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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.
***
Ms. ___ was admitted to ___ on ___ and had a
stereotactic frame placed in pre-op with Dr. ___. She
then went to MRI and had brain imaging. Following this she was
taken to the operating room where under MAC she had a new left
sided DBS lead placed. She tolerated the procedure well and was
brought to the PACU post-operatively for further management. She
remained stable, had a noncontrast CT scan of the head which
showed no acute intracranial abnormality, and she was
transferred to the floor. On ___ she underwent an MRI scan of
the Brain. Prior to the scan her right sided DBS generator was
turned off. Following the MRI her right sided generator was
turned back on to 2.0 volts 210 pulse wave and 60 Hertz as per
her prior settings. She was deemed fit for discharge and on the
afternoon of ___ was discharged to home with instructions for
followup and relevant medications.
***. | PERIPHERAL CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is a ___ ___ man with high risk
MDS and chronic diastolic heart failure recently admitted for
several days of hemoptysis and CT showing ? PNA vs. other
process
found to have a positive AFB smear from ___, who presented to
clinic ___ with fever and SOB, s/p ICU transfer for Afib with
RVR improved with Dilt/metoprolol, now hemodynamically stable in
NSR sputum +klebsiella.
#Afib with RVR: Transferred to ICU on ___ for this, now
converted to sinus and hemodynamically stable since then.
Cardiology following. TTE with no evidence of pericardial
effusion. Resumed home metoprolol with holding parameters.
#Fever/SOB: Recent admission with chest CT ___ showing LL
predominant multifocal consolidations c/f multifocal infection
v.
vasculitis v. COPD v. pulmonary infarcts. He was treated for
HCAP. Sputum sample ___ grew AFB, repeat samples neg now off TB
precautions. Beta glucan level also highly elevated on ___.
However, most recent B-glucan is negative without a clear
therapy. Has had ongoing intermittent productive cough. CT chest
___ shows rapid progression of pulmonary infection. He is
growing klebsiella on his sputum cultures which could certainly
account for his interval change on imaging and it appears to
have
been somewhat high grade as is on three different cultures
despite therapy. Per pulmonary recs, should obtain chest CT 2
weeks after treatment for klebsiella to evaluate for possible
secondary infectious process. If no improvement or significant
residual disease per imaging, bronchoscopy would then be
indicated. Pulmonary also recommended evaluation for aspiration
risk given distribution of disease but this may be difficult to
obtain due to TB precautions.
-crypto antigen in blood and urine histo negative
-ceftazidime (___) then changed to ceftriaxone to
complete 14d course ___, off ___ and vanco since ___
-appreciate ID recs-see note AFB unlikely at this point,
negative
sputums x3
-repeat CT chest 2 weeks after most recent
-weekly fungal markers
-IgG level 796 on ___
#Acute on chronic diastolic heart failure: BNP on admission was
elevated at 4800 and patient was mildly volume overloaded on
exam the afternoon of ___, resumed home lasix. CXR ___
shows
mild pulmonary edema; however, repeat ___ in the setting of
worsening SOB showed progressive pulmonary edema w/ bilateral
effusions. Continues on home regimen of lasix 40mg BID and
baseline crackles at b/l bases.
-Lasix IV x 1 on ___, consider repeat dose if no improvement
-telemetry for continuous 02 monitoring
-monitoring strict I/Os
#Coagulopathy: Likely vit K deficient, received PO vitamin K.
Low suspicion for inhibitor but we checked a mixing study since
if he did have an inhibitor with worsened hemoptysis treatment
would be different.
-vitamin K 5mg x 1 on ___ and ___
-f/u mixing study
-restarted prophylactic heparin daily dosing and when
checking PTT, this should be done peripherally (not from his
port)
#HR MDS: He has been maintained on dacogen for about a year now,
currently on C14 so holding now in the setting of active
infection. Exjade on hold while inpatient.
-transfuse to maintain hgb > 7,
-will need Lasix prn with transfusions
#Acute on chronic kidney disease: CKD stage III attributed to
HTN
and vascular disease. Cr slightly above baseline of 1.4-1.6
though downtrending since admission. Possibly in the setting of
volume overload.
-Lasix as above
-Trend Cr
-Avoid nephrotoxins
-Hold lisinopril
#Hernia: Etiology likely due to previous abdominal surgery in
___ ? incisional-related. No abdominal discomfort or
tenderness.
