. Patient's pacemaker was interrogated by Electrophysiology
service, and was functioning appropriately (DDD @60bpm).
Considered vascular etiology given carotid U/S ___ with
bilateral 40% stenosis, and NCHCT with atherosclerotic
calcification of carotid siphons and vertebrobasilar system,
although with the latter, would have expect higher BPs. Of note,
patient has MRI brain ___ w/empty sella, showing only pituitary
stalk. Rechecked TFTs which were normal- TSH 0.67, FT4 1.3 and
7AM cortisol 4.7, which was within the normal range. Taken
together, overall picture was most suspicious for generalized
autonomic dysfunction given longstanding ___, distinct
from multisystem atrophy. It is likely that patient's aggressive
home blood pressure regimen was a contributing factor as well.
For management, patient's home imdur were held. Her metoprolol
succinate 100mg daily was reduced initially as fractionated
metoprolol tartrate 25mg TID, and home atenolol was
discontinued. Her amlodipine was reduced from 10mg to 5mg daily.
Her home furosemide and valsartan were held with a plan to
consider restarting after repeat chemistries following discharge
given ___ during hospitalization. At time of discharge,
patient's blood pressures ranged from 125-152/68-71. Given
concern for autonomic dysfunction, patient should have tilt
table testing and additional follow-up with Dr. ___ Dr.
___.
# UTI: Patient was asymptomatic in that she did not endorse
dysuria or urinary frequency, although her overall malaise was
likely in part related to UTI. UA on admission notable for WBC
and bacteria. Patient received macrobid x1 in the ED. Urine cx
x2 subsequently grew out pan-sensitive E. coli. Patient was
treated with three day course of ceftriaxone 1 gm IV Q24H (Day
1: ___, Day 3: ___. Patient's mental status and fatigue
improved upon conclusion of treatment.
# ___: Baseline Cr 0.8-1.1. Patient had Cr bump to 1.6 in the
setting of hypotension and UTI as above. BUN/Cr>20. Patient was
treated with IVF boluses, and her valsartan and furosemide were
held. Patient's hypotension had resolved and her Cr had improved
to 1.0 at time of discharge. Patient should have repeat
chemistries and her blood pressure should be re-evaluated prior
to restarting furosemide and/or valsartan as discussed above.
# Constipation: This has been an ongoing issue for this patient,
which has worsened concurrently with her ___. On
presentation, she endorsed having had no BM for 4 days, although
was passing flatus. She did not have a BM in ED in spite of
lactulose x2. On the floor, she endorsed abdominal distension
which was pushing up on her chest. S/p mineral oil enema, the
patient had a well-formed, large BM, and her abdominal
distention and chest pressure improved. She was continued on her
home senna 8.6mg BID. She was started on docusate 100mg BID and
miralax daily. She was provided a script at time of discharge
for Lactulose 15ml q8hr if no BM>48hrs and also recommended that
she use ___ Fleet mineral oil (not saline) enema if no BM>48hrs,
which have worked in-house.
# Chest pressure:
# CAD s/p Lcx DES ___ for angina
# Severe PAD w/ failed revascularization attempts:
Patient presented with right sided chest pressure at rest which
was accompanied by anxiety. Per the patient's daughter, her pain
resolved with SLN x1 in the ambulance. No ischemic EKG changes.
Trop <0.01 x2. Symptoms may have represented angina, but were
more likely related to concurrent anxiety, as well as from
pressure from distended abdomen in the setting of constipation
as above. As above, chest pressure resolved after patient had BM
with mineral oil enema. She had no further episodes of chest
pain. She was continued on home atorvastatin 20mg ___ 325
mg daily, Plavix 75mg daily. As above, her home atenolol was
discontinued and her metoprolol 100mg succinate was reduced in
the setting of her hypotension, first as fractionated tartrate
25mg TID, and then to metoprolol succinate 75mg daily for
discharge. Her home valsartan was held in the setting of her
hypotension and ___ as discussed. Patient should have repeat
chemistries in the outpatient setting and reassessment of blood
pressure prior to restarting valsartan as above.
# HFpEF: TTE (___) with LVH, LVEF 70%, and no significant
valvular
disease. proBNP 1079 (311 in ___ and bibasilar atelectasis
on exam. Patient without JVD, peripheral edema/sacral edema, and
lungs were clear on exam- overall appeared euvolemic. Patient's
home metoprolol succinate 100mg daily was reduced to 75mg in the
setting of hypotension as above, and her home atenolol was
discontinued. Her home amlodipine 10mg was reduced to 5mg daily
in the setting of hypotension as above. Her home isosorbide
mononitrate ER 60mg daily was held in the setting of
hypotension. Her home valsartan 160mg daily and furosemide were
discontinued in the setting of hypotension and ___. As above,
the patient should have repeat chemistries in the outpatient
setting and reassessment of blood pressure prior to restarting
valsartan and furosemide. Discharge weight is 89.8kg.
# Hypoglycemia
# Type 2DM: Patient's home metformin was held in house. She was
continued on her home lantus 30U QAM, her home Novolog 10U
w/breakfast and 10U w/dinner, and was also started on an
in-house sliding scale. Patient was instructed to restart her
home Metformin following discharge.
# Hypothyroidism: Patient was continued on home levothyroxine
175mcg daily. As above, patient had TFTs checked on ___ given
empty sella syndrome as part of hypotension workup. TSH 0.67 and
FT4 1.3.
# Hyperlipidemia: Patient was continued on home atorvastatin
20mg qhs.
# Hypertension: Patient was on both metoprolol succinate 100mg
daily and atenolol 50mg daily at home. To simplify her
medication regimen, atenolol was discontinued. Given patient's
hypotension, her metoprolol was initially reduced to tartrate
25mg TID, and then converted to 75mg for dischage. Patient's
home amlodipine 10mg daily was reduced to 5mg daily and
isosorbide mononitrate 60mg daily was discontinued. As above,
patient's home valsartan 160mg daily and furosemide 20mg QAM and
10mg ___ were held in the setting of hypotension and ___ as
above. Patient should have repeat chemistries in the outpatient
setting and reassessment of blood pressure prior to restarting
valsartan and/or furosemide.
# GERD: Patient was continued on home ranitidine 150mg BID.
# Bilateral knee pain s/p right total knee replacement
# Cervical spondylosis: Patient was continued on home lidocaine
patch, lidocaine ointment, acetaminophen, and home gabapentin
300mg qhs.
TRANSITIONAL:
=============
- Discharge weight: 89.8kg Discharge Cr: 1.0
- Patient's levodopa-carbidopa was increased with a plan as
follows: ___ tablet 3x/day and increase by ___ tablet qweek
(i.e., 1 ___ tab next week) as tolerated to help
with her rigidity and bradykinesia.
- Please consider changing patient from extended release to
immediate release levodopa-carbidopa, as this may help reduce
her side effects.
- Patient's atenolol was discontinued. Her home metoprolol
succinate 100mg daily was reduced to metoprolol succinate 75mg
daily in the setting of hypotension.
- Patient's home amlodipine 10mg daily was reduced to 5mg daily
in the setting of her hypotension.
- Patient's home isosorbide mononitrate 60mg daily was held in
the setting of her hypotension. Please evaluate patient's blood
pressure prior to restarting.
- Patient's valsartan and furosemide were discontinued in the
setting of hypotension and ___. Please evaluate patient's blood
pressure and obtain repeat chemistries before restarting.
- Patient should have tilt-table testing given concern for
autonomic dysfunction, and additional follow-up arranged with
Dr. ___ Dr. ___. Please note that this follow-up
cannot be arranged until tilt-table testing has been conducted.
- Patient had run out her nortryptiline 25mg QHS, which was
restarted.
- Patient was started on docusate 100mg BID and miralax daily,
and she was also continued on her senna 8.6mg BID. She was given
a script for lactulose 15mg q8h if no BM>48hrs and also
recommended to try Fleet mineral oil (not saline) enema if no
BM>48hrs, which worked during inpatient stay.
- Patient has follow-up scheduled with her outpatient
neurologist, Dr. ___ (___) on ___
11:30AM.
- Code status: Full (confirmed)
- Contact: ___, sister, ___ ___, sister,
___ ___, sister, ___
***. | DEGENERATIVE NERVOUS SYSTEM DISORDERS 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.
***
Hosptial Course Summary
___ year old female with afib, sick sinus syndrome s/p pacer,
longstanding HTN who presents with 1 week of dyspnea whose
hospital course included gentle diuresis complicated by
lightheadedness and fatigue and complicated disposition.
.
Active Issues:
# Dyspnea: Patient presented with acute dyspnea. Etiology
appeared multifactorial including decompensated heart failure
mediated by uncontrolled BP, URI and brochospastic disease.
Patient was given nebulizer treatments and was also diuresed
using IV lasix. Patient was transitioned to PO torsemide.
Patient's SOB resolved by discharge and was able to ambulate
without difficulty. Patient would have benefited from further
diruesis however this was limited by dizziness (see below).
.
# Dizziness: After aggresive diuresis, patient complained of
vertigo without hearing abnormalities or tinnitis. Patient was
given meclizine prn with good results. Patient did not have
orthostatic hypotension and was not lightheaded. Patient was
able to ambulate on discharge with physical therapy.
.
# Acute Renal failure: ___ lytes with Cr. 1.3 (baseline 1.0).
Likely prerenal as occurred after diuresis. However could also
be from increased dose of lisinopril.
- Will continue to monitor especially in setting of diuresis
- Renally dose meds
- Will continue lisinopril for now and continue to monitor
.
# HTN: On admission, patient's BP was poorly controlled. HCTZ
was discontinued given introduction of torsemide. Lisinopril was
increased to 40mg with better control of BP. Further titration
including introduction of nifepidine should occur as outpatient.
.
Inactive Issues: The following were inactive issues while
patient was admission. No medication changes or interventions
were necessary:
- Atrial fibrillation/SSS s/p pacer
- Hyperlipidemia
- Osteopenia
- Chronic Knee pain s/p MVA
.
Transition of Care:
1) Code status: Full code; this was readdress with patient and
daughter (HCP) who both confirmed code status. However given
patinet's wishes (i.e. desire to live on own and be able to do
everyday activities), this should be readdressed by outpatient
providers
2) Pending: none
3) Disposition: Home with daughter with ___ and home ___ Patient
did not have acute needs for SNF however team believed she would
benefit from assisted living. Patient currently lives in senior
housing by herself. This concern with addressed with daughter
and patient. Patient was very upset at prospects of losing her
independence. Patient agreed to home with daughter for mean time
and discuss options for ALF as outpatient.
4) Transitional issues;
-----a) INR check at ___: arrangements made prior to
discharge
-----b) BP check: if elevated would consider started nifedipine
***. | HEART FAILURE AND SHOCK 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 SUMMARY FOR ADMISSION:
================================
___ w/PMHx notable for atrial fibrillation and possible CHB with
junctional escape (no PPM), hypothyroidism, lumbar spinal injury
with chronic lower extremity weakness, ESRD recently started on
HD (___), obstructive uropathy with chronic in-dwelling
foley, chronic left ureteral stricture with chronic L PCN,
multiple previous MDR UTIs (ESBL E.coli, pseudomonas, MRSA, and
strenotrophomonas), currently completing IV antibiotic course
for UTI; admitted for ongoing evaluation of HIT and treatment of
new RUE DVT.
ACUTE ISSUES ADDRESSED:
==========================
# Thrombocytopenia, concern for HIT
PF4 sent prior to recent discharge positive. Notably platelets
with signs of recovery which was concerning as heparin product
held during last admission, this also could be in the setting of
resolution of
recent urinary tract infection. Review of chart notable for Heme
Onc visit with Dr. ___ history of transfusion and
notably ___ previously without evidence of bleeding. RUE US
___ with evidence of DVT in right brachial vein. Initially
placed on argatroban drip and SRA sent, which returned negative.
Argatroban discontinued.
# Occlusive deep vein thrombosis of right brachial vein: Noted
on RUE US ___ but not commented on ___ US patient anti
coagulated initially with argatroban, but after SRA negative,
switched to heparin gtt bridge to warfarin. Discharged on 5mg
warfarin daily with d/c INR of 2.1.
# Recurrent complicated UTI.
# Chronic L ureteral stricture s/p chronic L PCN
Patient with recent PCN exchange on ___, though ___ had
previously attempted to recannalize the L ureter without
success. CT AP on admission with evidence of stranding of left
kidney, treating with Ceftriaxone based on ___ sensitivities
which were confirmed on ___ E. Coli sensitivity, for 14 day
course to complete ___. Midline placed, but had to be removed
due to leaking. Final dose given on day of discharge ___.
Treated with PO Vancomycin as prophylaxis until completion of
antibiotics.
# Afib
# Possible CHB with junctional bradycardia
Rhythm dates back to ___, given junctional rhythm no pacemaker
was placed.
# Depression/Anxiety/Grief
Patient's wife recently passed away in the ___. Home
sertraline and lorazepam continued.
CHRONIC ISSUES:
================
# ESRD on HD (___)
# Chronic bladder outlet obstruction s/p TURP c/b urinary
retention and chronic foley
Continued ___ HD scheduled.
# Recent eosinophilic pneumonia
Diagnosed in ___ with for which he is followed by Dr. ___
___ as an outpatient. He had been placed back on 10 mg
prednisone daily recently for unclear reasons (previously on 2.5
mg prednisone for IgA nephropathy). Outpatient pulmonary follow
up scheduled.
# Normocytic anemia
Follows with Dr. ___. Suspect ___ AoCD d/t inflammation and
renal failure related.
# Hypertension
Continue home amlodipine
# Hypothyroidism
Continue home levothyroxine
# HLD
Continue home atorvastatin
# Gout
Continue home allopurinol
# Chronic leg pain ___ prior crush injury
Continue home oxycodone 10 mg q6h PRN and oxycontin 10 mg BID.
# OSA
He has evidence of restriction on PFTs, which is likely
attributable to a combination of his volume status and body
habitus. He has no evidence of fibrosis on prior chest imaging.
TRANSITIONAL ISSUES
===================
[ ] IPMN (previously identified). Will need outpatient
monitoring
with MRCP in the future
[ ] Pulmonary follow up scheduled
[ ] Next INR should be drawn by ___ on ___ and sent to PCP
for updated warfarin dosing.
Name: ___.
Location: ___ - ___
Address: ___, ___
Phone: ___
Fax: ___
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
***. | COAGULATION DISORDERS |
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. ___ was admitted to the gynecology service after
undergoing a total laparoscopic hysterectomy. The patient had
been scheduled for a supracervical hysterectomy and
intraoperatively, the decision to convert to total laparoscopic
hysterectomy was made due to obstructive paracervical fibroids.
Please see Dr. ___ note for full details
of the procedure. The procedure was otherwise uncomplicated,
anesthesia was tolerated and blood loss was minimal. The patient
recovered well and on POD#1 passed her voiding trial. Her diet
was advanced to regular, and her pain was well controlled on
oral medications. She was discharged home on POD#1 with follow
up with Dr. ___ for ___.
***. | UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY 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.
***
Admission Summary:
___ ___ only man with IDDM, ESRD on iHD (since
___, transfusion dependent anemia, urothelial carcinoma
untreated s/p R PCNU for hydroureteronephrosis, presenting with
cough, fevers, and CXR.
Acute Issues:
#Goals of Care: Mr. ___ expressed that he did not want to
suffer and has become very symptomatic from his pulmonary edema.
In line with his goals, he was made DNR/DNI. However, after much
discussion, the patient wanted to continue dialysis and wanted
to go home with O2 with plans to do outpatient dialysis. We
expressed concerns about the patient's ability to outpatient
dialysis as he has become very weak and symptomatic with little
activity. We also discussed the futility of HD to remove enough
fluid for his pulmonary edema to improve. Lastly, we discussed
with the patient and the family our concerns that he has days to
weeks with his worsening respiratory status. However, the
patient continues to want HD. The patient continues to want
hospitalization but is no ICU transfer. He refused to sign a
MOLST at discharge.
#Pulmonary Edema
#Hypoxic respiratory failure
Mr. ___ presented with cough, fevers, and a new O2 requirement
on admission in the setting of volume overload. His CXR on
admission was notable for small bilateral pleural effusions and
central pulmonary edema. We attempted aggressive fluid removal
at dialysis, but he was unable to tolerate more than one liter
per session due to hypotension, even with pre-treatment with
albumin and midodrine. He remained persistently hypoxic,
requiring 2L O2. Consistent with Mr. ___ wishes for his care,
he was discharged to home on 2L of oxygen with plans to continue
HD.
#Pyelonephritis
Mr. ___ has a right chronic percutaneous nephrostomy tubes
since ___ due to obstructive uropathy from untreated
carcinoma with squamous cell features. He was febrile on
admission, and his urine cultures crew stenotrophomonas and
enterococcus. His PCN tube was exchanged on ___ and he was
treated with 7 days of cefepime.
Chronic Issues:
#End stage renal disease, on hemodialysis - continued MWF HD,
attempted agressive fluid removal in setting of volume overload,
but he could not tolerate it due to hypotension even with
pre-treatment with albumin and midodrine.
#Anemia, transfusion dependent - He was transfused with 2units
of pRBCs on ___
#Type 2 diabetes - He was maintained on an insulin sliding
scale.
TRANSITIONAL ISSUES:
--------------------
[] GOALS OF CARE: Patient is DNR/DNI with hospital transfer but
no ICU transfer. He will go home on O2 with plans to go to HD.
New Medications:
Hydromorphone liquid 1 mg/mL: 1 mL q4-6 hours as needed for
pain/respiratory distress
Ativan 0.25 mg q6 hours as needed for shortness of breath
CODE STATUS: DNR/DNI
***. | KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM 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 SUMMARY
===================
This is a ___ woman with a history of mechanical mitral
valve after an episode of endocarditis, recent GIB found to have
deilofoys lesion, chronic shortness of breath who presents for
evaluation of shortness of breath, found to have evidence of
multifocal pneumonia and decreasing hemoglobin concerning for GI
bleed.
ACUTE ISSUES
===================
# Multifocal PNA
Patient with chronic dyspnea, sent in from clinic due to elevted
D dimer with concern for PE. CTA without PE but did show
evidence of multifocal PNA. She is afebrile, no cough, but had
mild leukocytosis in clinic, did have reported hypotensive
episodes at home prompting discontinuation of lisinopril. Given
recent hospitalization and CT findings will treat as HAP. She
has significant allergy history and reports very severe hives,
does not recall anaphylaxis, and is not sure which medications
in her list caused the more severe reaction. Given her well
appearance and minimal symptoms, will defer MRSA coverage and
treat with levofloxacin for 7 day course to be completed on
___.
# Anemia
# History of Deulifoys lesion
# Hemolysis
# Supratherapuetic INR
Patient with history of hemolysis from mechanical valve with
known mild paravalvular leak, again with evidence of hemolysis
on labs this admission that are stable. D-dimer also elevated
and coagulpathy as below. DIC is not likely given platelets,
fibrinogen are normal, and we are treating the potential cause
with abx as above. GIB very possible given hx of gastric lesion
and decreasing H/H. She is supratherapeutic on her warfarin
which could exaserbate GI bleed. Warfarin was held on ___, and
re-started on ___. She will follow up with PCP and Dr. ___
as an outpatient. INR will fluctuate in setting of levofloxacin
and should be monitored closely. Hemoglobin was monitored for 24
hours and remained stable and so she was discharged. SPEP and
UPEP were sent in ED, and pending at discharge.
# DOE
Likely her PNA is contributing significantly, but she has also
had chronic symptoms that are unlikely due to this infection.
Her BNP was elevated suggestive CHF exacerbation although she is
showing no evidence of volume overload and in fact appears to be
dry, tolerated 1L fluids well. BNP maybe be elevated in the
setting of chronically elevated mitral valve gradients. No PE on
CTA. Continue to follow mitral valve as an outpatient.
# Troponin elevation
EKG stable, MB flat, no chest pain. Likely elevated in the
setting ___ and possible stress from underlying infection.
# Dieulafoy lesion
S/p EGD that showed a dieulafoy lesion in the duodenum at D2/D3.
The area was actively bleeding (endoclip). Patient has been
hemodynamically stable, and Hgb remained stable as discussed
above.
# Mechanical mitral valve on warfarin
# Paravalvular leak
# Elevated transmitral gradients
Patient is chronically anticoagulated as outpatient, but INR has
been supra-therapeutic for the past 6 months. Last TTE ___
showed stable mild paravalvular leak and mitral valve gradient
of 12. Coumadin held on ___, planning to have her take 4mg on
___.
===============
CHRONIC ISSUES:
===============
# CKD - 1.3 on admission, improved to 1.1.
# HTN - Patient anemic but hemodynamically stable. Continued
metoprolol. Patient has been taken off lisinipril and furosemide
as of 2 days ago.