We will continue to monitor closely
#HTN:
-Continue metoprolol with holding parameters
-Hold lisinopril given acute on chronic renal failure
#CAD: Continue ASA 81
# FEN: No IVF, replete electrolytes, regular diet
# Prophylaxis: SQ heparin daily
# Access: Port
# Communication: ___ (___)
# Code: Full (confirmed)
# Disposition: home, to complete 1wk course of ceftriaxone
outpatient, f/u next week ___ or sooner if issues arise
***. | OTHER RESPIRATORY SYSTEM O.R. 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. ___ presented w/ a nonhealing L ___ toe ulceration. The
patient states that he had had a small ulceration prior to his
angioplasty in ___, and that this has continued to worsen. He
was placed on antibiotics on admission and heparin gtt.
He was brought to the Endovascular Suite for lower extremity
angioplasty and then
to the OR for debridement of the wound base. Please see the
dictated operative notes for further details of the patient's
procedure, but briefly, the in stent stenosis at the AK pop and
he underwent an angioplasty for the same. He then underwent
debridement with podiatry. He was continued on heparin and then
transitioned to Coumadin. The plastic surgery team was
following him as an outpt and was notified of his admission.
They will see him on follow up.
***. | OTHER VASCULAR PROCEDURES WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ was admitted to ___ on ___ for an elective
right total hip replacement. Pre-operatively, he was consented,
prepped, and brought to the operating room. Intra-operatively,
he was closely monitored and remained hemodynamically stable. He
tolerated the procedure well without any complication.
Post-operatively, he was transferred to the PACU and floor for
further recovery. On the floor, he remained hemodynamically
stable with his pain was controlled. He progressed with physical
therapy to improve his strength and mobility. He was discharged
in stable condition.
***. | 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.
***
Patient was given R femoral block for R TKA and then surgery was
cancelled secondary to an elevated WBC and Hct.
Patient was admitted for ___ clearance secondary to femoral
block.
On POD 1 - patient had an unwitnessed fall when getting up from
the commode and hit the back of her head/neck/shoulders.
Neurologically intact. c/o HA 6 hrs later, head CT WNL.
Patient failed to ascend/descend stairs safely on POD ___
femoral block.
Patient was discharged to home on POD.
***. | BONE DISEASES AND ARTHROPATHIES 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 ESRD on PD, CAD s/p CABG, CVAs, and
depression presented with weakness, poor PO intake, and
diarrhea.
# ESRD on dialysis: During the admission the patient was
switched from peritoneal dialysis to hemodialysis due to
difficulty with doing PD at home. A tunneled IJ placed ___,
and was revised ___. She underwent HD without difficulty and
will get dialysis every ___ as an outpatient. In addition,
transplant surgery consulted and recommended that the patient
follow up with them as an outpatient to remove the PD catheter
and place an AV fistula. The patient underwent upper extremity
vein mapping during her stay. Her LEFT ARM should be preserved
for AV fistula.
# Weakness/fatigue: The patient complained of chronic fatigue
and weakness on admission. The etiology was most likely
multifactorial, including depression, anemia, poor nutrition,
uremia, hypovolemia, C.diff infection. Her TSH was normal. The
patient's weakness seemed to improve during admission with
treatment of her C. difficile, starting HD, continuing
sertraline, and improvement in her PO intake.
# Orthostatic hypotension: The patient had orthostatic
hypotension throughout admission, with reported dizziness when
standing and when turning head. The patient had been
experiencing these symptoms for many months. The hypotension
did not improve with better fluid status once starting HD and
stopping the diarrhea, nor did it improve with better PO intake.
AM cortisol level was normal, thus not likely adrenal
insufficiency. Started meclizine to prevent dizziness. Was
treated with fludrocortisone and midodrine in an attempt to
improve her orthostasis. There was some minor improvement with
uptitration of her doses of midodrine and fludrocortisone.
However patient continues to be orthostatic though improved.
Patient was advised to wear compression hose to help with this,
however, refused due to discomfort with them. Patient was also
closely monitored during transfers to avoid falls. These
precautions should continued to be in place to avoid falls as
she becomes symptomatic upon standing
(light-headedness/dizziness). There is also room to uptitrate
her medication (fludrocortisone/midodrine) to help with her
orthostasis should she remain symptomatic. She should also
continued to be advised to wear compression hose when
transferring from sitting to standing position. She should sleep
in a propped-up position and avoid lying flat during the day as
part of autonomic training to prevent orthostasis.
# Diarrhea: The patient on admission complained of several days
of diarrhea. Her C. difficile test was positive, and she was
treated with ten days of metronidazole, finished ___. On ___
continued to have diarrhea. Was restarted on metronidazole,
___. Repeat C.diff testing was negative. Patient should
complete 10 day course of metronidazole (last day ___.
# Depression: Pt reports feeling depressed since her CABG in
___, with worsened symptoms since her CVA. Started on
sertraline at last admission in early ___. Mood seemed to
improve during her admission.
# Diabetes: Pt with insulin-dependent type 2 diabetes. During
admission titrated down her evening glargine from 25 to 10 units
due to morning hypoglycemia. In addition, patient was on
sliding scale of humalog insulin. Finger-stick blood sugars
remained between 109-200 on this regimen from ___, she
did not require any sliding scale doses over this time period.
Finger-sticks were checked 4x daily. Adjustments to her
glargine/sliding scale doses should be made as indicated by her
blood-sugar checks.
# Anemia: Iron studies during last admission consistent with
anemia of chronic disease. Iron studies from this admission
revealed low (but improved) iron levels to 28, high ferritin,
low TIBC consistent with anemia of chronic disease. Prior to
admission on ___ received 20,000 units epogen; on ___ she
received 3000 units due to low blood counts. In her outpatient
clinic she should continue to get epogen and may benefit from
iron infusions.
# History of CVA: continued on ASA and clopidogrel.
# HLD: continued atorvastatin
TRANSITIONAL ISSUES:
- Pt prior to admission got Epogen 20,000 units on ___. Here
received 3,000 units on ___. Will need to continue epogen
injections at outpatient HD, DOSE TO BE ADJUSTED BASE ON
PATIENTS HEMOGLOBIN.
- Iron studies revealed low iron levels of 28. ___ need IV iron
at HD.
- Will need to follow up with transplant surgery as outpatient
for removal of PD catheter and placement of AV fistula.
- Altered insulin regimen during admission, decreased her
evening glargine from 25 to 10 units due to morning
hypoglycemia. She should follow up with her PCP for further
management.
***. | MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL 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.
***
On ___ Ms. ___ was admitted to the neurosurgical service
and under general anesthesia underwent a pipeline embolization
of a L ICA aneurysm. She tolerated the procedure
well, groin angiosealed, was extubated and transferred to the
Neuro ICU in stable condition. Neurologically she remained
grossly intact.
On ___ She was voiding independently, ambulating independently,
and tolerating an advanced diet. She was discharged home on
aspiring and plavix with instructions for follow up.
***. | CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
*** yo with recent admission for acute gastroenteritisis, NSETMI
___ without intervention, hx of CAD, HTN, COPD, breast ca s/p
mastectomy with ___ presented to ___ with
severe SOB on ___. Her Trop peaked to 5 on ___ and she had
ST depressions in I, aVL, v4-v5.
.
#. CAD: NSTEMI with peak of Trop on ___. Seems that patient did
not elect for intervention until recently. As this was a large
infarct as evident by her Troponin elevation and her second
NSTEMI in ___ year, deemed best to intervene. Patient underwent a
cardiac catheterization with placement of BMS to LAD X2 on ___.
She was continued on ASA 325mg daily, Plavix 75mg daily,
Metoprolol 12.5mg PO BID. She was not treated with Heparin as it
was >48H since her NSTEMI. She did not have any episodes of CP
or SOB during admission.
.
#. Pump: EF 39% (___) on stress test-50% (___) on TTE.
Patient should have a repeat echo in 6 weeks.
.
#. Rhythm: Normal sinus rhythm
.
# HTN: Continued Imdur 60 mg daily and held ___ in the
setting of acute renal insufficiency.
.
# Depression/ anxiety: Continued Paxil 10mg daily and Ativan
0.5mg PO prn
.
# Breast cancer: continued Tamoxifen
.
# CRI: Patient was hydrated and given mucomyst pre-cath with
good effect as her creatinine did not elevated and was 1.5 at
discharge.
.
# Prophylaxis/GERD: changed PPI to H2B as Plavix was started
.
#. Code: full (confirmed, though this is a recent change)
.