# Hyperlipidemia - Continued atorvastatin 40 mg PO QPM
# CAD - Continued asprin 81 mg qd and atorvastatin.
# Neuropathy - Continued gabapentin 300 mg PO DAILY:PRN
# Hypothyroidism - Continue levothyroxine 125 mcg PO DAILY
# Nutrition - Continued folic acid 2 mg PO DAILY, B12 1000 mcg
PO DAILY, Vitamin D 400 UNIT PO DAILY
TRANSITIONAL ISSUES
====================
[] Levofloxacin last dose ___, 750mg q48 hours (renally
dosed), to take on ___, and ___.
[] Repeat INR on ___ (has cardiology follow up that day),
will need close monitoring of INR while on levofloxacin.
[] Goal INR 2.5-3.5, needs bridging if subtherapeutic.
[] ___ clinic emailed regarding close monitoring of
INR at discharge. Anticoagulation plan also discussed with
pharmacy.
[] ___, patient with increased MV gradients on TTE, continue to
follow with Dr. ___.
[] SPEP and UPEP pending at discharge (was ordered in ED given
anemia).
NEW medication:
- Levofloxacin, as above
CHANGED medication:
- Warfarin 4mg to be taken on ___.
Weight at discharge: 67.4 kg (148.59 lb)
Cr at discharge: 1.1
Hgb at discharge: 8.1
INR at discharge: 3.6 from 4.6 on ___
#CODE: Full code (presumed)
#CONTACT: ___ ___
***. | 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.
***
Ms. ___ was admitted directly from the the IV infusion
center under Dr. ___. On the night of her admission (___)
an MRI head was performed which showed a stable left parietal
lesion, no new mass lesions and increased right frontal sinus
mucosal thickening and enhancement. Ms. ___ q4 neurochecks
were stable and unconcerning. She received adequate pain control
for her headache, which did not worsen throughout her stay. Ms.
___ was seen by the neurooncology consult service who agreed
with our diagnosis of sinusitis but recommended a lumbar
puncture given her history of CNS involvement of her lymphoma. A
lumbar puncture was performed on the morning of ___. Cell
counts, cytogenetics, flow cytometry, LDH, protein, glucose, and
gram stain w/ culture were ordered. The results of these tests
will be followed up by Dr. ___. The diagnosis of sinusitis
was explained to the patient and she was prescribed levofloxacin
750mg once daily x 2wks. The patient was instructed to call Dr.
___ office to schedule an appointment for ___.
***. | OTITIS MEDIA AND URI 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 PMHx HTN, obesity, OSA, DM2 who presents to the ED
after an episode of presyncope and subacute history of chest
tightness.
ACTIVE ISSUES:
==============
# Chest pain
Mr. ___ had been having low level exertional chest pain
dating back a few months that seemed to be getting worse. After
having a beer on ___ night felt very unwell on ___ with
chest tightness and presyncopal symptoms, came to the emergency
room still having some chest tightness that resolved with SL
nitro. Serial EKGs revealed mild J-point elevation in the
lateral leads stable from priors but no acute ischemic change,
tropx2 negative. TTE with preserved systolic function and no
regional wall motion abnormalities. Low suspicion for unstable
coronary artery plaque rupture. CT coronaries showed no
obstruction.
# Presyncope
Patient recalls a story of presyncope while drinking alcohol at
dinner, likely vasovagal. No associated palpitations or heart
rhythm irregularities on telemetry. No murmurs on exam.
Mild symmetric LV hypertrophy, otherwise no structural
abnormalities on echo.
# Facial numbness
Unclear etiology. No neurological deficits on exam and
self-resolved.
# OSA
CPAP while in-house.
CHRONIC ISSUES:
===============
# HTN
Stable. Continued home lisinopril and home HCTZ.
# DM2
Stable. Home glipizide held and on sliding scale while in-house.
Patient started on statin prior to discharge per guidelines.
# G6PD deficiency
Stable.
CORE MEASURES:
==============
# CODE: Full presumed
# CONTACT: HCP: ___
Relationship: spouse
Phone number: ___
Cell phone: ___
TRANSITIONAL ISSUES:
====================
1. Needs hepatitis B vaccine
2. Started on Atorvastatin 80mg PO for diabetes
***. | ANGINA PECTORIS |
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. ___ had a planned admission to the antepartum
service prior to induction of labor for poorly controlled
diabetes and multiple medical issues complicating this
pregnancy.
.
She was monitored on the antepartum service. Given her increased
lower exremity edema, she underwent lower extremity dopplers to
rule out a DVT, which were negative, and a cardiac echo which
showed an EF>55% and borderline hyperdynamic left ventricular
systolic function.
.
She began her induction of labor on ___ with pitocin. She
was placed on an insulin drip prior to the induction. Her
delivery was complicated by shoulder dystocia. Please see
operative report for details.
Postpartum, she was initially transitioned to twice daily NPH
with humalog at breakfast and dinner postpartum. She was
subsequently transitioned to her pre-pregnancy regimen of lantus
with humalog in the morning, which was down-titrated over the
course of several days with input from ___ Endocrinology to 6
units of lantus at night with a humalog sliding scale due to
hypoglycemia.
.
She was followed by social work for coordination of resources as
well as physical therapy for evaluation of difficulty walking
due to lower extremity edema. She was discharged home in stable
condition with home physical therapy and a walker on postpartum
day 8 with outpatient followup.
***. | VAGINAL DELIVERY WITH COMPLICATING DIAGNOSES |
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 afib (not on anticoagulation)
and GIST s.p resection (___) presenting with increased pelvic
pain, nausea, and poor PO intake with imaging with RLQ mass
concerning for recurrent GIST.
ACTIVE ISSUES
============
#Abdominal Pain
#RLQ mass
Presented with abdominal pain with nausea and poor PO intake.
Most concerning for recurrent GIST. CT with RLQ mass in same
location as previous tumor. Patient known to be at high risk for
recurrence due to previous tumor arising from the small bowel,
tumor size >10 cm, high mitotic rate, rupture at time of
diagnosis, and disease within mm of surgical margins. ACS was
consulted and the patient was taken to the OR for and
ileocecectomy. For details of the operative procedure please see
the surgeon's operative note.
Following a brief uneventful stay in the PACU the patient was
transferred to the surgical floor. APS was consulted for pain
control post op. An epidural was placed and a dilaudid PCA was
started. The patient's diet was advanced to clear liquids and
when he was passing flatus his diet was advanced to regular
which was well tolerated. Once taking PO the patient was started
on oral pain medication with good effect and pain control. ___
was consulted for evaluation and recommended discharge home
without services. On POD 3 the patient was tolerating a regular
diet without nausea or emesis, his pain was well controlled on
oral pain medication. He was ambulating independently and was
ready for discharge home with close follow up in the ___ clinic.
#Anxiety
Has not told daughters about current admission. Expresses desire
not to inform them until after their college graduation. Placed
on privacy alert given his preference that his daughters not
receive clinical updates without his permission. Continued home
diazepam prn. Social work was consulted.
CHRONIC ISSUES
=============
#Atrial fib/flutter: CHADS-VASc is 0. Patient preference is to
for-go anticoagulation. No current need for rate control.
#Asthma: Continued home albuterol prn and home flovent
#Insomia: Continued home ___ 8 mg QHS PRN
***. | EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 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.
***
Ms. ___ was a ___ year old woman with a history notable for
HCV c/b cirrhosis (s/p Harvoni, TIPS), transitional cell
carcinoma (s/p gem-cis chemotherapy, cystectomy w/ileal loop
urostomy), HTN and T2DM who presented to ___ with RLE pain and
was found to have severe hydronephrosis and associated acute
obstructive renal failure, bacteremia, decompensated cirrhosis,
and severe pulmonary hypertension.
ACTIVE MANAGEMENT:
=====================
#Goals of Care
#Death
Patient was made CMO following meeting on including HCP and
Palliative care on ___. Her care then focused on pain
management with IV dilaudid and ativan. She was pronounced dead
on ___ at 1131 am when the nurse called the primary team to
the bedside. Death was attributed to acute hypoxemic respiratory
failure secondary to decompensated cirrhosis.
#Decompensated Cirrhosis with portal hypertension
#Hyperbilirubinemia
MELD-Na 33 on admission, from 13 in ___ the sharp increase was
mostly attributabled to her severe ___ and ___ increase in Cr.
TIPS was confirmed to be patent on RUQUS from ___. Given the
patent had diffuse abdominal tenderness, SBP was suspected,
although there was minimal ascites and no tappable fluid pocket;
she was empirically treated with antibiotics. No evidence of
variceal bleeding. Patient initially received albumin for volume
resuscitation, and was continued on her home rifaximin and
pantoprazole. Home direutics were held i/s/o acute renal
failure. INR started increasing (up to 3.0) and total bili
ranged from 2.0 to 3.0
___
#Hydronephrosis
Pt admitted with a Cr > 5 with baseline 0.7 just one month
prior. Possibly multifactorial, with bilateral hydronephrosis
seen on US and CT c/f ileal conduit stricture causing acute
obstructive renal failure, as well as recent heavy NSAID use in
last month (which patient had been taking for her RLE pain). The
patient initially had a stomal catheter placed on ___, with
little improvement. Cr peaked at 6.1 on ___, but down-trended
after she had bilateral percutaneous nephrostomy tubes placed by
___ team on ___. By ___, Cr had normalized. On ___ Cr peaked
again at 1.6, nephrostomy tubes were upsized and Cr normalized.
On ___ there was a 48 hour rise up to 1.3 before normalizing,
likely ___ to poor PO intake.
#Bacteremia
#Leukocytosis
Blood culture from admission (___) grew GPCs in pairs and
chains, and eventually speciated to vancomycin-resistant
enterococcus, micrococcus, and stomatococcus. Possibly a
contaminant given only 1 tube, but patient had a persistent
white count for several days. She remained afebrile throughout
admission. Patient was initially broadly covered with vancomycin
+ ceftazidime, but vancomycin was converted to daptomycin on ___
when sensitivities resulted. ID followed the patient and
recommended treatment with ceftazidime (completed ___, to
treat for a likely GI source of SBP, and daptomycin (completed
on ___. Leukocytosis persisted until ___, although no clear
etiology was determined.
#Pulmonary HTN
#ST elevations on EKG
Shortly after admission, patient had an EKG c/f ST elevations in
leads V1-V3. Cardiology evaluated the patient and determined
that a STEMI was very unlikely. Troponins were elevated i/s/o
acute renal failure, but CK-MB was wnl. A TTE was performed, and
showed elevated PA pressure and dilated, hypokinetic RV
consistent with new onset pulmonary HTN. The likely etiology is
portopulmonary HTN, given her liver disease. Unlikely ___
pulmonary emboli given negative V/Q scan, and unlikely ___ left
heart failure given TTE w/o evidence of LV dysfunction. Right
heart catheterization was attempted on ___ following resolution
of the ___. However she could not tolerate lying on the
procedure table. Further work-up was deemed not necessary
following family meeting on ___.
#Abdominal pain
#Nausea/Vomiting
Pt had diffuse and significant abdominal pain on admission, with
associated nausea/vomiting. This was thought to be largely due
to her significant uremia, acute renal failure, and significant
hydronephrosis. Given cirrhosis, elevated WBC, and AMS there was
initial concern for SBP, but her US on arrival showed only trace
ascites. Her CT Abd/Pelvis from ___ CT demonstrated colitis,
which may also have contributed to her pain, although the
patient remained afebrile and had no diarrhea to cause concern
for C diff. As above, the patient was empirically treating for
intra-abdominal infections and SBP, and given aggressive pain
control with Dilaudid 0.25-0.5 mg IV Q3H:PRN. Tube feeds were
attempted though she began having intermittent projectile
vomiting. KUB on ___ showed a greatly distended stomach. She
was given reglan and bowel rest. The following day, KUB showed a
decrease in distension. Tube feeds were intermittently attempted
however she would then have recurrent abdominal pain and
vomiting. KUB on ___ showed stomach distension again. Tube
feeds were never run faster than 10cc/hr rate when they were
given. Feeding tube was withdrawn on ___.
#RLE pain
#Back Pain
Patient's presenting complaint was severe RLE pain. MRI from OSH
showed degenerative facet arthropathy with some impingement on
L3-L5 roots, which is the likeliest cause of her symptoms.
Severe hydronephrosis was also very likely contributed to her
back pain, although this is much less likely to have caused the
thigh/leg pain. No MRI findings were c/f metastatic tumors in
the patient's femur or lumbar spine. As above, patient's pain
was managed with Dilaudid.
#Suicidal Ideations
There was initial concern that patient may have been suicidal in
ED on presentation. This was discussed with the patient's
brother-in-law ___ on ___, who stated that she may
have had occasional passive suicidal ideations over the 2
weeks prior to her admission, likely attributable to her severe
RLE pain. He is not aware of her making any attempts to overdose
on NSAIDs. Over course of admission, patient denied suicidal
ideations, but endorsed depression and had a flat affect at
times.
#Anion-gap metabolic acidosis
#Lactic acidosis
Patient had AGMA and elevated lactate on admission, likely in
the setting of acute renal failure and lactic acidosis from
volume depletion and infection. Repeat lactate level the
following day was normal.
CHRONIC ISSUES:
===============
#T2DM - Not on medications at home, but was maintained on ISS
while hospitalized until placed on CMO.
#Hypothyroidism - Continued home levothyroxine until placed on
CMO
#Hypertension. Initially held home meds i/s/o acute infection,
c/f hypotension
#GERD. Continued home PPI
# CONTACT: ___ |Brother-in-Law| ___
***. | EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 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 MMP presents with VT storm and ICD firing, transferred
from outside hospital for EP ablation.
.
# Ventricular Tachycardia:
Patient presented from outside hospital with VT storm, initially
thought to be of ischemic etiology due to scar tissue. TSH and
digoxin level were within normal limits. Patient had been
loaded on amiodarone at outside hospital and was continued on
amiodarone drip at 0.5mg/hr and beta blocker on presentation to
___. On the night of admission, patient had frequent runs of
NSVT, longest 15 beats, which started while he was sleeping.
While awake, patient reported feeling a sensation of "warmth"
during some of these runs of NSVT. He was started on low dose
metoprolol (both patient and daughter do not recall reason for
listed atenolol allergy) and amiodarone drip dose was increased
to 1mg/hr, after which frequency of NSVT runs decreased quickly.
During attempted EP ablation of VT tract the next morning,
Electrophysiology team was able to map out patient's left
ventricle and felt that VT was coming from right ventricle.
Patient reported having chest pain during EP procedure, so the
procedure was cut short, and patient was sent for Cardiac
Catheterization with the presumption that his VT may have been
of ischemic etiology. The patient had a PCI of the LCX/OM with
drug-eluting stent, however, felt that this wasn't in the right
location to be causing his VT. The patient had no further runs
of VT and no further EP procedure was done. If he develops VT in
the future he may need his right ventricle mapped to look for a
focus of the VT. The patient will follow up with Dr. ___ as
an outpatient.
# Shortness of Breath:
Patient experienced worsening shortness of breath during
hospitalization, likely multifactorial. He presented with two
weeks of worsening productive cough and was treated for Right
lower lobe pneumonia with broad spectrum antibiotics; only
normal oropharyngeal flora grew from his sputum culture.
Patient appears to have long history of hospitalizations for
COPD and CHF exacerbations with prolonged courses of recovery.
He was found to have a right sided pleural effusion on admission
to ___ he was noted to have had this effusion in the past
which was previously drained and found to be transudative.
Effusion appeared to be loculated on lateral decubitus films
taken during this hospitalization. Patient's O2 requirement
increased post EP and Cath procedures. He was thought to have
aspirated during the EP procedure, so flagyl was added to his
antibiotic regimen. Pulmonary embolism was considered but felt
to be of low suspicion. Lower extremity ultrasound was negative
for DVTs bilaterally. Ultimately, he was treated for COPD
exacerbation with steroids, despite minimal wheezing on exam,
after which his symptoms improved. He was discharged home with
services on oxygen (which he had prior to this hospitalization).
# COPD Exacerbation:
Patient has prior smoking history, intermittently requires O2 at
home, usually with CHF exacerbations. He has had multiple known
exacerbations for CHF and COPD in the past with prolonged
recovery. His oxygen requirement was variable with up to 6L NC
and a face tent. He was started on IV methylprednisolone and
then prednisone taper. His oxygen requirement decreased to 4L
NC. He will follow up with his PCP ___ discharge for further
management. He was discharged with Advair.
# Coronary Artery Disease:
Patient was ruled out for MI at the outside hospital, and EKG
was without evidence of acute ischemia. Patient was continued on
home aspirin, statin, plavix, and beta blocker. Patient was sent
to Cath lab immediately after having chest pain in the EP lab.
Cardiac Catheterization showed three vessel coronary artery
disease, 100% stenosis of mid LAD but patent LIMA-LAD graft, and
significant disease in the Left Circumflex. The left circumflex
had 90% proximal stenosis before the origin of the AV branch and
an 80% stenosis after the AV and before OM1, and was totally
occluded distally. A Drug-eluting stent was placed in the
proximal-mid Circumflex. The
SVG-PDA and SVG-OM were known occluded and were not looked at.
A femoral bruit was noted post procedure, not known to be old,
but femoral ultrasound showed no pseudoaneurysm or fistula.
Patient did have a couple of episodes of chest pain in the day
post catheterization with no EKG changes; he noted that the
chest pain was similar to pain he experiences at home sometimes
for which he does nothing.
# Hypertension:
Blood pressure was well controlled during hospitalization. He
was discharged on his home low dose of tamsulosin, metoprolol.
He will follow up with his primary care physician for further
management.
# Hyperlipidemia:
He was continued on Zetia/Simvastatin.
# Afib: Well rate controlled, currently A paced. On no
anticoagulation although CHADS score is 6. He was continued on
aspirin and plavix.
# CRI: At baseline 1.7. He was given mucomyst prior to cardiac
catheterization.
# Diabetes:
Patient was continued on basal glargine plus an insulin sliding
scale during this hospitalization. His blood sugars were
elevated while on steroids for COPD exacerbation.
# BPH:
He was continued on his home meds.
***. | PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ VESSELS OR STENTS |
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 was brought to the operating room on ___ and
underwent endovascular placement of a left carotid stent (please
see Operative Note for more details). The procedure was without
complications. The patient was closely monitored in the PACU and
then transferred to the floor in stable condition where she
remained hemodynamically stable. The patient's diet was
gradually advanced and well tolerated. Overnight, she complained
of chest pain. EKG and cardiac enzymes were sent and cycled, all
with reassuring results. Pain later resolved, whoever she later
complained of frontal headache, which she attributed to her
sinus condition, that resolved with oral medications as well.
She remained independant and ambulatory post-operative day 1.
Given favorable clinical progress, she was discharged to home on
POD #1 in stable condition.
Follow-up has been arranged with Dr. ___ in one month
with surveillance of the carotid arteries via carotid
ultrasound. The patient was started on her home medications
prior to discharge, as well as Plavix for the newly placed
stent.
***. | CAROTID ARTERY STENT 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.
***
A/P: ___ yo male w/ no ___ who presents w/ one day of abdominal
pain, elevated lipase and CT findings consistent w/ acute
pancreatitis.
#. Abdominal pain: Patient presented w/ 1 day of abdominal pain.
In the ER he was found to have an elevated lipase at 800s and CT
abd/pel revealed changes consistent with pancreatitis. He had no
history of pancreatitis, no trauma to the abdomen, had not taken
any new medications but did report ___ drink binge drinking
episode on ___, 3 days PTA. His calcium and trigleceride levels
were found to be normal. He had a RUQ U/S which showed no stones
or obstruction. He was NPO kept NPO on HD 1 and his diet was
advanced on HD 2. He tolerated this well. His pain was
controlled with morphine from which he was switched to percocet.
He was discharged on percocet prn for pain with enough for 4
days.
.
#. Fever: Patient had a low grade fever to 100.6 on arrival to
the floor. This was thought to be due to his acute pancreatitis
with a component of pain contributing to it. No infectious
source was found and patient remained afebrile for the rest of
his hospitalization. He was not treated with antibiotics.
.
#. leukocytosis: Patient had an elevated WBC to 19 on admission.