#. Communication:
Next of Kin: ___
Relationship: DAUGHTER
Phone: ___
Other Phone: ___
***. | PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-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.
***
A/P: ___ yo M with CKD, DM2, s/p LUL lobectomy, and s/p recent
BKA admitted with nausea, vomiting and chest pain. Hospital
course by problem.
# Chest pain: The patient had pain in the low chest and
epigastrum following nausea and vomiting, in the setting of very
high blood pressures. His CTA was negative for free air, PE and
aortic dissection. His cardiac enzymes, LFTs and pancreatic
enzymes were normal, given that his troponin was at his
baseline. The most likely explanation is that he had severe
nausea and vomiting leading to secondary chest pain and
hypertension. This idea is supported by the location of his
pain, the fact the pain follows nausea and vomiting, and that it
was best treated with toradol. Other possibilities included
angina without infarction, gastritis or gastroparesis.
His symptoms were very atypical for angina. However, given his
history of diabetes and peripheral vascular disease, he should
have a pharmacologic stress test at some point to assess for
coronary artery disease. He notes that he has had nausea and
vomiting as the only symptom of bacteremia in the past, but two
sets of blood cultures were negative until the time of
discharge. The final results were pending. His pain was
controlled with toradol and low doses of IV dilaudid for
breakthrough. By hospital day 2 he was no longer requiring pain
medications. He was given one dose of IV pantoprazole for
possible gastritis, and then continued on PO omeprazole.
# Nausea and vomiting: It is unclear why the patient had
sudden-onset, repetitive vomiting. The most likely cause would
be a food-borne toxin, though it is odd that he was able to eat
again so soon after his symptoms resolved, and that he mostly
vomited phlegm. He does not have signs of continuing infection.
It seems unlikely that angina could provoke such violent
vomiting, but if he has repeated symptoms associated with
exertion that resolve at rest, he should consider further
cardiac work-up. His symptoms were not associated with eating,
making gastroparesis less likely. He did benefit from taking
Reglan, and was given a prescription for Reglan to be used as
needed at home.
# Hypertension: The patient had blood pressures up to 200/120 in
the setting of nausea, vomiting and chest pain. His very high
blood pressures appeared to be secondary to his symptoms, and
resolved with treatment of the pain and nausea. He did remain
hypertensive (for a diabetic especially) with a heartrate in the
___, and his metoprolol dose was increased to 50mg BID.
# DM2: Patient reports that he has not been able to seen his PCP
for management of his diabetes in over a year because of
multiple hospital admissions. His HbA1c was 6.5%, showing good
control, so he was kept on his regimen of lantus, 12 units at
night. He has an appointment this ___ with his PCP.
# Asthma: The patient was continued on albuterol as needed. He
had been on cromolyn according to an old pulmonary note from Dr.
___, but the patient reports this was stopped.
He seems to be managing well with the albuterol.
# Chronic renal failure: Likely associated with the diabetes.
His creatinine is currently at his baseline.
# Anemia: The patient has a microcytic anemia. Iron studies in
___ were consistent with anemia of chronic disease. If he is
consistently anemic, these studies could be repeated to see if
iron repletion could be helpful.
***. | 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.
***
Ms. ___ is a ___ y/o woman with T2DM, fibromyalgia, GERD,
hypothyroidism who p/w palpitations, found to have unstable
AVNRT. On presentation the patient's heart rates were found to
be in the 170s-180s with associated hypotension to the ___.
Given persistent SVT, she was given adenosine with return to
normal sinus rhythm. Her labs were notable for a hepatocellular
injury with ALT/AST: ___ likely secondary to hypotension.
The patient was evaluated by the electrophysiology cardiology
team, who recommended an AVNRT ablation. The patient's LFTs
improved, and her heart rate remained in normal sinus rhythm.
She was discharged home with plan to follow up with outpatient
EP for an AVNRT ablation.
==============
ACTIVE ISSUES:
==============
# AV Nodal Reentry Tachycardia: The patient presented with
palpitations and her heart rates were found to be in the
170s-180s with associated hypotension to the ___. Given
persistent SVT, she was given adenosine with return to normal
sinus rhythm. The patient was evaluated by the electrophysiology
cardiology team, who recommended an AVNRT ablation. The patient
was scheduled for an ablation on ___. Amlodipine and
losartan were held in the setting of hypotension. Amlodipine was
restarted upon discharge.
# Hepatitis: Her labs on admission were notable for a
hepatocellular injury with ALT/AST: ___ likely secondary to
hypotension due to AVNRT as above. ALT/AST improved to 349/330
on day of discharge.
# Hyperthyroidism: The patient was found to have a TSH of 0.08.
She has had difficulty with her levothyroxine dosing as an
outpatient due to need for frequent adjustments. Her does was
decreased to levothyroxine 112mcg daily, and her TSH should be
followed-up as an outpatient.
==============
CHRONIC ISSUES:
==============
# Diabetes Mellitus: Levemir was decreased from 30 units to 28
units due to hypoglycemia in the morning.
==================
TRANSITIONAL ISSUES:
==================
- Patient should follow-up with EP as an outpatient for AVNRT
ablation on ___
- Levemir was decreased from 30 units to 28 units due to
hypoglycemia in the morning. ___ require further titration as an
outpatient.
- TSH low to 0.08. Home levothyroxine decreased to 112mcg daily.
Please follow-up repeat TSH in ___ months to assess for
improvement of hyperthyroidism.
- Amlodipine and losartan held in the setting of hypotension.
Amlodipine restarted upon discharge. Please check BP and
re-start losartan as needed.
- Code: Full
- Contact: ___ ___ (fiancé)
***. | CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ M with HTN, COPD, ESRD on HD and limited stage small cell
lung cancer diagnosed ___ who presented with increased
dyspnea with RUL collapse and R effusion, started chemotherapy
during this admission.
# Dyspnea: The patient had increased dyspnea over three weeks
that was most likely secondary to the growth of his small cell
lung CA and its obstruction of the R upper lobe bronchus as seen
on the CTA obtained in the ED. CTA also showed collapsed R upper
lobe and moderate effusion at the base of the R lung. The
patient also had diffuse wheezes over the non-collapsed L lung
on exam which likely due to his COPD. He was written for
standing albuterol nebs and kept on his home Atrovent and Advair
with hopes to relieve his symptoms. He had HD on the day of
admission. In subsequent days the wheezes in his lungs decreased
dramatically. Additionally, BS started returning to the
auscultation fields over the RUL/RML.
# Lung CA: Patient was diagnosed with limited stage small cell
lung cancer in ___. He was due to start on taxol on the day of
admission as an alternative therapy given his ESRD. A ___
oncologist was consulted who desired to keep him on carboplatin
and etoposide, which is standard for small cell lung CA. He was
transferred to the inpatient oncology service. On the inpatient
oncology service he started chemotherapy
(carboplatin/etoposide), which was immediately followed by
dialysis to get rid of the excess agent following treatment.
This was done on days 2 and 4 of his admission. Radiation
oncology was also consulted. He will need to undergo a similar
regimen as outpatient for his next cycle of chemo in 3 weeks.
# ESRD: Patient usually gets HD on ___ and
___. He had HD on ___ with no complaints except for his
left upper extremity swelling. Renal was consulted and the
patient got HD on the day of admission, day 2 and day 4. He was
continued on his home renal medications
# LUE swelling: The patient was intially concerned for some left
upper extremity swelling following HD on ___. OSH DVT workup
was negative. By patient report, the swelling resolved largely
prior to admission. His arm was mildly swollen, not warm to the
touch.He never spiked a tempreature during the admission.
# Anemia: Patient is on epo. Renal fellow recommended holding
his epo given his active lung CA.
# HTN: The patient's blood pressure was stable on this admission
and he has not been hypertensive while in house. We continued
him on his home lisinopril.
# Hyperlipidemia: This issue was stable. The patient was
continued on his home simvastatin.
# Gout: This issue was stable. The patient was continued on his
home allopurinol.
.
----
Outpatient follow up
The patient will need to have his next cycle of chemotherapy in
approx. 3 weeks time scheduled with dialysis approx. 1 hour
after each chemo session
-He will need 2L of home oxygen at rest and 3L on ambulation at
home
***. | OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year old male with a past medical history of COPD on home O2,
CKD (baseline creatinine 1.2-1.7), CAD s/p CABG, sHF (EF
___, PVD s/p fem-pop and ___ transferred from OSH with
dyspnea, hypoglycemia, and ARF. Analysis of his urine revealed
ATN and his GFR recovered to 2.3 from a nadir of around 6.