This was thought to be due to an acute phase reaction because of
his pancreatitis. No infectious source was found. He was not
treated with antibiotics. His WBC decreased and it was 13.8 on
the day prior to discharge.
.
#. HTN: Mr. ___ was found to have hypertension during this
admission with SBPs 140-162. He states that he was told he had
high blood pressure one year ago at his school clinic and that
he should try diet and excercise and decrease his alcohol intake
to improve his blood pressure, however, he has been
unsuccessful. He was not started on antihypertensives during
this admission and was encouraged to refrain from drinking
alcohol. He should follow up with his PCP about possibly
starting a medication to treat his hypertension.
.
# Hepatic steatosis - seen on imaging and referred to PCP.
***. | DISORDERS OF PANCREAS EXCEPT MALIGNANCY 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 HTN, DM, h/o CAD s/p DES to LCX OM ___ presents with
chest discomfort with negative cardiac enzymes and EKG and found
on cardiac catheterization to have no culprit lesions and no
significant new CAD. Patient was discharged on home CAD
medications and without chest pain.
# Chest Pain / ?ACS = Atypical based on symptoms, no EKG changes
and no elevated cardiac enzymes. Home CAD medications were
continued however a heparin drip was not started. However, given
prior admission with atypical presentation and blockage, a
cardiac catheterization was performed on ___ which showed no
culprit lesions and no significant new CAD.
# CAD = Status post DES to ___ OM ___. Cardiac risk
factors include HTN and T2DM. Patient was continued on home
aspirin 81mg, clopidogrel 75, and atenolol. Consider switching
to metoprolol and adding an ACEi as an outpatient.
# Type II Diabetes Mellitus on Insulin: Last HbA1c 7.2% and was
on metformin and glipizide (held for cardiac catheterization)
and was continued on home insulin detemir 45-55 units qHS and
insulin aspart 10 units qDinner. On a followup note, patient
did not know that she was on insulin (did not know that insulin
detemir or insulin aspart where in fact insulins) even though
she had been taking these drugs for many years and she is
followed closely by the ___ and her
medications are being actively managed (being titrated off
sulfonylureas); this medication knowledge deficiency will need
to be addressed as an outpatient.
# Aortic Systolic Murmur = Noted the day after admission,
previous echocardiogram on ___ noted no aortic
stenosis/regurgitation, followup as outpatient as necessary.
# Hypertension: Chronic stable issue on home on atenolol 50mg
daily, chlorthalidone 25mg daily, and lisinopril 40mg daily at
home.
# Positive Leukocyte Esterase = Noted on UA in ___ ED but
patient has no irritative voiding symptoms or fever. Followup
urine culture could not be obtained. Followup as outpatient if
any UTI symptoms.
# Hypothyroidism: Chronic stable issue continued home
levothyroxine 75 mcg PO daily
# GERD: Chronic stable issue transitioned to pantoprazole daily
# Depression: Chronic stable issue continued home venlafaxine ER
75mg PO daily
# CODE: Full Code (deferred full discussion). Emergency contact
is ___ (friend who is currently on ___)
otherwise ___ (___) also friend
___ on ___:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Potassium Chloride 8 mEq PO TID
9. Venlafaxine XR 75 mg PO DAILY
10. Clopidogrel 75 mg PO DAILY
11. GlipiZIDE 10 mg PO BID
12. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
***. | CIRCULATORY DISORDERS EXCEPT AMI WITH CARDIAC CATETERIZATION 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.
***
Pt was transferred to ___ neurology stroke service after
urgent outpatient MRI revealed acute-subacute strokes in the
occipital lobes and cerebellum. On the neurology stroke service,
pt had frequent neurological exams, which revealed no obvious
focal deficits including intact visual acuity and coordination.
Pt was evaluated by neurosurgery, who recommended outpatient
followup with no need for surgical intervention. Repeat imaging
findings were consistent with the previous outpatient scan. Pt
also received an echocardiogram, which was within normal limits
but limited due to non-assessment for PFO. Bilateral ___ US was
conducted to rule out paradoxical thromboembolus, and was
negative for DVT. Pt was discharged on dual platelet therapy and
outpatient f/u.
Transition Issues:
-Pt will need to continue taking Aspirin and Plavix for DAPT
-Pt will need to wear ___ of Hearts for the near future and
have monitor checked for any events suggestive of paroxysmal
arrhythmia
-Pt will need to follow up with PCP (who will arrange Neurology
followup through Atrius) and Neurosurgery in the near future
***. | 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.
***
___ F with severe fistulizing Crohn's c/b small bowel
resections, sigmoidectomy, and ___ pouch p/w fevers and
rectal pain
# Sepsis: Patient with reported fevers at home though afebrile
on admission and with leukocytosis, source suspected abscess
within per-rectal fistula. CXR was normal, UA normal and BCx
NGTD. Immunocompromised on chronic Prednisone. Patient did not
have a fever while inpatient and WBC was actually lower than
prior chronic leukocytosis values. MRI pelvis was initially
concerning for an abscess within a fistula though she was
draining foul smelling mucous. GI and colorectal were consulted.
Plan was to observe ovenight follow up MRI read and decide if
she needs exam under anesthesia and potentially drainage under
anesthesia. Patient was unwilling to stay in house overnight for
final MRI read. After discussion with GI and CRS, ok for
discharge and if MRI does in fact show abscess on final read she
will be called back in for drainage. No need for antibiotics.
# Fistulizing Crohn's: Complicated, requiring multiple
surgeries. Patient has been hesitant to continue immunomodulator
therapy and has been maintained on chronic steroids with stable
(but not improving) fistulous disease. Continues to have stool
output through pouch (suggesting fistula) as well as
enterocutaneous at sacrum. MRI pelvis performed as above and
colorectal surgery consulted in house as above. She was
continued on TPN.
# Microcytic Anemia: Patient with decreasing Hgb to 10.4 on
presentation with ___ value of 11.4 with low iron at that
time. Likely ___ small bowel disease and prior resections
causing decreased iron absorption. PO supplementation would
likely thus be ineffective and patient should be considered for
iron infusions periodically.
Transitional Issues:
- MRI final read pending
- She may need to return for drainage, GI to follow up MRI and
discuss with patient
***. | 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.
***
___ y/o F with history of R MCA stroke s/p hemicraniectomy
presents for elective R cranioplasty. She was taken to the OR on
___ with no intraoperative complications. Patient was extubated
post op and transferred to the ___ for recovery. Her post-op CT
head showed pneumocephalus with some worsening midline shift.
She was kept in the PACU overnight with a nonrebreather. Her
post-op exam remained stable.
On POD 1, her exam was back to baseline and she was transferred
to the floor. Her nonrebreather was discontinued in the evening.
On ___ Patient complaining of abdominal pain. KUB was obtained
which revelaed stool in the sigmoid colon an rectum. Attempted
to disimpact pt, but stool not formed. Administered Fleet enema
and dulcolax.
On ___ Patient remained stable.
On ___ Patient's PEG not working, ACS paged x2, Pancrelipase
5000 2 CAP x1 w/no result.
On ___ Patient's PEG continued to be non-functioning. The acute
surgical service was consulted which ordered another round of
Pancrelipase. The PEG tube resumed working. Her pleurex
catheter was drained by nursing.
___, Ms. ___ neurological exam remained stable. She had a
KUB xray to evaluate her stomach after concern for continued
loose stools and hardening of her right upper quadrant. The scan
showed compaction of stools which required both enemas and a
manual disimpaction. Her complaint of abdominal pain was
alleviated.
___, Ms. ___ was discharged to a long term skilled nursing
facility.
***. | OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. 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.
***
___ with recurrent diverticulitis who underwent lap sigmoid
colectomy on ___ performed by Dr. ___ without
complication. On POD 1 pt was found to be hypotensive with an
epidural and was switched to PCA and given intravenous fluids.
Pt's hypotension resolved on PCA. Her pain was appropriately
controlled. On POD 3 Pt's diet was advanced to clear liquids,
foley catheter was discontinued, she had return of bowel
function, and was restarted on home medications. On POD 4 pt
tolerated a regular diet without nausea, had restarted her home
medications and was ambulating well without assistance. Pt was
discharged home and instructed to follow-up with Dr. ___ in
clinic as described below.
***. | 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.
***
___ elective admission for RIGHT C5-C6, C6-C7 FORAMINOTOMY.
Post-operatively in the PACU patient had a transient episode of
hypoxia and was unresponsive, required an oral airway and Ambu
ventilation and returned to ___ after about 90 seconds
and was verbile.
He was stablized and transfered to the floor. No complications
reported over night. Patient was discharged home with
perscriptions on ___.
***. | BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION 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.
***
___ without significant other ___ presenting with worsening
vesicular rash despite treatment with valacyclovir prior to
admission.
# Herpes zoster ophthalmicus:
Patient presented with worsening herpetiform rash in V1
distribution with involvement of his right eye. Was evaluated by
ophthalmology who did not see corneal defects. He had some
moderate periorbital swelling but no pain with eye movement or
vision changes (apart from due to topical ointment). There was
no other evidence of orbital cellulitis. He was treated with IV
acyclovir with gradual improvement of symptoms and discharged on
oral valacyclovir in addition to multiple eyedrops as detailed
in medication section. Pain well managed with tylenol, HIV test
negative. Patient was instructed not to drive until vision
returns to baseline which he is agreeable to. Will need to
discuss Shingles vaccination with PCP as outpatient. He is
already set up for an ophthalmology appointment the day after
discharge. Pt asking about air travel, has plans scheduled for
later this week. Advised to see PCP to ensure vesicles are
crusted over entirely before risking exposure to his
family/friends as well as other travelers on airplane.
# Anemia
Reports history of thalassemia, at baseline, iron, TSH wnl. Can
have CBC checked as outpatient.
# Hypoglycemia
Present on AM chem panel after fasting overnight, asymptomatic.
Will monitor and rx accordingly. No hx DM. Do not feel related
to systemic illness at this time, likely spurious laboratory
value.
# Elevated BP readings
Elevated up to 150's systolic at time. Patient reports being a
bit nervous during BP readings. Will need BP checked as
outpatient and if still high can initiate pharmacotherapy but
suspect some anxiety ___ being hospitalized as main contributing
factor.
====================
TRANSITIONAL ISSUES:
====================
[ ] Please assess BP as patient was hypertensive during hospital
course.
[ ] Please continue to monitor anemia, pursue age appropriate
screening.
[ ] Last day of acyclovir: ___
#FULL CODE
#CONTACT: ___ (domestic partner, ___, ___
Time spent: 50 minutes
PCP notified of discharge
***. | OTHER DISORDERS OF THE EYE 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.
***
Assessment/Plan: Ms. ___ is a ___ year old with non-ischemic
diastolic heart failure (EF 50% ___, cardiac catheterization in
___, adenocarnicoma (Stage 1A s/p right upper lobectomy), hx
of
cardiac arrest s/p ICD, hx of provoked PE, frequent PVCs, HTN,
OSA (has never worn CPAP), HLD who presented to ___ on ___
with back pain, shortness of breath, nausea and substernal chest
"burning" chest pain and nausea in setting of anxiety. She
underwent a CT Scan which was negative for PE, echo showed mild
LVH and reportedly improved EF of 50-55%, EKG without signs of
ischemia and mildly elevated troponins and abnormal stress test
who was transferred on ___ for further care and cardiac
catheterization.
# TROPONINEMIA/NSTEMI/CHEST PAIN: similar presentation as past
history of elevated troponins and negative occlusive CAD per
coronary angiogram. S/P cath ___ showed clean coronaries.
- Continue Atorvastatin 80mg and ASA 81 mg daily
- Continue metop succinate 100 mg daily
- Start lisinopril 2.5 mg daily
- Start Imdur 30 mg daily
- F/U with cardiologist in ___ weeks
# Nonischemic cardiomyopathy/ diastolic heart failure
(presumably related to ETOH); now with EF of 55% (improved) and
no signs of volume overload.
- Continue Lasix 20mg daily
- Continue Metoprolol and lisinopril as above
- Daily weights, Low sodium diet heart healthy diet
# Depression/Anxiety: Home regimen consists of Celexa 20mg
daily which was stopped at CHA as QT was reportedly mildly
prolonged; they started ___ 10mg daily; EKG on arrival with
QT of 420. QT 446 this am.
- Continue ___ for now, prescription given for 1 week at
which time she will see her PCP
# GERD:
- Continue Omeprazole
# Obstructive sleep apnea: does not wear CPAP; has never been
fitted.
- Recommend initiating CPAP use to decrease cardiac risk
factors; defer to PCP upon discharge to initiate OSA treatment
# DISPO: Discharge home today
***. | ACUTE MYOCARDIAL INFARCTION DISCHARGED ALIVE 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 woman with know PAD presents to clinic with new wet
gangrene of the second and third left toes. She is admitted to
the hospital for IV antibiotics and pain management. Foot xray
did not show osteo. Cilostazol was increase to 100mg BID from
50mg BID. Gabapentin was added for pain management.
Her pain improved with treatment of the infection. We elected to
treat her conservatively as unfortunately angiogram in ___ showed complete occlusion of all three tibial vessels with
no significant runoff into the foot. At that time, we
angioplastied the left superficial femoral and proximal
popliteal arteries.
Medication for chronic conditions continued throughout
hospitalization.
New medications include:
-Increase cilostazol to 100mg BID,
-Bactrim BID for 10 days
-Add gabapentin 200mg TID for pain
We will continue tylenol TID and have arranged for ___ services
to assess wound and ___ in clinic in one week.
***. | CONNECTIVE TISSUE 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.
***
___ woman w/ HTN, HLD, CAD s/p PCI w/ 2 stent placement in ___,
IDDM on long-acting insulin who was admitted with hypoglycemic
coma after overdosing on Lantus. The patient was admitted to the
medical ICU with hypoglycemia that was corrected with D10. She
was transferred to the medical floor after achievement of
normoglycemia. Her hospital course was notable for a troponin
leak to 0.36 with flat MB, without chest pain or EKG changes.
Cardiology was consulted and felt that this most likely
represented missed plaque rupture vs. demand ischemia from
hypoglycemic state, and recommended no further inpatient workup.
The patient was also seen by psychiatry for concern for suicidal
intent with Lantus overdose, but the patient was felt not to be
suicidal and for medication error to be a result of poor health
and medication literacy. The patient was seen by the
endocrinology and diabetes educator teams, who changed her
diabetes regimen and provided education about long-acting
insulin. She was also seen by social work, and more extensive
elder support and social services were set up for her home.
ACTIVE ISSUES
=================
# IDDM: Patient presented after being found unresponsive and
with FSG in the ___. She received D10 in MICU and was
transferred to the medical floor after blood glucose normalized.
___ was consulted for ideal glucose
management regimen. She was stable on regimen of 10 Lantus and
glipizide daily. She was also seen by diabetes educator. Due to
concern for ability to manage medications at home, social work
was consulted for setting up increased ___ and elder services at
home.
# CAD:
# Elevated Troponin: TroponinT peaked at 0.37, MB was flat. No
ECG changes and the patient remained symptom-free throughout
hospitalization. Cardiology was consulted, and felt that
presentation was most consistent with demand ischemia in setting
of hypoglycemia vs. plaque rupture causing ischemic event likely
in past, now with normalized MB. Per ___ records, patient
has history of 2 stents placed in ___. Normal TTE and stress
test in ___, and TTE during admission was without wall motion
abnormalities and with normal EF. Home ASA, Plavix, and statin
were continued. Home metoprolol was changed to carvedilol as
above.
# Hypertension: Floor course complicated by hypertension up to
180s systolic; hypertension improved with switching metoprolol
to carvedilol 25 mg BID.
# Hyperkalemia: K peaked at 5.6, but trended down to 4.4 before
discharge. Patient was continued on low K diet.
# Normocytic anemia: Hgb as low as 9.4; patient had anemia to
10.2 during outpatient in ___, so was stable with prior.
Likely consistent with anemia of chronic disease.
# 2 cm lung nodular opacity- This was seen overlying the right
lung base and confirmed on oblique CXR. CT chest in ___ remarks
on stable nodule. Patient will likely need continued CT chest
follow-up as outpatient.
# Depression/psychosocial supports: Patient emphatically denied
SI; presentation with hypoglycemia/lantus overdose was most
concerning for poor health literacy and inability to care for
self at home. Psychiatry was consulted and felt that the patient
was not suicidal. Outside psychiatry records also suggest odd
affect and concern for functioning but no concern for overt
depression. Social work was consulted for establishing elder
services and in home therapy at home.
CHRONIC ISSUES
===============
# Hyperlipidemia: Home statin continued.
Transitional Issues:
[] Please continue to monitor glycemic control on new insulin
regimen of Lantus 10 unit qPM and glipizide 10 mg daily.
[] Patient was set up with increased services at home for
insulin administration and medication teaching.
[] Mild hyperkalemia to 5.6 noted during admission; downtrended
to 4.4 on discharge. Please monitor potassium at outpatient
visits. Patient should follow low potassium diet.
[] Home metoprolol switched to carvedilol 25 mg BID for improved
BP control. Blood pressures 150s/70s on discharge; consider
further anti-hypertensive medication increase.
[] Given troponinemia during admission, should receive
outpatient stress echocardiogram to evaluate for coronary artery
disease.
[] Please continue to monitor symptoms of depression; patient
has an appointment with social work at ___
and should be connected with a psychiatrist.
[] CXR during admission noted 2 cm nodule in the right mid lung.
Per ___ records, was consistent with prior CT scans. Please
continue interval monitoring of right lung nodule.
Code: Full
Contact: ___ (sister) ___
***. | POISONING AND TOXIC EFFECTS OF DRUGS 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.
***
___ M with MMP including 2-vessel CAD, HTN, dCHF, DM-II,
hyperlipidemia, COPD, HCC (s/p liver transplant) in ___ who
presents with new episodes of syncope and nonspecific EKG
changes.
.
.
#Syncope: Question as to whether patient had full LOC. History
most consistent with orthostatic changes based on his positional
changes immediately before symptom onset. Recent increase in
diuretic dose. However, need to consider cardiac and
neurological etiologies. Given lack of CP, no acute SOB an ACS
event less likely but he has multiple risk factors, including
HL,DM, 2V CAD. PE low liklihood given stable BP, no new
tachycardia, oxygen requirement at baseline. No focal neuro
findings to warrant CT /MRI head at this juncture. Patient had
orthostatic hypotension while hospitalized. We believe this is
more likely to be due to vasal-vagal episode related to
orthostatic hypotension secondary to meds and dehydration. We
held lasix dose x 2. He was able to ambulate in halls, he denies
having any symptoms while hospitalized.
-r/o ACS with 3 sets cardiac enzymes were all negative
-We held lasix x 2 doses. He should continue home dose of 60mg
BID
-D/c spirolactone
-Decreased dose of isosorbide mononitrate from 60mg ->30mg Qday
-___ stockings may also help with symptoms
.
#CAD-Last cardiac catheterization done in ___ and showed
clean LMCA, LAD with 50% mid vessel stenosis, LCX w/ mild
diffuse disease and an RCA which was totally occluded but with
good collaterals. Currently, he is having no CP or worse SOB
from his usual COPD baseline. He denies palpitations. EKG
similar to priors with no overt ST elevations or depressions,
but minimal TWI in the precordial leads and in II, III, aVF.
However, patient has multiple risk factors, including DM, HL,
HTN, known 2VD.
-r/o ACS with x 3 sets CEs are negative
-Telemetry monitoring- no episodes on monitor during his
hospitalization
-continue statin, fibrate, ASA, isosorbide (dose decreased as
noted above), beta blocker therapy
.
#PUMP Function -Last TTE done ___ which showed LVEF
preserved at >60%. Diastolic dysfunction and mild symmetric LVH,
no prior note of any valvular abnormalities. CXR with minimal
bibasilar edema but markedly improved from prior x-rays.
Euvolemic on exam. Held lasix dose x 2 as noted above. Then
restarted at 60mg BID. D/c spirolactone.
.
#HTN: Currently normotensive on exam, BP sl low at 105/64 at
admission. Orthostatic hypotension as noted above. Med changes
as noted above.
-Continue lasix at 60mg BID
-D/C spirinolactone
-continue lopressor, decreased Isosorbide Mononitrate from 60mg
->30 mg daily due to syncope episode and lower BPs
#COPD: Patient is on home oxygen therapy. Breathing appears
comfortable, will continue to monitor. Been on 2L at home since
___. Followed by Dr. ___. Sats now in high ___, NAD. CXR
with no PNAs, minimal bibasilar fluid, improved from priors.
-continue on NC oxygen 2L
-continue on daily Spiriva, Advair
-Albuterol PRN
# LEFT KNEE Pain: Patient fell down on his knees as he was
entering the elevator on the day of admission. There is no
visible trauma noted on exam, minor left knee sweeling. Xray of
left lower extremety shows no fracture. He continues to complain
of severe left knee pain worse when rotating his foot and leg
laterally. Patient state to have some pain relieve with
oxycodone. He had an orthopedic consult who recommend patient
keeping leg elevated while sitting or laying down, ice and pain
medication for pain control. He may need MRI in the future and
___ with orthopedic surgeon if he continues to have pain
within ___ weeks. He was also instructed to ___ with his
PCP ___ ___ weeks. He also saw ___, he was able to ambulate in
the hall and able to go up and down the stairs. ___ recommended
that he continue to have home ___ and that he uses walker and
elevated toilet seat at home to help with symptoms.
-Pain management with: oxycodone 5 mg Q6hrs as needed for pain.
He was given
- Avoid NSAIDs due to renal function
- Aplying Ice for pain control
- Home ___, and should use walker and raised toilet seat as
needed
.
DM-II: Fingersticks have been 140-280s range on day of
admission. No known neuropathy complications of note.
-will continue on usual home NPH regimen (34AM, 14PM units)
-continue on SSI as prescribed prior to admission. He was
instructed to continue to check FSG and to call his PCP if he
has continuous FSG >300
-Continue diabetic diet
#History of HCC/liver transplant: Followed by Dr. ___. No new
RUQ pain on exam. Transplant date was ___. Currently on
Cellcept 500mg and Prograf 1mg twice daily. Tacrolimus level was
2.5 prior to discharge. Liver transplant team was consulted. His
Prograft dose was increased from 1mg BID to 1.5mg BID. He was
also instructed to have blood draw for Tacro levels draw on
___ and have results faxed to Dr. ___. Tacro level
goal is <6. He will also need to have a ___ appointment
with Dr. ___ he was in his way to the appointment on the
day of admission when he had a syncope episode and was
hospitalized. His LFTs and tbili were WNL. Continue on Bactrim
SS daily.
.
#ARF atop CRF: ___ be related to recent increased Lasix dose of
60mg BID and spirolactone since ___ admission for ___
exacerbation (at ___. This may be due to pre-renal
reasons, such as increase lasix and dehydration. Creatine 2.8 at
admission, held lasix x 2 doses. Urine Na 54/ urine osm at 400-
This appears to be pre-renal, however difficult to assess given
that he is on lasix. UA negative except for protein 30. His
creatine decrease to 2.3 today. Given that patient has dCHF and
had previously gone into CHF exacerbation with changes in meds,
we made the following med changes listed below. He will need to
___ with Dr. ___. He was also given
prescription to have blood draw with BMP to be done on ___,
___ and have results faxed to his PCP.
-D/c spirolactone
-Continue Lasix 60mg PO BID
-avoid nephrotoxic medications
-no NSAIDs
.
#h/o HIT - History of acute drop in platelets with heparin
products, will avoid on this medication on admission.
.
#Depression -appropriate affect, stable mood.
- Continue on home Paxil
.
# FEN: cardiac/diabetic regular diet, good PO so no IVFs given,
cont daily Vit D/Ca.
.
# PROPHYLAXIS: **avoiding all heparin products given h/o HIT.
-TEDS, pneumoboots
-cont PPI
.
# CODE: full code
.
#Communication: w/patient and wife (HCP)
***. | SYNCOPE AND COLLAPSE |
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: This is a ___ yo man with left septic
arthritis (strep virdans) in ___ s/p surgical debridement, on
vancomycin who presented from rehab with erythema of left
shoulder concerning for cellulitis, found to have strep
bacteremia and possible early right shoulder septic arthritis.
.
# Bacteremia, strep viridans: From initial cultures in ED,
likely drawn off PICC though source not documented, PICC
removed. Subsequent blood cultures negative. He was seen by ID
and orthopedics. He underwent bilateral arthrocentesis to
evaluate for potential source of infection. His left shoulder
did not appear infected. His right shoulder returned with 15,000
wbc, which could be due to arthritis (gram stain and culture
negative) but not entirely clear. Given this repeat
arthrocentesis was done ___ and WBC improved to 1200, suggesting
possible infectious arthritis that had been treated in the
interim (again gram stain and culture negative). He was
initially treated with vancomycin given pcn allergy, however he
was switched to ceftriaxone on ___ and tolerated this without
any suggestion of allergy. This may all be contaminants but for
now await speciation which was strep viridans, s/p picc removal,
TTE without vegetation, ID following, vanco trough
supratheraputic so changed to daily dosing, repeat trough after
4th dose (___). s/p shoulder arthrocentesis bilaterally. PICC
line removed. Strep both vanco and pcn sensitive. He will
continue on ceftriaxone 2 grams daily via picc and will need
weekly cbc with diff, bun/crt, lft's, ESR, and CRP to be faxed
to ID (___). He will follow up with ID on ___ and
continue ceftriaxone through that appointment. PICC was placed
___, imaging reviewed by MD, tip in mid SVC and OK to use.
.
# Left shoulder erythema: Non-blanching. Initially thought to be
cellulitis, seen by derm, but did not improve with antibiotics,
not warm or tender, suggesting likely not infectious. Suspect
related to recent surgery and will resolve slowly.
.
# Constipation: cont. dulcolax as per his request with lactulose
enema prn or suppository.
.
# Bilateral shoulder pain: Given neck pain radiating to fingers
could be referred pain from OA of spine. Likely has rotator cuff
tear and oa of shoulder pain as well.
He was treated with lidoderm patches, two for right, one for
left shoulder with good effect, and offered low dose oxycodone
prn but did not need this.
- he will need to follow up with orthopedics in 2 weeks
.
# Atrial fibrilation: He was continued on beta blocker with rate
controlled. He was on coumadin on admission but this was held in
the setting of possibly needing to go to the OR for septic
arthritis. It was going to be resumed, however he was due to
have a spinal injection ___ with ortho spine and was told to
hold coumadin starting 10 days prior to this, so coumadin was
held until after this procedure.
- restart coumadin at home dose after spinal injection at
chronic pain appointment.
.
# Hyponatremia: He has a history of SIADH in the past and was at
times hyponatremic during this admit but improved with fluid
restriction.
.
# Lipodermatosclerosis: This was recently diagnosed at ___
___ and reportedly he has had this in the past, but his lower
extremity edema was thought most likely related to stasis. He
was recommended to use compression hose and elevate his legs as
much as possible, and otherwise continued with wound care
(vaseline with tube grip dressing) and home creams inlcuding
steroid cream.
.
# ? h/o CAD: on plavix at ___, held initially as may need OR,
now on hold for spinal injection restart after ___.
.
# Stomatitis: Ulcers on mouth previously HSV negative, continued
on lidocaine and maalox.
.
# Hypertension, benign: Labile in house continued on ___,
metoprolol and lasix though he refused to take lasix bid.
.
# Urinary frequency: He noted urinary frequency, has a h/o BPH,
this was stable during admit, UA/culture negative, likely BPH
related given s/p turp.
.
# Chronic pain: He takes oxycodone, cont. this, awaiting spinal
injection and visit with ortho spine ___ at 12:40 pm, that his
son would like him to get to if possible.
.
# ___ swelling: likely stasis, elevation and compression.
.
Full code.
.
Patient is very particular about bowel regimen and creams.
Allow patient to direct this care.
.
Contact: Son, ___
***. | SEPTIC ARTHRITIS 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.
***
# Cellulitis: Patient has history of MRSA and multiple
furuncles. On admission, left leg was swollen and tender to
palpation. Large boil noted on anterior aspect below left knee.
In addition, she had lesions in bilateral armpits concerning
for MRSA. There were no signs of intra-articular infection
given full ROM w/o pain. Ruled out for DVT. Found to be
febrile with WBC of 25.8. She was started on
vanc/cipro/clindamycin on admission. Home fentanyl and morphine
was discontinued given that patient was febrile. General
surgery I&D'ed knee and armpit lesion- found to be a
multi-loculated lesion. They were able to drain 50cc of pus
(with some blood) from the knee abscess. Cultures grew back
MRSA. Blood cultures were negative. Cipro and clindamycin were
discontinued as patient remained afebrile after day 1 of
admission. She was continued on vancomycin- remained afebrile
with decreasing WBC. However, given that pain contract was
in-place with outpatient providers, she was unable to be
discharged with IV access. She was switched to doxycycline and
did well. She will complete a 14-day course antibiotics.
Lastly, she seems to be colonized with MRSA so we recommended
mupirocin 2 app TID x 5 days and daily chlorhexadine washes (she
was given scripts for these). In regards to the two I&D's, she
will have home services for BID dressing changes.
# Hyponatremia: Patient found to have sodium of 128 on
admission. Thought to be secondary to low volume. She received
NS at 100cc/hr. Sodium on discharge was 132.
# DM2: Continued home dose of Lantus and HISS with good control
of her sugars
# HTN: Continued home doses of amlodipine, atenolol, and
lisinopril.
# Chronic pancreatitis: We initially held on home fentanyl
patch and IV morphine for now given fevers (concerned for
increased absorption). Pain was controlled with oxycodone for
pain. Once fevers resolved, fentanyl and morphine were resumed.
Received zofran for nausea. Continued on home viokase.
# Emergency Contact: ___ (___)
Relationship: fiance
Phone number: ___
***. | 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.
***
Mr. ___ was admitted for symptoms that started over the last
two weeks (coincidentally or not, corresponding to the time
since he started his fourth potentially-sedating psychiatric
medication, mirtazipine). He was admitted to rule out stroke
with an MRI. He was given aspirin, which will not be continued
as there is no evidence for stroke. Risk factors include smoking
history.
His MRI (DWI/ADC diffusion sequences) did not show any evidence
of stroke. The final Neuroradiology report should be followed
up. His exam remained the same or better on the morning
following admission. He was cleared by ___ as safe to go home
with vestibular therapy for gait imbalance. His fasting lipid
panel was unremarkable (HDL low ___, LDL 51, TC 103). His A1c%
was normal (5.1%). His liver labs were c/w priors (AST/ALT in
the low ___ INR 1.4, normal t.bili 0.7), c/w his chronic
HCV/cirrhosis.
His Remeron (mirtazipine), the medication that started just
prior to the symptoms over the last two weeks, was stopped. The
aspirin ordered on admission for r/o stroke was stopped (the
patient's platelet count is in the ___. The patient was
discharged to home with all other medications continued as
before.
***. | DYSEQUILIBRIUM |
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 h/o restrictive (likely from obesity) and
obstructive pulmonary disease, diastolic CHF, OSA, morbid
obesity who underwent a uncomplicated TAH/BSO for intraoperative
benign disease on ___
.
# PostOp Care: The patient was initially transferred to the ICU
immediately post-operatively for monitoring of her fluid shifts
given her multiple medical co-morbidities. She did well post op
and was transferred to the gyn floor on POD1. The patient's
pain was initially controlled with a Dilaudid PCA until her diet
was advanced to regular. At this time the patient was
transitioned to oral dilaudid. The patient was ambulating
independently. Physical therapy was consulted to assist the
patient with ambulation but she was doing well on her own.
.
# Restrictive Lung disease: The patient was extubated in arrival
to the FICU without complication. She did well post-intubation
on O2 by NC. CPAP and 2L NC ordered for night per her home
regimen. Post-operative chest xray showed atelectasis vs.
aspiration, but no evidence of pneumonia. Home bronchodilators
were continued. Respiratory therapy worked with the patient and
she received nebulizer treatments while in house.
.
#GU: The patient has a history of chronic renal insufficiency.
I/O's were strictly monitored. Fluid boluses were kept a
minimum. Daily Cr was followed. The patient's foley was
discontinued on post-operative day 5. The patient voided
spontaneously. Prior to discontinuation of foley catheter a
urine culture was sent. The results of this are still pending
and will need to followed up on as an outpatient. At time of
discharge the patient's urine output was excellent and creatine
was at baseline.
.
# FEN/GI: Daily electrolytes and CBC were checked for the
patient. Her electrolytes were repleated as needed. Her diet
was gradually advanced to regular with passage of flatus. At
time of discharge, the patient was tolerating a regular diet and
in good condition.
.
# CAD: Patient has a history of PTCA and BMstent placement in
RCA in ___ and cath in ___ showing diffsue disease (no
intervention) and is on statin, plavix, imdur, toprol, asa at
home. The patient's aspirin was restarted on post-operative day
#1. She was continued on her statin, metoprolol throughout her
hospital course. Her blood pressures remained in normal range.
Her valsartan was restarted on POD #5 and her plavix was
restarted on POD#6.
.
# OSA: CPAP and 2L NC at night per home regimen.
.
# IDDM: Patient on glargine BID at home. Monitored on ISS and
bedtime glargine which was titrated up as patient's diet was
advanced. ___ was consulted and gave daily recommendations
for insulin. The patient was discharged home on 60 units of
glargine QHS in addition to a humolog sliding scale per ___
recommendations.
.
# Hyperlipidemia: The patietn is on statin and zetia at home.
Her home medications were restarted on post-operative day #1.
***. | UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY 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.
***
MIXED RESPIRATORY FAILURE:
Mr. ___ was admitted with respiratory failure, worse
ventillatory than hypoxic, thought to be due to an
aspiration/hospital-acquired pneumonia. His hypoxia rapidly
corrected with significant improvement ___ lung volumes
(recruitment) on CXR. His ventillatory failure was gradually
improved with bronchodilators and antibiotics, and he was
extubated without complication on ___. He was initially
started on vancomycin and zosyn on admission on ___
vancomycin was discontinued on ___ when sputum cultures
returned pseudomonas. Speciation return Enterococcus and
Pseudomonas on ___ and the patient was started on Cefepime to
finish on ___.
There was concern that neuromuscular weakness may be
contributing to his poor respiratory status, though it was
unclear whether this was a primary problem or secondary to
deconditioning from being on the ventillatory (he was also on a
vent for two weeks earlier ___ ___ at ___ with
aspiration PNA; he had difficulty weaning at the time). At
___, negative inspiratory forces were recorded at -11, -20 and
-23 on ___ prior to extubation.
Of note, the patient has a history of pancytopenia and was noted
to have a relative leukocytosis of 8.0 on admission. WBC had
decreased to 2.8 upon discharge.
After discussion with the family, the patient underwent a
trach/PEG placement without complications. On the second day
post operatively, the patient developed repeated desaturations
while on the vent to the mid ___, but was asymptomatic. A
bronchoscopy revealed multiple mucus plugs which were extracted.
However, overnight the patient spiked a fever to 101. The
patient's cultures became positive for pseudomonas, which was
sensitive to ceftazidime which was started on ___ to be
continued until ___. (Of note, the patient's previous
pneumonia was pseudomonas treated with cefepime). Please call
___ to follow up microbiology sensitivites on the
sputum cultures.
HYPERTENSION:
Mr. ___ has baseline hypertension on home doses of
amlodipine and lisinopril. Blood pressures were initially ___
the 140's systolic on admission, but climbed after he was
extubated. Prior to speech and swallow evaluation, he was
maintained on IV metoprolol and hydralazine. He was later
changed to his prior medciation amlodipine when he was cleared
to take PO's. His Linisopril was not resumed as his blood
pressure was well controlled on Amlodipine.
LETHARGY:
Mr. ___ initially presented to ___ for
lethargy. His pramipexole for ___ Disease had been held
by the OSH for concern that medication side effects could be
contributing; head CT and EtOH level were negative. It is
likely his ventillatory resp failure upon admission to the OSH
was also contributing to his somnolence. While at ___, he did
not have problems with somnolence once off sedation for the
ventillator. Pramipexole remained held.
WEAKNESS:
Mr. ___ was recently diagnosed ___ months ago with
___ Disease. Neurology evaluation here showed dementia
and right foot drop. He was felt to likely have what have
arteriosclerotic disease which is chronic small vessel changes
___ the brain with white matter abnormalities and lacunes. While
the patient was on the floor, he had acute respiratory distress
and hypercapnia ___ the CT scanner while evaluating for possible
stroke. The patient was intubated and transferred to the ICU,
and doing well when he was weaned from the vent. He tolerated
approximately 6 hours extubated before needing to be reintubated
for work of breathing. Of note, the patient's NIFs were ranging
from -8 to -13 on minimal vent settings. Patient was further
evaluated by the Neuromuscular service where an EMG was
performed, indicating the patient has the diagnosis of ALS. A
spinal MRI was obtained revealing no evidence of cord
compression or cauda equina that could be causing his weakness.
WEIGHT LOSS:
He has had a 30 pound weight loss ___ the last ___ months. It is
unclear whether this has been secondary to behavioral/PD-related
problems or malignancy, a more likely possibility is ALS as
discussed above.
HISTORY OF BPH:
He had as foley on admission and was continued on his home
tamsulosin dose once he was taking PO's, restarted on discharge
PENDING ISSUES FOR FOLLOW-UP:
Follow up Pseudomonas cultures/sensitivities
***. | TRACHEOSTOMY WITH MV >96 HOURS OR PDX EXCEPT FACE MOUTH AND NECK WITHOUT 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.
*** with h/o dementia, CAD, ___, chronic orthostatic
hypotension and frequent falls over past several months,
admitted after two witnessed falls without syncope or injury.
# Frequent falls
# Chronic orthostatic hypotension
# Suspected dysautonomia from ___
Patient has marked orthostatic hypotension without appropriate
HR response, both at home and here, as well as lower extremity
weakness and rigidity which likely explains his falls. His
orthostasis is likely due to autonomic dysfunction from
___ disease (has cogwheel rigidity on exam to support
this) as well as orthostasis secondary to venous insufficiency
and medications. AM cortisol was unremarkable. After
presentation, the patient's Imdur was discontinued to improve
orthostatic blood pressure response. However, the patient
continued to have orthostatic hypotension. As a result, the
patient's midodrine was increased to 7.5mg TID. Patient
continued to have orthostasis on ___ however, given his
resting blood pressure was already in the 160s, no further
medication titration was undertaken. He will need continued
physical therapy and evaluation of his ___ disease for
further management.
# Dementia
B12, TSH unremarkable. Treponemal antibody unremarkable. Likely
related to patient's ___ disease.
CHRONIC ISSUES:
===============
# BPH
Continued finasteride
# ___ disease
Continued home Carbidopa-levodopa ___ mg TID.
# CAD s/p CABG ___ & multiple prior PCIs
No symptoms or EKG findings to suggest active ischemia. No chest
pain off of isosorbide mononitrate.
# Moderate left pleural effusion
Asymptomatic. No clinical evidence of infection or heart
failure, which raises concern for malignancy. Wife reports
patient is followed as outpatient by a thoracic surgeon and
effusion has been stable on serial CT scans, reassuring against
an aggressive malignancy. She reports that thoracentesis was
offered but patient opted against given his advanced age.
However, she was not aware of the possibility malignancy --
could consider diagnostic ___ as inpatient or outpatient if
would affect
prognosis/goals of care.
# Stage 1 sacral pressure injury (present on admission)
TRANSITIONAL ISSUES:
====================
[] Patient's Imdur was discontinued during this hospitalization
due to concern it was contributing to orthostasis. Please
follow-up regarding symptoms of chest discomfort. If yes, weigh
risks and benefits of starting anti-anginals in the setting of
ongoing orthostasis and falls.
[] Can consider repeat TTE as outpatient to evaluate cardiogenic
cause of falls; however, no known history of aortic stenosis
that would be consistent with cardiogenic syncope.
[] Patient has left sided pleural effusion. Remained
asymptomatic during this hospitalization from a respiratory
standpoint. Recommend follow-up as needed.
# CODE: Full presumed
# CONTACT: Proxy name: ___
Relationship: WIFE Phone: ___
Extensive discussion with patient and family including wife and
son-in-law at bedside today, going over various aspects of his
care and plan for rehab, patient and family all agreeable with
rehab transfer today. Multiple questions answered.
Suspect his Orthos numerically may not be corrected WNL but with
med adjustments his symptoms are better, denies
dizziness/lightheadedness today, remain week and would benefit
from extensive rehab.
Total time spent today on discharge by me was more than 30 mins,
in counseling and discharge coordination.
***. | SYNCOPE AND COLLAPSE |
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.