# COPD exacerbation/dyspnea: On presentation the patient
complained of dyspnea worse than baseline, especially with
exertion. He was given steroids, nebulizers and a dose of
imipenem at OSH prior to transfer. His exam was notable for poor
air movement and diffuse wheezing. ABG on admission showed pO2
90, pCO2 33, pH 7.32, HCO3 18. CXRs showed no focal infiltrate
or vascular congestion. He was continued on steroids, standing
nebs and given azithromycin x 5d. He was started on sodium
bicarbonate to lessen the respiratory burden of his metabolic
acidosis from ARF. His dysnpea gradually improved with these
measures. The pulmonary team followed the patient throughout his
hospital stay. He was discharged on a slow prednisone taper due
to his frequent steroids use. Sodium bicarbonate was
discontinued prior to discharge. The patient has follow up with
his outpatient pulmonologist. Baseline O2 requirement was not
increased.
# Acute on Chronic RF: The patient's baseline creatinine is
1.2-1.7. His acute renal failure developed between discharge to
rehab and his current admission. The patient had no evidence of
obstruction on renal ultrasound. Placement of a foley catheter
in the ED yeilded approximately 100cc of urine. Urine
electrolytes, including FeNa and UNa, fluctuated through his
hospitalization. Urine microscopy revealed many muddy brown
casts. His creatinine slowly improved to 2.3 at discahrge. He
was given LR at 75 cc/hr for 1.5L while in the recovery phase of
ATN. Peripheral eos normal and urine eos were normal. He likely
developed ischemic ATN due to an increased dose of furosemide,
concurrent ___ and decreased PO intake. Less likely was AIN
secondary to antibiotics. He was provided a low Na, low K, and
low Phos diet. No indications for dialysis were met.
# RLL lung mass: The patient's extensive smoking history, weight
loss, and declining respiratory reserve raise the suspicion for
malignancy. CT chest from ___ revealed: dense 11 cm
consolidative mass in right lung base, more likely
neoplasm such as mucinous adenocarcinoma than infection. The
patient did have a recent admission for pneumonia which makes
resolving infection a possibility. Pulmonary and interventional
pulmonary consulted and recommended repeat CT in ___ weeks. If
resolution is not seen bronchoscopy/EBUS with biopsy will be
offerred.
# Altered mental status/hypoglycemia: The patient presented to
OSH with a glucose of 30. He was given D50 and transferred to
the ___ ED where he again developed a hypoglycemic episode.
Factors contributing to hypoglycemia including renally cleared
sulfonylurea and ARF. The patient recovered with octreotide and
pulse steroids (for COPD).
# DMII: Interolarant of oral hypoglycemics due to impaired GFR.
Most recent A1C 8.7. The patient experienced critically high
glucose readings on admission in the setting of prednisone and
octreotide. He was started on Lantus 20units QHS and sliding
scale insulin. His standing and sliding scale insulin doses will
need to be decreased as prednisone is tapered.
# Systolic HF: Most recent EF ___. The patient was euvolemic
to mildly hypovolemic during his hospital stay. The patient was
discharged on furosemide 40mg daily.
# CAD s/p CABG: The patient denied chest pain this admission. No
acute changes were seen on EKG. The patient recently had a
coronary cath at ___ which demonstrated patent grafts. He was
continued on continue ASA, simvastatin and metoprolol.
# History of A.flutter: The patient was in NSR throughout his
hospitalization. No arrhythmias or other events were noted on
tele. He was continued on his home doses of metoprolol and
diltiazem.
#HTN: Normotensive on metoprolol and diltiazem. Holding losartan
due to ___.
Losartan can be restarted once creatinine stabilizes if the
patient is hypertensive.
TRANSITIONAL ISSUES
*******************
1. Follow up CT chest in 4 weeks
2. Trend creatinine to stabilization
3. Taper prednisone (last dose ___
4. Titrate insulin dosing (as patient is weaned off prednisone)
5. Nebulizer treatments PRN
6. Pulmonary and nephrology follow up
***. | CHRONIC OBSTRUCTIVE PULMONARY DISEASE 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 ___ trauma service on ___
after being involved in a high speed motor vehicle accident,
injuries included TBI, pelvic fracture, traumatic diaphragmatic
rupture, and portal vein injury. He was unstable and taken
directly to the operating room, where he had a cricothyroidotomy
performed, b/l chest tubes, exploratory laparotomy and repair of
diaphragm and portal vein. He was taken to the TSICU. On POD3
he underwent washout, IVC filter placement, tracheostomy and
Dobbhoff placement. On POD___/4 he underwent GT placement and
partial closure, on POD ___ he underwent abdominal closure.