***
___ old with cardiac history CAD S/P to be CABG ___, AVR
with CE Magna tissue valve ___, chronic atrial fibrillation,
progressive mitral insufficiency now severe and calcific mitral
stenosis at least mild presents low BPs, challenges of rate
control of A. fib with evolving consideration for transcutaneous
MVR for management severe mitral insufficiency MV clip limited
by mitral valve structure and significant MAC and at least mild
calcific mitral stenosis. Improved heart rate control with
digoxin. BP's better now off lisinopril, torsemide on hold.
Input from social worker and ___ with concerns safety at home.
Plan:
- stop torsemide, consider adding back x2 week if weight gain or
leg swelling
- stop lisinopril for now
- start digoxin 0.125 mg daily
- have labs rechecked in 1 week (specifically chem and dig
level) Explained to hold AM
- discuss with Dr. ___ EKG in 1 week is needed after
starting digoxin
- stop atorvastatin due to interaction with digoxin
- switch to Rosuvastatin 20 mg every night
- start Metoprolol succinate 25 mg at night (had been tolerating
Metoprolol tartrate 6.25mg Q6H while inpatient)
- continue support hose for edema
- Follow-up with Dr. ___ in 2 weeks (had appointment but its
further out. daughter knows to follow up
- Follow up with Dr. ___ as soon as possible
- Nutrition suggested adding multivitamin w/ minerals and trying
Ensure Enlive TID
- Follow up with Dr. ___ seen by Dr. ___ to further
discuss possible TMVR
- Medications switched to bubble packs organized through ___
pharmacy due to some patient confusion. ___ where
his other medications were removed from his profile to avoid any
duplication. Daughter has information in order to contact ___
pharmacy if any further questions arise. ___ pharmacy assures
us that they will be renewing his bubble packs each month, free
of charge for home delivery.
- suggested obtaining home blood pressure monitor
- social work consult suggested maximizing home services
including Meals on Wheels. They also discussed how he should
think about considering an assisted living facility which is
much different than a nursing home.
# Dispo: home with ___ and ___. Daughter brought him home
***. | CARDIAC ARRHYTHMIA AND CONDUCTION 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.
***
The patient was admitted to the surgical ICU. He was diagnosed
with acute CHF exacerbation with pulmonary edema and acute renal
failure. An echo and a renal ultrasound were done (see
results). The nephrology team was consulted for assistance with
diurese. Over the course of his ICU stay he received IV lasix
boluses, then a lasix gtt with good effect. He progressively had
decreasing oxygen requirements. His renal function stabilized
as well. Transplant hepatology was consulted with no further
recommendations. His blood pressure medications were increased
as he had slightly elevated blood pressures during his stay as
he neared discharge.
He was ambulating, tolerating a regular diet, and was breathing
comfortably on room air with SaO2 of 100% on discharge to home.
***. | HEART FAILURE AND SHOCK 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.
***
Ms. ___ is an ___ year old woman with history of HTN, HLD
who presented to ___ from an outside hospital after a fall
down stairs, found to have R rib fx
___ non-displaced, ST depressions in V3-6 and elevated troponin.
ACTIVE ISSUES
=============
#Mechanical fall
#Non-displaced rib-fracture. Patient presented to OSH on ___own 5 stairs, reportedly after tripping on a
grandson that was playing on the stairs. Per report from
patient's daughter, she was altered after the fall with eyes
open
but not responsive immediately to verbal stimuli. Reportedly
awoke after having her name called multiple times. Was at mental
status baseline by hospital day 1. Patient endorsed LOC after
the fall but denied head
strike, ___- or retrograde amnesia. She denied prodrome prior
to fall. She was initially managed by the trauma surgery service
but transferred to the hospital medicine service on ___ given
non-operative nature of injuries. NCHCT at OSH wnl. Fall appears
mechanical vs multifactorial but pursued
broad syncope workup given patient's advanced age and
co-morbidities. Telemetry showed no evidence of arrhythmia. TTE
___ showedEF > 55%, moderate AR, minimal AS, mild TR and thus
no evidence of structural lesions (severe AS, HoCM) that would
lead to syncope without prodrome. Orthostatics checked on ___
and negative. Continue pain control with TraMADol 25 mg PO
Q6H:PRN pain, Acetaminophen 1000 mg PO/NG Q8H, Lidocaine patch.
___ evaluated patient and noted no ___ needs.
#NSTEMI. Initial EKG concerning for ST depressions in V3-V6,
with
troponin elevated to peak 0.14 and then downtrended to 0.06 as
of
___, likely demand in setting of fall and pain. TTE with no
focal wall motion abnormalities. Patient's
symptoms are not suggestive of angina or MI and her fall was not
preceded by
chest pain. She did have right-sided chest pain post-fall but
was persistent from presentation onward, described as sharp
chest pain and bilateral arm pain, exacerbated by moving too
abruptly or taking deep breaths. Denied associated
diaphoresis, nausea, vomiting, SOB, light-headedness or
palpitations; appears to be MSK in
nature and ___ to rib fracture.
- Continued home ASA 81 daily
- Continued simvastatin daily
- Will likely need further cardiac risk stratification in
outpatient setting (Exercise stress)
# ___
Cr elevated to 1.4 from baseline 0.9, currently down to 1.2.
Unclear etiology. Likely pre-renal vs CIN given recent study.
Encouraged good PO intake, gave 1 L IVF on ___ and creatinine
improved to 0.8. Held home lisinopril initially and HCTZ iso
___.
# New O2 requirement. Resolved.
Was not on O2 at home but here satting in low ___ on 1L NC on
___. No evidence of edema or PNA on CXR, although images show
low lung volumes with some increased interstitial markings on
the right
side likely ___ low volume. Pro BNP normal at 93 on ___. Most
likely ___ splinting from rib fracture. Improved with incentive
spirometry and pain control.
CHRONIC ISSUES:
===============
#HTN
SBPs running high to 150s.
- Continued home metop succ 50 daily fractionated to metop
tartrate 25 BID
- Held home lisinopril and HCTZ iso ___ as above, restarted home
lisinopril on day of discharge
#HLD
- Continued home simvastatin 40 daily
#ASCVD Prevention
- Continued ASA 81 daily
- Continued Simvastatin 40 daily
#Vitamin D deficiency
-Continued vit D 2000U daily
Transitional Issues
- Will likely need further cardiac risk stratification in
outpatient setting (Exercise stress) given STD in anterior leads
and troponin leak.
- Holding home Hctz in setting of recent ___. Please recheck BMP
during PCP appointment, check blood pressure. Restart home Hctz
if clinically indicated.
>30 minutes spent on discharge planning including face to face
time.
***. | MAJOR CHEST TRAUMA 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.
***
___ G1 admitted at 30+3 weeks gestation with preterm
contractions.
.
Ms ___ was contracting every ___ minutes on arrival to
labor and delivery. Her cervix was 2cm dilated. She was afebrile
and without any evidence of infection or abruption. CBC,
coagulation studies, urinalysis, and urine toxicology screens
were negative. Fetal testing was reassuring. She was started on
po Nifedipine for tocolysis and given a course of betamethasone
for fetal lung maturity. The NICU was consulted. Her
contractions spaced out significantly and she was transferred to
the antepartum service. She had minimal contractions for the
remainder of the admission. She was betamethasone complete on
___. She was discharged home on ___. She will continue bedrest,
po Nifedipine, and will have close outpatient followup.
***. | THREATENED ABORTION |
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 neurosurgery service the day
prior to surgery for lab work and early brain lab MRI.
Patient underwent a brain lab MRI the morning of surgery and was
taken to the operating room on ___ for a right frontal
craniotomy for tissue biopsy. Several superficial and deep
specimen samples were taken intraoperatively and sent for
permanent staining in pathology.
Patient was extubated in the operating room and transferred to
the PACU. He underwent a post operative CT scan which showed no
post operative hemorrhage.
ICU course was uncomplicated. He was noted to have some
asymptomatic bradycardia and questionable ST segment depression
on EKG. A cardiology consult was obtained, findings were not
concerning for a cardiac event and no further workup was
recommended.
Patient is being discharged home. He will see us in about 7
days for suture removal and follow up with Oncology for further
treatment.
***. | LYMPHOMA AND NON-ACUTE LEUKEMIA 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.
***
Ms. ___ is an ___ female with ___ Afib with RVR (on
metoprolol, apixaban, and amiodarone), HTN, CKD, dementia, and
hypothyroidism transferred at family request from ___
in ___ for tachycardia and dyspnea with labs and imaging
consistent with acute on chronic HFrEF (EF 47%), likely due to
progression of tachyarrhythmia-induced cardiomyopathy (EF now
19%) due to persistent Afib w/ RVR. On ___, following
TEE/cardioversion, pt converted from afib with RVR to sinus
bradycardia. Converted back to AF on ___. She was loaded with
amiodarone for 6 days prior to repeat cardioversion ___, again
to sinus bradycardia, with subsequent pacemaker implantation
___.
TRANSITIONAL ISSUES
===================
[ ] Please perform frequent dressing checks at site of pacemaker
implantation (left upper chest wall). If recurrent bleeding or
oozing, consider holding apixaban for ___ days.
[ ] LVEF now 19%. Would recommend ongoing medication
optimization.
[ ] At rehab, we would strongly recommend daily standing weights
and notifying the MD on call if weight changes by 3 pounds in
either direction.
[ ] We would also recommend daily pulse rate checks and if
elevated the MD should be notified as this may indicate
recurrent atrial fibrillation.
[ ] Please also monitor for signs of heart failure daily --this
should include daily weights, lung auscultation for rales,
jugular venous distention, and lower extremity edema.
Furthermore, daily pulse oximeter should be checked to ensure
patient is not becoming hypoxic.
[ ] Once renal function and creatinine normalized, consider
resuming diuresis and adjust dose accordingly (presumed home
euvolemic dose of PO Lasix 40-60 mg daily). If planning to
resume diuresis, would also monitor and replete electrolytes
frequently.
[ ] With regard to her amiodarone, she should remain on 200mg
BID for 2 weeks through ___, then the dose should be reduced to
200mg daily going forward.
[ ] Consider restarting lisinopril if renal function improves
and blood pressure tolerates
Long term considerations (for cardiology/PCP follow up):
[ ] Consider restarting metoprolol ___ LV dysfunction and
history of atrial fibrillation
[ ] 4 mm left upper lobe pulmonary nodule. Per ___
criteria, for incidentally detected single solid pulmonary
nodule smaller than 6 mm, no CT follow-up is recommended in a
low-risk patient, and an optional CT in 12 months is recommended
in a high-risk patient.
[ ] Ongoing evaluation for MitraClip ___ moderate MR on our
TTE. To be followed up as an outpatient with Dr. ___.
ACUTE ISSUES
=============
#Atrial Fibrillation with RVR
#Sick sinus syndrome
Patient with recent history of atrial fibrillation requiring
cardioversion at ___ in ___ and subsequently
converted back into atrial fibrillation in the following weeks.
Presented with atrial fibrillation with rates 120s-130s. Despite
diuresis, A fib with RVR persisted. ___ the relatively rapid
progression of her tachyarrhythmia-induced cardiomyopathy, as
demonstrated on TTE on ___, successful TEE/cardioversion was
performed on ___. Afterward, patient continued to have
asymptomatic sinus bradycardia in the ___. Metoprolol was held.
Her amiodarone and apixaban were continued. Unfortunately, on
___ she went back into atrial fibrillation with rates in the
110s. A repeat cardioversion was performed on ___ which was
again complicated by asymptomatic sinus bradycardia with HR
___. We withheld metoprolol and amiodarone; a pacemaker was
implanted ___. We restarted her apixaban 2.5 BID and amiodarone
200 mg BID which will be continued through ___ before
decreasing to to a dose of 200 mg daily indefinitely.
# Acute on chronic HFrEF (47% EF previously, EF now 19%)
Patient presented with tachypnea and tachycardia, BNP 24,000 and
bilateral pleural effusions consistent with CHF exacerbation.
She underwent TTE On ___ that showed marked progression of
cardiomyopathy with LVEF 19%, severe global LV, systolic
dysfunction, moderate RV, global systolic dysfunction (before
47%), and 2+ MR. ___ her atrial fibrillation with rapid
ventricular rate, we suspect that her worsening EF is likely
secondary to tachycardia induced cardiomyopathy. Patient was
diuresed with IV Lasix and transitioned to PO, remaining
euvolemic remainder of admission. She could not tolerate
neurohormonal blockade with metoprolol ___ her bradycardia
(see below). At rehab, we would strongly recommend daily
standing weights and notifying the MD on call if weight changes
by 3 pounds in either direction. We would also recommend daily
pulse rate checks and if elevated the MD should be notified as
this may indicate recurrent atrial fibrillation. Please also
monitor for signs of heart failure daily -- this should include
lung auscultation for rales, jugular venous distention, and
lower extremity edema. Furthermore, daily pulse oximeter should
be checked to ensure patient is not becoming hypoxic. She was
euvolemic at time of discharge; lisinopril and diuretics
continued to be withheld due to elevated creatinine
(downtrending).
# Moderate mitral regurgitation
At ___, family discussed the option of Mitral Clip with
the cardiologists. Patient was evaluated by our structural heart
team who recommended she follow up as an outpatient for further
consideration. If they are still interested in this
intervention, please call the structural heart clinic at
___ to schedule a follow up appointment with Dr. ___.
#Hypoactive delirium
History of hypoactive delirium in the setting of decreased
neurocognitive reserve with advanced dementia. Per family's
report, outpatient sleep physician has attributed this delirium
to sleep apnea. Patient was intermittently unresponsive
throughout her admission without symptoms of pneumonia or UTI;
this was presumed to be due to baseline dementia and hypoactive
delirium.
CHRONIC/STABLE ISSUES:
======================
#Hypothyroidism
- Continued home levothyroxine
#Rhematoid Arthritis
- Continued home methylprednisolone
- Continued home Hydroxychloroquine
- Held home leflunomide as nonforumlary. Can be restarted as
outpatient.
- Held home celecoxib as nonformulary. Can be restarted as
outpatient.
#GERD
- Continued home famotidine
***. | PERMANENT CARDIAC PACEMAKER IMPLANT 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 woman pmh endometriosis presented to the ED ___ with
neck pain, ear pain, ear drainage, h/a and fevers.
#ACUTE OTITIS MEDIA
Upon admission, T was 99.3, pt was HDS. Labs revealed WBC of
16.1. CT head was performed which revealed "CT orbits, sella
with partially opacified middle ears and mastoid air cells
bilaterally, left greater than right. No erosive changes. No
overlying soft tissue abnormality." An LP was performed because
of headache and had 1 WBC. Exam was significant for b/l erythema
of the canals, as well as bulging of the ___ with significant
erythema. Pt initially treated with IV ceftriaxone, then
transitioned to IV unasyn and then to PO augmentin. ENT was
consulted and evaluated and agreed with diagnosis of acute
bilateral otitis media. Pt was initially treated with ofloxacin
drips but upon discharge was written a script for ciprodex
drops. Pt also discharged with augmentin to complete ten day
course.
**TRANSITIONAL ISSUES**
New medications:
-->Augmentin 875 mg PO BID to complete 10 day course (end date
___
-->Ciprodex 5 gtt to both ears BID for 10 days (end date ___
--> Fluconazole 150 mg, 1 tab x 72 hours (3 tabs), in case
patient develops yeast infection
-ENT recommends follow up in ___ weeks after discharge. Please
arrange ENT f/u.
***. | OTITIS MEDIA AND URI 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.
***
Presented for cardiac catheterization and was admitted for
preoperative workup. On ___ he was taken to the operating
room for aortic valve replacement. Please see operative report
for further details. Postoperatively he was taken to the
intensive care unit for monitoring. Over the next several hours,
he awoke neurologically intact and was extubated. On
postoperative day one, he was started on betablocker,
anticoagulation, and diuretic. He was continuing to progress
and was transitioned to the floor. Chest tubes and epicardial
wires were removed per protocol. He worked with physical
therapy on strength and mobility. On post operative day three
he was started on heparin drip to bridge until his INR was
therapeutic on Coumadin. He remained on a Heparin gtt until
therapeutic today x 2 INR's. He is ambulating freely, taking po
food and fluid without issue. His Coumadin will be managed by
Dr. ___ I have spoken to them personally. He will
receive 2mg today. He will be discharged to his Mothers house
today.
***. | CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION 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/ PAD s/p L distal SFA & proximal popliteal artery
angioplasty ___ and more recently s/p R SFA stent on ___.
He presented to clinic on ___ with w/ LLE rest pain. He was
first admitted for iv heparin and angio then d/c home in 3 days
___. He was re-admitted on ___ and underwent L femoral
endarterectomy w/ SFA angioplasty.
Post op course was uneventful. All his ___ hospital med was
resumed.
He is ambulating with no difficulty.
He is discharge home in stable condition. He will follow up in
___ clinic in 1 month. He will continue his statin and
aspirin.
He will take Plavix 75mg daily for 30 days.
***. | OTHER VASCULAR 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.
***
# Shortness of breath/cough: Admitted with shortness of breath,
no evidence of pneumonia on CXR. Symptoms were consistent with
bronchitis imposed on pre-existing BOOP and possible
contribution by post-nasal drip. Started on 125 mg solumedrol
in ED then transitioned to Prednisone 10 mg QD on the floor
(started ___. Also started on levofloxacin (renal-dosing) for
5 day course. Received albuterol and ipratropium nebs PRN and
continued flonase nasal spray. Symptoms have improved over
hospital course with resolved shortness of breath, no hypoxia,
and stable VS. Will continue Prednisone 10 mg through ___ then
taper to regular home dose of 2.5 mg QD. Will continue
levofloxacin 750 mg Q48H with last dose on ___.
.
# Urinary tract infection: Urinalysis on admission consistent
with UTI. Last UTI ___ demonstrated pan-sensitive E.coli so
levofloxacin coverage was deemed adequate. Urine culture w/ no
growth and no symptoms during hospital stay.
.
# Abdominal tenderness: Initially complained of RUQ pain however
abdominal labs (LFTs, amylase, lipase) normal and symptoms
resolved by ___. ___ have be related to UTI or Foley. KUB
unremarkable.
.
# Alzeimer's dementia: Pt was closely followed by
geropsychiatry. Continued home regimen of Remeron and Aricept.
.
# Anxiety: Pt occasionally had worsening shortness of breath
with tachypnea to the ___ without hypoxia. CXR at the time was
unremarkable. Nebulizer treatments helped resolve these episodes
as well as distraction in the form of conversation about a
different topic.
.
# Osteoporosis: Continued alendronate, calcium and vitamin D.
.
# Depression: Continued home regimen including Remeron and
attended to sleep hygiene.
.
# Heat intolerance: Initial complained of heat intolerance, TSH
was normal, and symptoms resolved.
.
# Prophylaxis: Was given heparin sc for DVT PPx and bowel
regimen
.
# FEN: Kept on regular kosher diet
***. | BRONCHITIS AND ASTHMA 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.
***
Mr. ___ is a ___ man with history of uncontrolled
HTN who initially presented with right face and arm weakness and
was subsequently found to have a left frontoparietal
intraparenchymal hemorrhage.
#Left frontoparietal IPH:
The hemorrhage was thought to be secondary to hypertension as
patient's systolic blood pressures were initially greater than
200. He also has longstanding history of hypertension but has
not been on medication because he has not regularly seen a
doctor.
Patient underwent MRI to evaluate for other causes of hemorrhage
but there was no evidence of underlying mass or vascular
malformation. A repeat MRI is recommended in 3 months.
Patient was evaluated by speech therapy, occupational therapy,
and physical therapy who recommended rehab.
#Hypertension:
Patient initially required nicardipine infusion to maintain SBP
less than 150. He was then transitioned to oral
antihypertensives. Blood pressures were well controlled on
lisinopril and labetalol at time of discharge.
Echo was done because of longstanding hypertension. Echo showed
normal EF. IT also showed a mildly dilated ascending aorta. A
follow-up echocardiogram is suggested in ___ year.
#Oropharyngeal dysphagia: patient initially failed swallow eval
so NG tube was placed. On subsequent evaluations, his swallowing
improved and he was advanced to modified diet. He was tolerating
modified diet so NG tube was removed.
# Alcohol use disorder: Patient endorsed drinking several beers
per night so he was initially placed on CIWA protocol. He never
exhibited signs of withdrawal.
=========================================================
Transitional Issues:
[ ] monitor blood pressure. titrate medications as needed
[ ] repeat MRI in 3 months
[ ] PCP follow up
[ ] Neurology Follow Up
[ ] repeat echo in ___ year
=========================================================
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
***. | 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.
*** w/ hx of seropositive RA, obesity, NASH, CHF, DM, chronic
anemia, and a hx of GIB (admission in ___ for melena, EGD w/o
source but w/ diffuse gastric metaplasia), who presented with
dizziness/weakness and labs concerning for acute on chronic
anemia.
# Acute on chronic anemia: c/f slow GIB though has not had
bleeding source found on prior EGD/colonoscopy. Hg remained
stable/uptrending here. She had no evidence of active bleeding
and was continued on home PPI. Labs were consistent with severe
iron deficiency and she received several doses of IV iron. She
underwent and EGD/colonoscopuy which showed...
# DM: on insulin at home, 40 lantus BID. Lantus was dose reduced
while inpatient while she was taking in only clears. She was
also placed on ISS
CHRONIC/STABLE PROBLEMS:
# Seropositive RA: held ibuprofen, continued home plaquanil. She
also receives tocalizumab as an outpatient
# CHF: euvolemic appearing. She reported HF history but not on
diuretic
# Low back pain and lumbar radiculopathy: follows in pain
clinic, has had
epidural steroid injections with good effect
Transitional Issues:
====================
[] F/u on final CT A/P read
[] GI to schedule capsule study following d/c
[] F/u w/ PCP for further work up for anemia
***. | RED BLOOD CELL DISORDERS 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. ___ was admitted on ___ for SOB and neck hematoma.
He had a Neck CT
which showed diffuse subcutaneous air in the neck and chest and
a pneumomediastinum with small bilateral apical pneumothoraces.
Thoracic surgery was consulted. A bronchoscopy was done which
showed swelling in the posterior aspect of the epiglottis. ENT
was consulted for endoscopic exam which showed a hematoma
involving the left false cords extending inferiorly involving
the epiglottis. They recommended NPO x 72 hours. He was
admitted to the SICU for airway monitoring. An Endoscopic exam
was done daily. He was on IV fluids. He was seen by voice
service. On ___ an esophagus study revealed no leak. He
was seen by Speech and Swallow who cleared him a regular diet
which he tolerated. He was discharged to home and will follow
up as an outpatient with ENT.
***. | OTHER MULTIPLE SIGNIFICANT TRAUMA 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.
***
Primary reason for hospitalization:
___ with MM s/p L femur prophylactic gamma nail for lytic
lesion admitted with pathologic fracture.
Active issues:
# L femur pathologic fracture: No operative management indicated
at this time per ortho tumor service since nail already in
place. His pain was initially controlled with IV morphine, and
he was transitioned to PO morphine due to problems with urinary
retention (see below). He started radiation therapy to the hip
(will receive total of 10 treatments). He has f/u appointments
scheduled with oncology and orthopedic surgery.
# Multiple myeloma: Pt was started on C#4 velcade during
admission, which he tolerated well. (Per pt, has received 3
cycles velcade in ___, none in ___.) He was discharged
home with plans to continue velcade cycle with dexamethasone as
outpatient. He was continued on PO bactrim for ppx.
# Urinary retention: Pt developed urinary retention on HD#2.
MRI Lumbar spine showed no e/o spinal disease. His retention
was thought most likely ___ IV morphine, and after transition to
PO morphine his retention resolved.
Chronic issues:
# H/o DVT: Pt has h/o DVT in setting of Revlimid tx. He was
continued on his home coumadin and his INR was maintained in
therapeutic range.
Transitional issues:
- He is scheduled for outpatient f/u for continued velcade and
radiation therapy.
- He should continue to have his INR monitored while on
coumadin.
- He has f/u appointment scheduled with orthopedic surgery.
- He maintained full code status throughout hospitalization.
***. | LYMPHOMA AND NON-ACUTE LEUKEMIA 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.
***
___ presented to the ___ on ___ after a fall. She
was evaluated by the orthopaedic surgery service and found to
have a left tibial plateau fracture. She was admitted,
consented, and prepped for surgery. On ___ she was taken to
the operating room and underwent an ORIF of her fracture. She
tolerated the procedure well, was extubated, transferred to the
recovery room, and then to the floor. On the floor she was seen
by physical therapy to improve his strength and mobility. But
she still needs rehab because she is unable to ambulate
independently.
The rest of her hospital stay was uneventful with her lab data
and vital signs within normal limits and her pain controlled.
She is being discharged today in stable condition.
***. | KNEE PROCEDURES WITHOUT PDX OF INFECTION 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.
***
Compression Fracture: Pt presented with L1 burst fracture and
acute L5 fracture. Patient with well controlled pain that
increases only with movement. She remained neurologically intact
below the waist. Ortho spine was consulted and planned for TLSO
brace. If pain worsens then plan for kyphoplasty. ___ felt she
would benefit from rehabilitation placement. She must wear the
brace for 3 months.
.
Osteopenia: continue calcium with vitamin D, consider
bisphosphonate as an outpatient.
.
***. | 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.
*** with history of cerebral palsy c/b quadriplegia and chronic
respiratory failure (s/p trach/PEG) here with sepsis presumed
secondary to ventilator-associated pneumonia.
# VAP: CXR w/ LLL opacity concerning for pneumonia. ___ setting
of chronic ventilator requirement, fever and increased
secretions a diagnosis of VAP is most likely. Patient has
history of resistant organisms ___ the past, including
Pseudomonas (resistant to cipro and meropenam) and Serratia
(resistant to ceftriaxone), although to date all organisms have
been cefepime sensitive. She was initially treated with
vancomycin, cefepime, and tobramycin with double-coverage of
Pseudomonas. Sputum culture eventually grew MSSA, and she was
transitioned to cefazolin IV on ___. On the day prior to
discharge she was transitioned to PO kephlex, with plan to
continue until ___. She had significant decrease ___
suctioning requirments due to decreased airway secretions. She
remained hemodynamically stable. Blood and urine cultures were
negative.
# Sepsis: Fever to 100.4 on admission, with slight leukocytosis
to 10.4k and hypotension to SBPs ___ ___ after multiple liters of
IVF. Most likely secondary to VAP. Of note, urine culture from
OSH ___ ___ reportedly grew Klebsiella (R ampicillin, S unasyn
/ CTX / cefazolin / gentamicin / Imipenem / levofloxacin /
Bactrim) and E Coli (R ampicillin, ceftriaxone and cefazolin,
levaquin, gentamicin, ertapenem). Blood and urine cultures here
were negative. She underwent doppler ultrasound of the bilateral
upper and lower extremities given persistent tachycardia during
her early hospital course, but these were negative for DVT.
Sputum cultures grew MSSA, for which she was treated with
cefazolin and transitioned to Keflex. Her leukocytosis resolved,
and lactate was within normal limits. She did not require
pressors. Of note, her overnight blood pressure tended to be
low, with systolic blood pressure ___ the ___ while sleeping.
At other points she was observed to be mentating well and
maintaining adequate urine output with similarly low systolic
blood pressures. Her blood pressure continued to be
intermittently low despite other signs of clinical recovery from
her VAP, and so it was determined that her episodic hypotension
was a physiologic response to rest/sleep and was not
aggressively treated. Midodrine was changed to Q8H (rather than
TID) with improvement ___ overnight pressures.
# Chronic Respiratory Failure: Patient is chronically
mechanically ventilated via tracheostomy. She receiveds enteral
nutrition via PEG tube. ___ TTS size 7.0 prior to
replacement ___ ED. She was ventilated on APV/CMV mode with 40%
FIO2.
# Bacterial vaginosis:
She completed a 5 day course of Metrogel intravaginally.
# Cerebral Palsy:
Continued baclofen TID and home dose phenobarbital.
# Med-Rec
Continued citalopram
#Hypothyroidism:
Continued home dose levothyroxine
TRANSITIONAL ISSUES:
======================
-MSSA ventilator associated pneumonia: patient will continue to
receive Keflex to complete a course for VAP until ___.
-Tracheostomy tube: ___ 7.0
-Midodrine changed from TID dosing to Q8H dosing
- Communication: legal guardian ___, ___,
___
-Full code
***. | SEPTICEMIA OR SEVERE SEPSIS WITH MV >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.
***
========
Summary:
========
___ male with ESRD due to FSGS on HD ___, DM type 2
(since age ___, HTN, OSA not on CPAP, presented with dyspnea.
============
ACUTE ISSUES:
============
# Dyspnea:
Patient presented with 1.5 months of dyspnea with associated
weight gain and orthopnea. Dyspnea was felt to be multifactorial
in origin including volume overload, OSA (not on CPAP as
outpatient), obesity hypoventilation, and anemia. BNP was
elevated on admission and patient with evidence of volume
overload on admission CXR. CTA was negative for PE. While there
was concern for cardiac dysfunction contributing to the
patient's dyspnea as well given cardiomegaly on CXR,
uncontrolled HTN and untreated CPAP. TTE performed that showed
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%) and
evidence of increased left ventricular filling pressure
(PCWP>18mmHg). EKG without evidence of acute ischemic changes,
patient without chest pain, and troponins stable. Weight at
admission was ~201kg and weight at discharge was 176.7 kg after
undergoing multiple sessions of HD. Per renal, dry weight
estimated to be about 175kg.
# Hypertension:
Patient reported poor compliance with medications, taking them
about three times per week. Hypertensive to 196/112 in ED which
improved with administration of home antihypertensive regimen
and removal of fluid via HD. TTE with mild symmetric LVH.
Amlodipine was discontinued from antihypertensive regimen give
improved blood pressure control after fluid removal with HD.
# End stage renal disease:
Stage 5 CKD secondary to FSGS. Patient first diagnosed with CKD
s/p biopsy ___ that showed advanced segmental and global
glomerulosclerosis though to be either primary or secondary to
obesity. No evidence of immune complex GN and no diabetic
changes noted. AV fistula placed ___, superficialization
___ and started on HD on ___. Currently on ___
schedule. Dry weight 201 kg per patient. Per renal, challenging
dry weight, with weight post ___ HD 176.7kg.
# Type 2 Diabetes Mellitus:
Present since age ___. Initially managed with oral hypoglycemic
but on insulin for past ___ years. On glargine 10 units nightly
with no mealtime insulin. Seen by ___ ___ who would like to
see patient in outpatient follow up.
===============
CHRONIC ISSUES:
===============
# Anemia:
Hgb on admission 8.1. Iron studies from ___ consistent with
AOCD. Continued on EPO ___ Units qHD
and Ferrous Sulfate 325 mg PO/NG BID.
# Sleep Apnea:
Patient non-compliant with CPAP as outpatient, stating that he
uses father's CPAP machine on occasion. Previously required 2L
at night with CPAP in ___ admission. CPAP was continued
during his hospital stay qhs.
====================
Transitional Issues:
====================
- Please ensure follow-up with sleep medicine doctor and sleep
study as patient has untreated sleep apnea.
- Please acquire euvolemic TTE as outpatient to assess for
pulmonary hypertension. If evidence of pulmonary hypertension is
present, patient will need follow up with pulmonary hypertension
physisican such as Dr. ___.
- Please emphasize importance of medication compliance for blood
pressure control.
- Home amlodipine was discontinued due to improved blood
pressure control status post fluid removal using HD. Please
further titrate blood pressure medications as clinically
warranted.
- Patient to continue previous dialysis on ___,
and ___.
- Weight at discharge 176.7 kg. Estimated dry weight per renal
175 kg.
- Please ensure follow-up with ___ diabetes team.
- CTA with 3 mm left lower lobe pulmonary nodule. As per
___ guidelines no follow-up needed in low-risk patients.
For high risk patients, recommend follow-up at 12 months and if
no change, no further imaging needed.
# CODE: Full code, confirmed
# CONTACT: ___ ___
***. | HEART FAILURE AND SHOCK 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.
***
___ hx EtOH cirrhosis c/b ascites, pleural effusion, edema and
grade 1 varices, as well as ganglioneuroma and anemia, presented
with recurrent dyspnea and right pleural effusion, with mild
improvement s/p therapeutic ___ on ___. TIPS performed
on ___, after which he failed extubation and was transferred to
the MICU for further management.
# Dyspnea/Hepatic ___ pneumonia: Pt
presented with worsening dyspnea and supplemental O2
requirement, found to have complete whiteout of right lung on
CXR due to recurrent hepatic hydrothorax. He had been unable to
tolerate higher dose of diuretics in the outpatient setting due
to postural hypotension so dose had been decreased. He was
otherwise decompensated by ascites and lower extremity edema on
admission. Therapeutic para (1.5L) and ___ (1.4L) were
performed by ___ on ___, which was complicated by hypotensive
episode to the systolic 70's. Peritoneal fluid analysis was
negative for SBP and pleural fluid found to be transudative. BP
stabilized back to baseline with albumin. Diuretics were held.
He had transient mild improvement in his dyspnea after ___
however fluid rapidly reaccumulated. Hepatology team felt he
would benefit from TIPS given diuretic refractory hydrothorax.
MELD score of 7 made him a good candidate as well as normal echo
without RV dysfunction in ___. Risks and benefits of TIPS
were discussed in family meeting on ___ with decision to
proceed. TIPS was performed on ___, after which he was unable
to be extubated so was transferred to the MICU.
In the MICU, he was started on ___ antibiotics for a
potential aspiration pnuemonia/HCAP, and demonstrated
progressively improving respiratory mechanics, and
___ on ___. He did not have a supplemental O2
requirement, but was maintained on the same for pneumothorax
(see next). Diuretics were restarted for volume management as
detailed below.
# Pneumothorax: First seen on AM CXR of ___, 1.6cm and
occupying the R apex. Serial radiographs performed subsequently
demonstrated resolution of pneumothorax with no intervention
other than supplemental O2. This was likely a procedural
complication of TIPS.
# Right Ventricular Dysfunction: Because of difficulty with
weaning pressors while in the ICU while on appropriate
antibiotic therapy, a cardiac ECHO was obtained that showed new
right ventricular hypokinesis. This was thought to be due to his
TIPS procedure, which may have resulted in acute RV overload or
new portopulmonary hypertension. His pressor requirement was
weaned without further issue. He was diuresed until clinically
euvolemic. Discharge weight was 171.6 lbs.
# Mitral Annulus Mobile Echogenic Mass: Incidentally found on
his surface cardiac ECHO of ___ that also identified the RV
dysfunction described above. Blood cultures were negative. TEE
was considered, but deferred as there was no suspicion for
endocarditis. Plan to follow up with cardiology in 4 weeks after
discharge and likely repeat TTE at that time to look for
resolution of mass.
# Anemia: Hgb on admission was 9.8 from recent baseline of
___. Chronic anemia is most likely from cirrhosis given
MCV in the mid ___. He has known grade I varices on EGD. There
was no evidence of active bleeding on exam. The slight downtrend
from baseline was thought to be due to hemodilution and remained
stable throughout hospitalization.
# Thrombocytopenia: Platelets downtrended in the MICU, thought
to be likely due to some combination of synthetic dysfunction
from acute liver injury after hypotension, and critical illness.
___ antibodies were sent for the low possibility
of HIT, and returned negative. Heparin products were
nonetheless held, and platelet counts remained stable throughout
hospitalization
# EtOH cirrhosis: Decompensated by ascites, recurrent hepatic
hydrothorax, edema and grade 1 varices (most recent EGD in OMR
from ___. ___ Class B and MELD score of 7. Presented
on this admission with recurrent diuretic refractory hepatic
hydrothorax as above. Noted to have very poor nutritional
status. Nadolol was discontinued after TIPS. Volume status was
maintained via diuretics, and was discharged on furosemide 80mg
daily and spironolactone 100mg daily with no episodes of
postural hypotension.
# Hyponatremia: Na 131 on admission, from baseline ___. Most
likely due to cirrhosis as above. Remained stable this stay. Na
135 at discharge.
==========================
TRANSITIONAL ISSUES:
==========================
- needs weekly labs drawn for LFTs, INR, Albumin and results
faxed to Dr. ___ at ___ (next drawn on ___
- should have CHEM10 drawn 2x weekly ___ and ___ and
have electrolytes repleted as needed by the rehab physician
- nadolol stopped during hospitalization and was not restarted
at time of discharge.
- follow up with Dr. ___ in clinic in ___ weeks, will need
repeat RUQ US with doppler
- Cardiology appointment in 4 weeks to monitor RV dysfunction
and possible repeat TTE for mitral annular mass
- Weight at discharge: 171.6 lbs
- Diuretic regimen: furosemide 80mg daily, spironolactone 100mg
daily
- Discharged to rehab for safety concern during amulation
- Underwent TIPS procedure
- Has persistent right lung pleural effusion
- FULL CODE
-CONTACT: Patient, ___ (___). Relationship: Daughter
Phone: ___
***. | PANCREAS LIVER AND SHUNT 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.
***
Mr ___ was admitted to the Medicine service with fever and
one episode of diarrhea s/p chemotherapy. Initially there was
concern in the ED for sepsis or acute infection as his blood
pressure was a little low and he had a fever. He was treated
with broad spectrum antibiotics empirically but these were
stopped when he reached the floor. Dr. ___ Oncologist
reported that he had a similar presentation/symptoms during his
last cycle of chemotherapy and that this is a common scenario.
Thus, he was monitored carefully for further s/sx of hypotension
or fever. His cultures, U/A, CXR were unremarkable. He was
ambulating without difficulty and was seen by Physical Therapy
during his admission who felt he was safe for discharge to home.
Dr. ___ that his morning glucoses had been slightly
low, thus his Levemir dose will be decreased to 10 units qhs
from 12 units. There are no other medication changes to his
regimen.
He has been instructed to follow up in ___ clinic.
***. | FEVER |
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 with h/o non-ischemic
cardiomyopathy and ventricular tachycardia s/p ICD placement in
___ who was transferred for optimization of heart failure
management.
.
# Congestive Heart Failure: Patient has a h/o non-ischemic
cardiomyopathy with EF ~30%. The patient had been having
worsening dyspnea on exertion and lower extremity edema over the
past few weeks at her rehab facility. The patient was admitted
to OSH, where she was aggressively diuresed. She then presented
to ___ for cardiac cath to ascertain the source of her new,
worsening, heart failure. Her cath was clean, so it is thought
that her CHF exacerbation may be secondary to pacemaker
malfunction and erratic heart rhythm. Electrophysiology was
consulted, and the patient's pacemaker was adjusted. The
patient was also found to have significant mitral regurgitation
on TTE. She will thus be evaluated for valvular surgery as an
outpatient.
.
# Renal failure: The patient was admitted to OSH with a Cr of
1.6. Her current baseline is uncertain, but it was thought that
this may have represented acute renal failure in the setting of
poor forward flow. The patient's Cr decreased with further
diuresis and she was continued on her home dose of Lisinopril.
.
# HTN: The patient has a history of hypertension. She was
continued on her home dose of Lisinopril and Metoprolol, and she
did not have any acute events during this admission.
.
# Type 2 Diabetes Mellitus: The patient has a history of DM2.
Her glipizide was held on admission, and the patient was placed
on SSI. She remained stable during this admission, and she was
discharged on her home dose of Glipizide.
.
# Dyslipidemia: The patient has a history of hyperlipidemia.
She was continued on her home dose of Atorvastatin during this
admission, and she did not have any acute events.
.
# Depression: The patient has a history of depression. She was
continued on her home dose of Fluoxetine and Mirtazapine during
this admission.
.
# Restless leg: The patient has a history of restless leg
syndrome. She was continued on her home dose of Ropinirole
during this admission.
***. | CIRCULATORY DISORDERS EXCEPT AMI WITH CARDIAC CATETERIZATION 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.
***
Mrs. ___ is a ___ year old woman with a history of DM2,
GERD, HTN, osteoarthritis c/b DJD, fibromyalgia, and depression
with a longstanding history of GI complaints, who was admitted
for further workup and management of abdominal pain with PO
intolerance complicated by active chronic headaches.
Active Diagnoses:
# Abdominal pain, N/V/diarrhea: Patient with mild ileitis on CT,
however may not entirely explain her symptoms. Differential is
broad but may include some component of gastritis, PUD,
infectious, IBD, ischemia, spondyloarthropathies, vasculitides,
neoplasms, medication-induced (NSAIDs), eosinophilic enteritis
and others. She has had similar episodes x10 over the past ___
years, and has had GI workup including EGD (H pylori negative).
Rectal exam with hemoccult testing was perfomed on this
admission was guiac negative. Physical exam was significant for
left upper quadrant and epigastric tenderness to palpation
without rebound tenderness or guarding. Her abodmen remained
soft and non-distended with active bowel sounds. Cardiac rule
out was negative for evidence of CV pathology. On presentation
to the floor, she was febrile to 102.9 with a WBC count elevated
to 12.0 and she was started on IV ciprofloxacin and
metronidazole. Abdominal film was unremarkable, with no evidence
of obstruction. Her diarrhea resolved on ___, however nausea
and vomiting persisted and responded well to IV zofran. Her PPI
was increased to BID and maalox was added with good relief and
her abdominal pain improved with 5mg oxycodone. She was made NPO
and her diet was slowly advanced until she tolerated a regular
diet. She remained afebrile with a normal WBC count for the
remainder of her admission, and at time of discharge her
abdominal pain had resolved. She was discharged with plans for
follow-up with her PCP and an appointment in ___ Clinic. She was
discharged with scripts for 3 days of PO cipro and flagyl to
complete a ___nd a new script to increase her PPI to
BID.
# Headache: Patient has known chronic daily headache which has
been active but stable during this admission. She manages it
with Tylenol at home, and tries to refrain from NSAID use due to
her GI issues. She felt that her headache was no worse than
usual, however it was not completely relieved with
acetaminophen. We discussed with her the option of starting
amitriptyline at night which may also benefit her insomnia,
however will leave this at the discretion of her PCP to be
possibly started as an outpatient.
Chronic Diagnoses:
# HTN: Patient was continued on her home doses of atenolol and
losartan. Amlodipine was initially held but then restarted. Her
BP remained stable and at baseline during this admission.
# DM2: Home metform was held and patient was started on sliding
scale insulin with qid BG checks while in-house. Her home
gabapentin was continued for neuropathy.
# Transitional issues
- outpatient GI f/u for consideration of EGD/colonoscopy and
further work-up of chronic GI issues
- f/u pending blood cultures
- consider starting TCA for headache ppx as an outpatient
***. | ESOPHAGITIS GASTROENTERISTIS AND MISCELLANEOUS DIGESTIVE DISORDERS 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 ___ year old male with OSA, morbid obesity,
chronic lower back pain recently discharged with chronic lower
back pain flare who was admitted on ___ with BRBPR, tachycardia
and stable HCT. He was seen by GI with plan for colonoscopy
under MAC anesthesia on ___ given obesity. Per prior
documentation, he also reported fevers, CP, SOB at home. CXR
clear, stool cultures unrevealing. CEs negative. Requests IV
narcotics for abdominal pain but wants to eat solid food.
Abdominal exam benign. UTox positive for cocaine; pt denies use.
Patient had colonoscopy on ___ that showed "A single sessile 5
mm non-bleeding polyp of benign appearance was found in the
distal descending colon. A piece-meal polypectomy was performed
using a cold forceps in the descending colon. The polyp was
completely removed. A single sessile 4 mm non-bleeding polyp of
benign appearance was found in the rectum. A piece-meal
polypectomy was performed using a cold forceps in the rectum.
The polyp was completely removed. Other We did not identify the
source for his GI bleeding."
.
On the day of anticipated discharge, he was ambulating around
the unit freely without complaints. He requested to be
discharged. He was instructed to resume his preadmission
medications and follow-up with his PCP ___ in the next
week. He was asked to call her office to schedule an appt.
.
Dr. ___ Dr. ___ telephone on the day of
anticipated discharge re: the clinical course. Dr. ___
she is aware of the need for follow up on the pulmonary nodules
incidentally seen, the polyp pathology, the elevated TSH and GI
evaluation for his anemia.
.
***. | 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.
***
The patient was admitted for hyperkalemia to 6.1 and acute on
chronic renal failure. No concerning EKG findings were noted.
She received two doses of kayexalate and had a good response to
this medication, with her potassium decreasing to 5.0 on day of
discharge. We suspect that the hyperkalemia was due to renal
failure and digoxin administration in the setting of that renal
failure.
Additionally, she was found to have acute on chronic renal
failure with a creatinine of 3.9 (1.6 on discharge, reported
baseline ~2.1). Urine lytes indicated FeUrea 29%, suggestive of
a pre-renal etiology. The patient also reported significant
thirst, consistent with volume depletion as the etiology for her
renal failure. She was gently rehydrated with IV fluids. Lasix
was held and PO intake was encouraged. This likely occurred in
the setting of poor PO intake, as well as possibly still too
high doses of diuretics on her last discharge. Urinalysis was
unremarkable. Her creatinine improved with fluids and was at
2.4 on discharge. On discharge, her lasix, lisinopril, and
digoxin should continue to be held. Her creatinine should be
rechecked in two days. If it has returned to baseline, her
lasix should be restarted at a lower dose than on prior d/c,
such as 40 mg po qday. Her lisinopril (2.5 mg po qday) and
digoxin (125 mcg po qday) can be restarted at the same doses.
Daily weights should be taken, and lasix restarted (or
uptitrated) if it increases >2 lbs. in ___ days. Adequate fluid
intake and nutrition should be encouraged.
The patient's INR was found to be elevated on discharge. Her
warfarin was held throughout admission but her INR remained
elevated, 4.5 on discharge, with no signs of bleeding. Her
labile INR could be in the setting of poor nutritional status.
Her warfarin should be continued to be held on discharge. INR
should be rechecked every two days until range is between 2.0
and 3.0, at which time warfarin can be restarted.
***. | 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.
***
Ms. ___ was admitted to the ___ Spine Surgery Service
on ___ and taken to the Operating Room for the above
procedure performed by Dr. ___. Please 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. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO 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.
***. | BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION 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 past medical history of chronic atypical
chest pain (myofacial per pain clinic) s/p electrocution,
refractory GERD and hypertension
.
# Pneumonia: Most likely explanation for patient's presenting
symptoms of chest pain, fevers/chills, nausea. Given his history
of significant, severe GERD with recent reflux episodes and
distribution of pneumonia (RML), concerning for aspiration
pneumonia. Patient's PORT score is: 85, Risk Class III which
correlates with 0.9-2.8% mortality suggesting outpatient or
inpatient treatment, depending on clinical judgment. Patient was
initially treated with Levofloxacin. Initial blood cultures,
however, grew out gram positive cocci in clusters in one bottle
so the patient was switched to Vancomycin for bacteremia
(possible MRSA bacteremia) coverage. The patient did not
decompensate and when the blood cultures came back coagulase
negative staph and all remainder bottles (7 bottles) did not
grow out bacteria, it was felt the positive blood culture was
likely contaminant. The patient's initial leukocytosis had also
responded well to Levofloxacin and IVF. The patient was
discharged on Levofloxacin, which should also cover for his
?sinusitis previously treated with Azithromycin prior to
admission. Patient responded well to incentive spirometer as
well.
.
# Chronic myofascial chest pain: Similar to patient's on-going
pain but more severe, possibly due to underlying pneumonia and
associated myalgia. Potentially concerning for acute coronary
syndrome given TWI on EKG but findings likely non-specific,
especially in setting of tachycardia. Patient was ruled out for
an MI and monitored on telemetry without events. He received ~2L
of intravenous fluids and boluses with resolution of
tachycardia. Patient's hypertension was noted to correlate with
episodes of pain. He was initially treated with his home pain
regimen and IV Dilaudid for breakthrough pain. This was
transitioned to MSIR with good effect, and good control of pain.
.
# Acute renal failure: Likely in setting of pneumonia with
fevers, malaise, poor PO intake since last night, ?emesis.
Patient's creatinine normalized with PO and intravenous fluids.
.
# Hypertension: Per above, most well controlled when pain was
controlled. Patient was continued on his home antihypertensives.
.
# Refractory GERD: Recent EGD with patient's primary
gastroenterologist, ___, demonstrated a small hiatal
hernia but otherwise normal mucosa throughout. The patient was
continued on Omeprazole 40mg daily and GERD precautions
(sleeping at an ___, no fatty meals close to bedtime).
Interestingly, patient found most relief with saltine crackers
during episodes of severe reflux.
.
# Code: Full, confirmed with patient
.
# Communication: Patient, wife ___ (___ ___
***. | RESPIRATORY INFECTIONS AND INFLAMMATIONS 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.
***
Ms. ___ is a ___ woman ___ significant for Childs
Class C EtOH cirrhosis who presented with altered mental status
secondary to hepatic encephalopathy and/or medication effect.
# Encephalopathy: Likely ___ hepatic encephalopathy given h/o
this in the past, triggered by recent lactulose non-compliance.
Sedating medications, particularly Benadryl and lorazepam (which
she was recently started on), may have also contributed to her
sedation. Urinalysis was positive and urine culture grew
100,000 E coli, but this was thought to represent a contaminant
(see below). There were no other signs or symptoms of
infection. Patient was treated with lactulose q2h (titrated to
___ BMs/day) and restarted on rifaximin. She was admitted to
the ICU initially for airway monitoring, but she was called out
to the floor on HD 2 after her mental status improved
significantly. Benadryl and lorazepam were discontinued.
Lactulose and rifaximin were continued on discharge.
# Elevated CK: CK was elevated to >1000 at OSH, which improved
to 700 after IVF. This was likely related to being found down.
# ?UTI: Patient has a history of MDR E.coli previously
attributed to colonization per ID. Her admission urinalysis was
positive and urine culture grew >100,000 E. coli. She received
a dose of Zosyn but this was discontinued as culture was thought
to represent colonization. She was afebrile and denied urinary
symptoms.
# EtOH cirrhosis: Child Class C with current MELD of 14.
Complicated by diuretic refractory ascites and recurrent hepatic
encephalopathy. Last EGD in ___ negative for varices.
Patient was taken off transplant list due to active EtOH use.
Home diuretics were held initially but were later restarted.
She was continued on lactulose and rifaximin as above.
# H/o EtOH abuse: Per ED report, patient drinks ___ bottle
wine/day, but patient adamant that she has not had anything to
drink since ___. She was continued on thiamine, MV, and
folate. Alcohol cessation should continue to be addressed as an
outpatient.
# ?Temporal lobe CVA: Head CT at ___ commented that
findings were most likely motion artifact. Neurological exam
without focal deficits and no clinical concern for CVA. Brain
MRI was deferred.
TRANSITIONAL ISSUES:
=====================
-Will need labs drawn on ___: please draw CBC,
chemistry (including BUN and Creatinine), liver function tests
(ALT, AST, TBili, Alk phos) and have them faxed to the liver
clinic at ___, attn: ___, MD.
-___ to have MDR E. Coli on urine culture at ___.
Treatment deferred given asymptomatic and thought to be a
colonizer based on prior assessments from infectious disease
-She was counseled on the importance of taking her lactulose TID
-She will need help from transplant coordinators to reduce her
rifaximin copay
-Should not take benadryl or ativan in the future
***. | 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.
***
The patient presented to pre-op on ___. Pt was evaluated by
anaesthesia.
The patient was taken to the operating room for a laparoscopic
sleeve gastrectomy for obesity. There were no adverse events in
the operating room; please see the operative note for details.
Pt was extubated, taken to the PACU until stable, then
transferred to the ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a PCA. Pain was
very well controlled. The patient was then transitioned to
crushed oral pain medication once tolerating a stage 3 diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO. The patient was
unable to tolerate oral contrast for the Upper GI Study on POD1.
She continued on NPO status overnight and re-evaluation with UGI
on POD2 which was normal. As a result, the patient was started
on a bariatric diet and was advanced to Stage III as tolerated
before discharge on ___.
ID: The patient's fever curves were closely watched for signs
of infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a
bariatric stage 3 diet, ambulating, voiding without assistance,
and pain was well controlled. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
***. | O.R. PROCEDURES FOR OBESITY 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.
***
Ms. ___ is a ___ year old woman with history of diabetes,
hypertension, tobacco use, who presented with 2 weeks of
progressive dyspnea on exertion and orthopnea, found to have new
heart failure with global hypokinesis and moderate MR with an EF
of 25%. She was diuresed effectively with IV Lasix 40 prn. She
received a right and left heart cath on ___, which did not
show significant coronary artery disease. Differential for the
underlying etiology of her heart failure includes non-compaction
given increased trabeculations seen on TTE, as well as post
viral cardiomyopathy. She was enrolled in the Pioneer study
prior to discharge and will be discharged on Torsemide 40mg
daily and metoprolol 12.5mg daily. She will follow-up with heart
failure clinic for further work-up of her dilated CM including
cardiac MRI. Discharge weight 74.25 kg (163.7 lb). Discharge Cr
0.9.
# Newly diagnosed dilated CM:
Patient initially presented to ___ with progressive
dyspnea and orthopnea. There, she was found to have new HFrEF
with global hypokinesis, EF 20%, severe MR with an initial
question of tethered valve on TTE. Repeat TTE at ___ showed
severe left sided hypokinesis (LVEF 25%) with moderate MR but
with normal mitral valve leaflets. Cath ___ did not show any
obstructive CAD, making ischemic cardiomyopathy less likely.
Non-compaction is possible given the trabeculations seen on TTE;
versus less likely underlying functional MR vs. viral etiology.
Workup revealing for HCV ab positive but viral load negative,
and HBV serologies c/w cleared infection. TSH WNL. She was
diuresed with IV Lasix 40 prn, with symptomatic improvement and
given IV iron supplementation. She was transitioned to PO
Torsemide 40 daily prior to discharge and was started on
metoprolol succinate 12.5 daily. The patient was enrolled in the
Pioneer study prior to discharge and will be randomized to
either enalapril vs. entresto. Can consider starting
spironolactone as outpatient.
Discharge diuretic: Torsemide 40mg daily
Afterload: As determined by Pioneer HF study
NHBK: Metop 12.5mg XL; consider starting spironolactone as
out-patient
Discharge weight: 74.25 kg (163.7 lb).
Discharge Cr: 0.9
#Non-obstructive CAD:
Noted on coronary angiography on ___. Started on aspirin and
statin.
# Anxiety
Patient had significant anxiety associated with her new
diagnosis of HFrEF. She was continued on home escitalopram and
received Ativan 0.5 prn while inpatient. She will need close
follow-up with her PCP.
# Diabetes
She was hyperglycemic this admission, likely initially due to
the steroids she received at ___ prior to transfer, and
later from diet noncompliance. She was maintained on insulin
fixed dose and sliding scale. Home metformin and Januvia were
restarted for discharge. A1c this admission 6.6. Will need close
follow-up as an out-patient.
TRANSITIONAL ISSUES:
====================
NEW MEDS:
- ASA 81
- atorvastatin 40
- pioneer study medication
- metoprolol succinate 12.5 BID
- torsemide 40
CHANGED MEDS:
- none
STOPPED MEDS:
- doxycycline 100 q12h
- lisinopril 10
[] Discharge weight: 74.25 kg (163.7 lb).
[] Discharge Cr: 0.9
[] Monitor volume status and weight for ongoing titration of
outpatient diuretics. Discharged on torsemide 40 daily.
[] Patient was persistently hyperglycemic this admission in the
200s (at times 400), though A1C was 6.6. Would monitor blood
sugar control on her home oral glycemic agents as an outpatient.
[] Monitor and manage ongoing significant anxiety. ___ benefit
from seeing a therapist or psychiatrist.
[] Has been enrolled in PIONEER study of Enalapril vs
sacubitril/valsartan. Will need close study follow up.
[] Did not start spironolactone due to borderline BPs; will need
reevaluation as outpatient.
[] deferred ICD on this admission pending reassessment of EF to
medical management.
***. | CIRCULATORY DISORDERS EXCEPT AMI WITH CARDIAC CATETERIZATION 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 man with no known medical history who
was referred to the ED by his PCP due to complaint of chest pain
and found to have a 90% PDA lesion now s/p DESx1 on Plavix and
aspirin.
ACTIVE ISSUES:
===============
#Chest pain:
Patient with angina, however ischemic work-up including echo
stress test, troponins x2, and ECG have been negative for
ischemic changes. Risk factors are also unimpressive including;
A1C 5.5%, total cholesterol 197, LDL 135, HDL 48. However, his
father had his first MI in his ___ and passed away from cardiac
complications in his ___. Therefore, this patient underwent a
coronary angiogram that showed 90% occlusion of the PDA which
received a ___ 1. He was loaded with Plavix and started on
Aspirin 81mg qd and Atorvastatin 80mg qd.
#HTN:
Patient had SBP's in thee 140-160's during this admission and
not any anti-hypertensived in the outpatient setting. Per
patient, would like to monitor his BP for now prior to starting
new medications.
# CODE STATUS: Full (presumed)
# CONTACT will discuss with patient
TRANSITIONAL ISSUES:
====================
- Monitor SBP and consider starting Amlodipine 5mg daily if
ongoing HTN.
- New medications started include:
- Plavix 75mg daily
- Atorvastatin 80mg daily
- Aspirin 81mg daily
***. | 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.
***
This is a ___ year old homeless man, history of assault and
battery, significant history of opiate use disorder s/p numerous
detoxes, previously diagnosed with mood disorder s/p numerous
psychiatric hospitalizations, 3 reported prior suicide attempts,
recently discharged from ___ who self presents
to ___ with SI, plan to hang himself in the setting of heroin
relapse. Interview with patient significant for several days of
low mood, poor appetite, sleep, energy, and concentration in the
setting of significant heroin, Xanax, and Adderall use in the
setting of medication noncompliance.
LEGAL/SAFETY:
- Patient admitted on a ___, CV signed and accepted upon
arrival to ___. Patient maintained his safety throughout
his admission on 15 minute checks with no evidence of
suicidality, self injurious behaviors.
- On ___ patient noted by staff for behavioral changes
following his girlfriend's visit. Mr. ___ was noted to be
disinhibited and "making weird noises," more engaged with social
interactions, which is not his baseline. Recheck of blood
glucose= 120's. Given history of substance use, staff requested
a urine sample, which Mr. ___ refused. Noted to be asking,
"what if I fail the test?" Team met with patient in morning and
expressed concern the patient had been using while on the unit
and that he could potentially be putting other patients at risk.
Given this and the limitations of inpatient treatment (despite
numerous psychiatric hospitalizations, there has been no
improvement in his utilization of higher level of care or
decrease in his chronic risk factors for self injurious
behaviors), team recommended discharge at this time with
follow-up at ___ for primary care and substance
abuse/psychiatric care. Although patient was reluctant, he was
amenable to care with no endorsement of suicidality.
PSYCHIATRIC:
#Substance Use Disorder: with significant use of heroin, prior
history of benzodiazepines, stimulants.
- Patient was closely monitored for signs and symptoms of
benzodiazepine withdrawal with no signs/symptoms-- he did not
require CIWA scale.
- Patient was placed on comfort medications for withdrawal of
opiates that included Bentyl, Robaxin, Tylenol, Immodium. He
experienced some minor symptoms of discomfort that was
responsive to supportive medications.
- Patient strongly encouraged to attend AA/NA/SMART recovery
groups, but he refused
- After discussion of risks vs. benefits, patient initially
agreed to naltrexone but after the incident described above,
stated he would not fill the prescription and would most likely
use immediately upon discharge.
#. Mood disorder NOS: with subjective symptoms of low mood,
neurovegetative symptoms x several days as noted above. Serial
mental status exams notable for reportedly depressed mood with
somewhat irritable and reactive affect but without clear
dysthymia/dysphoric. Noted to have good appetite throughout his
hospitalization with no difficulty attending to his ADL's and
with limited participation in groups and milieu therapy. Given
significant history of reactive mood, impulsivity, heavy
substance use, differential diagnosis includes substance induced
mood disorder vs. underlying character pathology with cluster B
traits (borderline and antisocial) vs. primary mood disorder.
Given lack of observed depressive symptoms including dydsphoric
affect, observed poor concentration, energy, and sleep as well
as his history of assaultive behaviors, denial of responsibility
of his actions (blaming treatment team that he will most likely
use heroin again, blaming others for losing custody of his
children), significantly reactive mood, would tend to favor SIMD
vs. decompensated character pathology.
- Despite lack of evidence for a primary mood disorder, given
patient's report that his mood improved in the past on Effexor,
after a discussion of the risks and benefits of this
medication(activating side effects, GI and sexual side effects),
restarted Effexor that was uptitrated to 150 mg po qd. Patient
tolerated this medication well with no complaints of side
effects.
- Patient with no participation in groups and milieu therapy
despite significant encouragement from the primary team to do
so.
#. Anxiety Disorder NOS: characterized by worry about housing
situation and when/if he would receive custody of his children.
- Effexor as noted above
- Given significant history of substance use, avoided
benzodiazepines and other addictive medications in this patient.
- Restarted quetiapine 100 mg po tid and prn anxiety/agitation,
which he tolerated well with improvement in his anxiety. In
addition started hydroxyzine 50 mg po qd bid prn which was of
limited benefit.
MEDICAL:
#. Type I DM: poorly controlled secondary to medication
noncompliance and ongoing substance use.
- Placed on diabetic diet
- HbA1c= 9.4
- Given noncompliance, ___ Diabetes was consulted.
Recommended changing Lantus to NPH 20 units. Diabetic consult
team had been following patient during his admission and he was
discharged on their latest recommended insulin regimen
#. Tendonitis: stable and chronic condition. Patient placed on
Naproxen 500 mg po q8h prn pain with good control of pain.
#. Hepatitis C: LFT's WNL.
- Avoided nephrotoxic medications
- Arranged follow-up with outpatient PCP for evaluation and
treatment.
RISK ASSESSMENT:
Mr. ___ is at chronically elevated risk for self harm with
factors that include male sex, reported depressed mood, history
of prior attempts, ongoing significant substance use,
homelessness, history of impulsivity and limited psychosocial
suppports. However, by far, his greatest risk factor his his
ongoing substance use, and patient was reluctant to engage in
substance use disorder treatment as evidenced by his refusal to
attend groups, AA/NA/SMART recovery, and by his refusal to fill
naltrexone upon discharge, saying, "I'm going to just use
anyway..." Of note, despite his significant chronic risk
factors, it should also be noted that inpatient hospitalization
has not mitigated these risk factors as evidenced by the fact
that following discharge, he never follows up with outpatient
providers and very quickly represents to an ED with SI in the
setting of relapse. His most protective factor in self harm is
his demonstrated ability to seek help when distressed.
***. | 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.
***
___ female with history of hypertension, rheumatoid
arthritis on Plaquenil, chronic right kidney cysts, and
___ esophagus, who admitted for ESBL E.Coli pyelonephritis
and xanthogranulomatous pyelonephritis.
# Xanthogranulomatous pyelonephritis:
# Acute ESBL pyelonephritis:
Patient with ESBL E.Coli pyelonephritis. Remote h/o anaphylaxis
reaction to PCN. Other than beta-lactams, E.Coli sensitive to
amikacin, gentamicin, ertapenem, tigecycline. She received
almost a week of therapy with tigecycline, some doses of
gentamicin with poor response evidenced by ongoing fevers, night
sweats, and leukocytosis. CT evidence significant for
xanthogranulomatous pyelonephritis. Sent from OSH for ertapenem
challenge vs antibiotic desensitization. ID recommended graded
meropenem challenge which was successfully performed in the ICU.
Pt tolerated the antibiotic well with no evidence of
hypersensitivity reaction. She was seen by urology who
recommended elective nephrectomy to be done at a later date. ID
recommended she remain on ertapenem once daily until nephrectomy
is performed. Urology will expedite seeing her in outpatient
clinic to arrange surgery. Home infusion services were arranged.
Radiology request placed for second opinion read on CT torso
done at OSH. Results pending at time of discharge.
# Rheumatoid arthritis: She was continued on hydroxychloroquine
at 100 mg daily, reduced from home dose of 200 mg daily, in the
setting of ongoing infection.
***. | RETICULOENDOTHELIAL AND IMMUNITY 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. ___ is a ___ year old male who presented to the ED with
2+ weeks of worsening headache. In the ED, ___ showed a large
area of right frontal edema with midline shift. He was
admitted to the neurosurgery service for close neurologic
monitoring. MRI with and without contrast was obtained which
showed findings consistent with glioma. Neurology was consulted
to rule out infection; they recommended deferring LP given risk
of herniation and low likelihood of infection and agreed with
plan for biopsy. The patient requested to be discharged home
with outpatient workup. He was scheduled for CTA head, fMRI and
MR ___ and was instructed to return for stereotactic biopsy on
___. The patient was discharged home in stable
condition.
***. | NERVOUS SYSTEM NEOPLASMS 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.
***
___ h/o chronic pancreatitis d/t pseudocyst with multiple
complications s/p drainage percutaneously as well as via ex-lap,
duodenitis s/p gastrojejunostomy, multiple intrahepatic,
perihepatic, and peripancreatic collections, portal HTN s/p
portal v. thrombosis with grade II esophageal varices, with
recent admission for S. pneumo pneumonia and bacteremia as well
as severe C.diff, now returning with Hct 21 and guaiac positive
stool, found to have likely bled from esophageal varices.
# Anemia: Patient with sudden HCT drop from 27 to 21 without
gross blood per rectum or hematemesis. Hemodynamically stable
and asymptomatic. Patient received 1 unit PRBCs with appropriate
bump in Hct to 27. BID IV PPI started. EGD and colonscopy did
not reveal clear source of active bleeding although 4 cords of
grade III varices were seen in the mid and distal esophagus,
with stigmata of recent bleeding. Bands were successfully placed
on 3 of the largest cords. Colonoscopy also revealed slow
oozing diverticulum. Per GI recs, he was started on sucralfate
slurry. This should be continued for 2 weeks post-banding,
through ___. After receiving large amount of fluid in the
form of albumin, he was found to have drop in Hct to 22.4. He
received another 1 unit PRBCs with Hct bump to 28. He was
stable and plan is for f/u endoscopy in 1 month to re-evaluated
varices.
# Portal HTN/ascites: Patient with complicated history of portal
vein thrombosis likely leading to portal HTN and ascites. At
this admission, having received large sodium load with IV as
well as PO sodium bicarbonate, his abdomen became increasingly
tense with accumulating ascites. He went to ___ for therapeutic
paracentesis with removal of 5.75L of fluid. He was given
50grams IV albumin following this. As part of workup for portal
hypertension, he had transjugular liver biopsy with measurement
of HVPA pressures. Porto-systemic gradient was found to be
9mmHg. Pathology still pending at time of discharge. Diuretics
were continued throughout admission.
# Strep pneumoniae bacteremia: Secondary to RLL pneumonia during
previous admission. Patient has been on ceftriaxone since ___
but covered with abx since ___ (cefepime) with planned 14 day
course, which he finished on ___. He had normal WBC count and
was afebrile throughout admission.
# Severe C. difficile diarrhea: Ongoing, though much improved on
PO vancomycin. Patient will need prolonged course, and should be
treated for 14 days following his last day of ceftriaxone
(throught ___. Patient also likely has an element of
malabsorptive diarrhea. Fecal fat found to be normal. Stool
elastase was still pending at time of discharge. Patient has
scheduled appointments for outpatient GI followup of diarrhea.
# Non-anion gap metabolic acidosis: Likely secondary to
diarrhea, with persistently low bicarb despite starting sodium
bicarbonate prior to discharge. ABG showed non-anion gap
metabolic acidosis. PO sodium bicarb was increased to 1300mg
TID, and IV sodium bicarbonate was administered x1 dose.
Subsequently, when the patient's ascites began to worsen (as
above), there was concern for this high sodium load and sodium
bicarb was stopped and replaced with calcium carbonate. As
patient's diarrhea improved, bicarb began to rise.
CHRONIC ISSUES
# Chronic pancreatitis c/b an infected pseudocyst requiring
drainage, recent ___ and recent hospitalization for MRI
finding of ? phlegmon vs developing abscess in ___
and hepatic areas: The fluid collections had decreased on last
imaging at prior admission. The patient was without abdominal
pain. Pancrealipase was continued.
# Biloma: Diagnosed during previous admission, determined to be
non-urgent. Patient to follow up with Dr. ___ Dr. ___
as an outpatient.
# Cachexia: seen by GI for evaluation of chronic pancreatitis
and chronic malabsorption during previous admission. Started on
supplements per nutrition and increased pancreatic enzymes with
meals per GI. No changes made at this admission.
TRANSITIONAL ISSUES
-Liver biopsy pathology pending at time of discharge
-Vitamin D level pending at time of discharge
***. | DISORDERS OF LIVER EXCEPT MALIGNANCY CIRRHOSIS OR ALCOHOLIC HEPATITIS 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.
***
Summary:
___ gentleman with history of EtOH cirrhosis
decompensated by ascites, esophageal varices status post banding
___ at ___), hepatic encephalopathy, who
presented to outpatient hepatology appointment for transplant
evaluation today and was found to be anemic below baseline (6.9
from high 7 range), short of breath, and mildly encephalopathic.
Acute Issues:
#Acute on chronic anemia
On admission, the patient described intermittent bouts of dark
black stool, most recently 2 episodes on the day prior to
admission. He additionally reported feeling generally fatigued
for several days with some SOB on exertion. The patient had a
recent EGD ___ showing large EV s/p banding x6, moderate portal
hypertensive gastropathy and mild GAVE. Due to concern for a
gastrointestinal etiology, the patient had an EGD ___ showing
no variceal bleeding but some gastropathy. He then had a
colonoscopy ___ showing a small polyp which was removed and a
larger polyp which was tattooed. A repeat colonoscopy was done
to remove the larger polyp. All polyps were benign. Throughout
the hospitalization, the patient required 4 units pRBCs for
Hg<7. He also had a trial of Vitamin K (___). He remained
stable on discharge.
# Child C- ETOH cirrhosis MELD Na 22, undergoing transplant
workup
# Refractory Ascites
# Hyponatremia
On admission, patient was noted to be mildly encephalopathic,
hyponatremic and with significant ascites on exam. Patient was
not encephalopathic throughout hospitalization. He had recurrent
ascites requiring requiring therapeutic paracenteses ___,
___ and one prior to discharge. Although MELD increased to a
max of 28 during admission and TBili remained elevated, the
patient was without evidence of SBP with several diagnostic
paracenteses. Diuretics were discontinued in light of persistent
hyponatremia. Patient was started on daily albumin 1 g/kg for 50
g. Patient remained hypotensive with SBP is below 100
consistently and was started on Midrin 5 3 times daily. Patient
remained on 1.2 L fluid restriction. TIPS was considered but was
deemed inappropriate due to elevated bilirubin and high MELD
score. Vital signs were stable and patient was safe for
discharge.
Liver transplant workup was finished during admission. Patient
was presented at transplant conference and was listed for liver
transplant. The transplant coordinator communicated with the
patient throughout admission and will be in touch regarding next
steps.
CHRONIC ISSUES:
==============
#Pancytopenia:
Patient was pancytopenic, which was believed to be likely ___ to
cirrhosis. Labs from ___ showed similar findings, so there
was less
concern for a consumptive process at this time. This was
monitored throughout hospitalization and remained stable.
#Severe protein calorie malnutrition
Patient had severe malnutrition in the setting of liver disease.
It was determined that he would need tube feeds. Patient had NGT
placement. The tube became clogged and was replaced during
hospitalization. The patient remained on tube feeds per
nutrition recommendations. Continue on home thiamine, folic
acid. The patient was set up for tube feeds during the
hospitalization. He will have the supplies delivered to his hoe
the day after discharge.
#BPH
Patient continued on home finasteride.
TRANSITIONAL ISSUES:
====================
[]Please consider vaccination to Hepatitis B
[]The patient was started on midodrine 5mg TID for hypotension
[]Please consider tolvaptan if Na <126
[]The patient is on a 1.2 L fluid restriction
[]His home diuretics were held due to hyponatremia
[]Incidental finding of some diverticula on colonoscopy ___
[]The patient required multiple therapeutic paracenteses during
his hospitalization. Consider weekly LVP through local GI
[]Continue oral nutritional supplementation
[]Continue to monitor weights (discharge weight: 71.8 kg)
[]Initial consideration for TIPS procedure which will be held
off at this time
[]Please encourage smoking and etoh cessation
[]Repeat CBC in 1 week given pancytopenia
[]Discharge INR 2.1
[]Blood cultures from ___ pending at discharge however no
infectious symptoms on discharge
***. | EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 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.
***
Ms. ___ was admitted to the hospital and taken to the
Operating Room where she underwent a right thoracotomy and
tracheobronchoplasty with mesh, bronchoscopy with lavage. She
tolerated the procedure well and returned to the TSICU extubated
and in stable condition. She maintained stable hemodynamics and
her pain was controlled with an epidural. Her ___ drain put
out a modest amount of thin, bloody fluid and had no air leak.
She underwent vigorous pulmonary toilet including chest ___,
incentive spirometry and nebulizer treatments and was able to
clear her secretions.
Following transfer to the Surgical floor she had some increased
pain and Ketamine was added with effect. By post op day #3 her
epidural was removed and her Ketamine was weaned off. Vicodin
was given for oral pain control and her scheduled acetaminophen
was stopped. She eventually required scheduled Tramadol as well
for adequate pain relief. Her right thoracotomy site was healing
well and her oxygen was gradually weaned off following more
diuresis. On POD 7 her labs were stable, WBC was 8. Physical
therapy denied to perform Chest ___. Interventional pulmonology
was consulted for further management of the patient's hypoxia.
Recommendation was made to use CPAP at night and promote
secretion mobilization. By the day of discharge (POD8) we were
able to wean her to room air with saturations at 92%-100% on
rooma air. She did not have any desaturations with ambulation.
She did not require home oxygen. Her chest x-ray appeared stable
compared to prior. She will follow up as an outpatient.
***. | MAJOR CHEST 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.
***
Mrs. ___ is a ___ year old woman with a PMH
significant for DM, HTN and MS (___) who presented to ___
for knee pain; found to have significant b/l ___ DVT in the
setting of IVC Filter placed for a thigh hematoma which occurred
while on Heparin/Coumadin after DVT s/p TRK during
hospitalization in ___. Her current DVTs were treated initially
with Lovenox and she was discharged on Coumadin with a Lovenox
bridge and a plan for consideration for IVC filter removal after
3 months of anticoagulation. She was discharged to rehab
following ___ evaluation.
ACTIVE ISSUES:
==============
# DVT: Previously developed b/l DVTs in the setting of a TKR
(___). Was started on a heparin drip but developed a large
thigh hematoma at that time. For this reason, she had an IVC
filter placed ___ and she did not continue with
anti-coagulation. She now presented with a second DVT, likely
with triggers of IVC filter and immobilization. She was
initially started on a heparin drip and then switched to
Lovenox. She was discharged on Warfarin with a Lovenox Bridge.
She will likely need 3 months of anticoagulation and will
follow-up with ___ for removal of the IVC filter.
# Knee Pain: Endorsed knee pain, which has improved with
Tylenol. Osteoarthritis noted on XR. Had been ambulatory after
recent rehab, but has been worsening, ___ recommended rehab.
CHRONIC ISSUES:
===============
# Multiple Sclerosis: Followed by ___ neurology. No active
issues. Note from Dr. ___ (___) states she is not on
therapy. Unclear why she is on carbamezipine.
# Diabetes: Patient on metformin at Home. She was on sliding
scale Humalog and diabetic diet while inpatient.
# HTN: Home Lisinopril was continued.
# HLD: Home Atorvastatin was continued.
# Flexor Spasms: Carbamezepine was continued.
# Incontinence: Home Oxybutynin was continued.
Transitional Issues:
====================
#B/l DVT w/ Filter in place:
[ ] Warfarin with Lovenox Bridge until INR >2.0 for 48 hours
(obtain daily INR)
[ ] Follow-up (per ___ with Dr. ___ in 3 months
for IVC Filter removal. ___ contacted and aware of this patient.
They are planning on contacting for follow-up.
[ ] Could consider NOAC if pt. is able to be titrated off of
carbamazepine. Would discuss with neurology as pt. was
previously started on this medication for flexor spasms.
#Long term goals of care: There is significant family concern
that patient is not safe at home. At rehab, would investigate
how appropriate a long term care solution may be if the pt. is
not able to rehab to a point that is safe for her to return
home.
# CONTACT: Husband, ___, ___
# CODE STATUS: Full, confirmed
***. | 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.
***
The patient presented to pre-op on ___. Pt was
evaluated by anaesthesia and taken to the operating room where
she underwent a ventral hernia repair, abdominoplasty and
panniculectomy. There were no adverse events in the operating
room; please see the operative note for details. Pt was
extubated, taken to the PACU until stable, then transferred to
the ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a
hydromorphone/bupivacaine containing epidural and then
transitioned to oral oxycodone, acetaminophen and tramadol once
tolerating a diet.
Once while ambulating out of bed to chair she had an episode of
brief syncope which occurred following epidural and patient was
asked to stand. Her glucose was 68 mg/dl following this
episode. Her blood pressure was 80/40 mmHg at the
time. The cause for her syncopal episode was unlikely due to
hypoglycemia but rather hypotension. Her blood pressure and
mental status improved prior to receiving 1 mg glucagon but
after turning off the epidural and sitting down.
___ diabetic center were consulted as she has had history of
post-prandial hypoglycemia, especially in the morning she was
put back on her post prandial acarbose and he epidural was
discontinued.
CV: The patient experienced a syncopal episode on POD1 which
coincided with hypoglycemia (BG 68) this was also in the setting
of a decreased hematocrit. She was subsequently given a 1L
fluid bolus, 2 units of PRBCs and glucose. She did not
experience any additional syncopal episodes,
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially on a bariatric stage 1
diet, which was gradually advanced to a bariatric stage 5 diet
and well tolerated. The patient was evaluated by the ___
___ hypoglycemia, pt known to their service.
Acarbose was resumed and no further hypoglycemic episodes
occurred. She will follow-up with ___ within two weeks of
discharge. Patient's intake and output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched and
decreased from 30.3 to 25.3 for which she received 2 units of
PRBCs. Her hematocrit subsequently remained stable.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
***. | HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL 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/ ___ history of UC s/p colectomy with ileal pouch anal
anastomosis, PSC, SBO, depression, GERD, Bipolar, PTSD
presenting with abdominal cramping and bleeding of unclear
etiology, found to have worsened pouchitis with ulcerations.
# Worsened pouchitis with clean based ulcers
# RLQ Abdominal Pain: Pt p/w acute onset RLQ abdominal pain with
associated bright red blood and dark blood clots in several
stools prior to admission. Concerning for pouchitis given her
history, mild pouchitis seen on MRE and flex sigmoidoscopy which
demonstrated worsened inflammation from prior. However location
of her pain is atypical for pouchitis. She was prescribed two
weeks of 10% hydrocortisone to insert into her pouch. No e/o
conversion to Crohn's on MRE. Given chronicity of hemorrhagic
adnexal cyst, peritoneal inclusion cyst and hydrosalpinx seen on
U/S and MRE these are less likely causes of her acute pain, and
outpatient gyn had previously recommended expectant management.
Liver/gallbladder pathology unlikely given benign LFTs and
imaging. At discharge, she was tolerating PO without further
nausea/vomiting though pain had not fully resolved.
- repeat imaging for gyn findings and follow up with outpatient
gyn
- outpatient GI follow up
# GIB, lower: Regarding episodes of blood in her stool, pt did
not demonstrate further episodes of bleeding and hemoglobin
remained stable during admission. Flex sigmoidoscopy showed no
obvious source of bleeding, ulcers felt to be less likely source
though remains a possibility.
# Ulcerative colitis. Hx of UC s/p total colectomy and ileal
pouch-anal anastomosis (___) c/b recurrent pouchitis and
intraabdominal abscess. Last flex sigmoidoscoy with biopsy
___ showed mild pouchitis, repeat flex sigmoidoscopy ___
confirmed slightly worsened pouchitis. Pt continued on
budesonide 9 mg PO QD and added hydrocortisone foam as above. At
home receives vedolizumab Q5 weeks and probiotic. Received home
reglan.
CHRONIC ISSUES:
# PSC: Continued on home cholestyramine 4 gm PO QD and ursodiol
600 mg PO BID
# Vit D deficiency: Pt continued on home Vitamin D 2000U QD
# GERD: Continued on home famotidine 20 mg PO BID
# Anxiety/PTSD/Depression: Pt was continued on home clonazepam
0.5 mg PO QHS:PRN, half of home valium (received 5 mg QHS, takes
10 mg at home), and Ativan 0.5 mg PRN nausea. Home hydroxyzine
100 mg QHS was held.
# ADD. Pt did not receive home methylphenidate SR 72 mg PO
QAM:PRN work/school or metadate CD (methylphenidate) 20 mg oral
QAM:PRN work/school
# Seasonal allergies. Pt received home albuterol inhaler and
fluticasone Propionate 110mcg 2 PUFF IH BID
# Headaches: fioricet prn, home medication.
TRANSITIONAL ISSUES
===================
[] follow up with PCP
[] F/u Hb, discharge Hb 10.6
[] F/u with gynecology regarding adnexal cysts and hydrosalpinx
seen on imaging
[] F/u flex sigmoidoscopy biopsies, follow up with GI
[] Continue hydrocortisone foam for two weeks (___)
[] F/u stool studies
#CODE: Full
#CONTACT: ___- ___
***. | OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC |
Subsets and Splits