On POD ___ he underwent ORIF of his pelvis. On POD
___ he underwent GJ tube placement. He was
transferred to the floor on POD ___.
Neuro: The pt had severe traumatic brain injury on admission, a
bolt was placed by neurosurgery on POD2 and his ICP was markedly
elevated. He was therapeutically cooled intravascularly with
improvement in his ICP. On POD4, his ICP improved and he was
warmed, the bolt was removed on POD5. His neurologic exam
slowly improved and by transfer out of the ICU on POD23 he was
awake, alert, and talking appropriately.
CV: The pt required significant resuscitation initially d/t the
severity of his injuries and massive bleeding. He was
transiently on pressors, but was hemodynamically stable after
rewarming
Resp: The pt require surgical cricothyroidotomy on admission d/t
lack of definitive airway. This was changed over to a
tracheostomy on POD3. He was weaned to trach mask ventilation
and on POD 21 from his initial operation his trach was
decannulated and he was weaned to room air. He suffered from
HCAP/Aspiration PNA and was treated with vanco/bactrim/imipenem
for Stenotrophomonas and MRSA pneumonia.
GI: The pt had a traumatic diaphragmatic rupture and required
gastrotomy initially to evacuate and reduce the stomach. He was
left open and his abdomen was serially washed out and closed.
He had a GT placed on POD7 from the initial operation, but he
had difficulty tolerating tube feeds. He was able to be fed
post-pylorically, but was unable to tolerate GT feeding. When
his GT was clamped he would vomit resulting in aspiration,
despite treatment with reglan and erythromycin. When he began
to improve neurologically he self-d/ced his dobhoff tube, son on
POD 14 from his GT placement, he had this tube changed to a G-J
tube. After this his tube feeds were advanced to goal and he
was tolerating them well.
GU: The pt's pelvic fracture was repaired by orthopedic surgery
service on POD14 from his initial operation. He had a foley
until this time, after which it was changed to a condom cath and
then removed.
ID: the pt suffered from high fevers following his initial
rewarming to 104. His cultures were significant for MRSA and
Stenotrophomonas pneumonia. His fevers continued until POD 18
by which point they spontaneously improved.
Mr. ___ was transferred to the surgical ward on ___. His
vital signs remained stable. He continued to be agitated and
impulsive at times requiring restraints due to safety concerns.
While receiving tube feedings, the patient vomited on multiple
occasions. Tube feeds were held during that time and the rate
of infusion was decreased to facilitate tolerance. On HD 26,
the patient passed his swallowing evaluation. His tube feedings
were discontinued and he was started on a regular diet with
strict aspiration precautions.
On HD 27, Mr. ___ began to vomit frequently while consuming
oral intake. He was only given applesauce and pureed foods,
which he seemed to tolerate better than thin liquids. At the
same time, his jejunal feedings were resumed. While he was able
to tolerate jejunal tube feeds, whenever PO feeding was resumed,
the patient vomited. For this reason the patient was kept on
jejunal tube feeds and kept NPO. The patient did, however,
tolerate oral medications with liquids, without issue. Aside
from times of medication administration and two hours after, Mr.
___ gastric tube was kept open to drainage. The clinical
staff at the rehabilitation facility should advance the
patient's diet as tolerated/clinically warranted based on their
assessment.
At the time of discharge on ___ the patient was doing well,
afebrile with stable vital signs. The patient was tolerating
his tube feeding, not ambulating, but with a rehabilitation plan
devised by ___ and OT, voiding without assistance, and pain was
well controlled. The patient was discharged to rehab. The
patient received discharge teaching and follow-up instructions.
The patient's wound vac sponge was removed and wet-to-dry
dressings were applied. The new wound vac should be replaced by
the rehabilitation facility.
***. | ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PDX EXCEPT FACE MOUTH AND NECK WITH MAJOR O.R. PROCEDURE |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
SAFETY: The pt. was placed on 15 minute checks on admission and
remained here on that level of observation throughout. He was
unit-restricted. There were no acute safety issues during this
hospitalization.
LEGAL: ___
PSYCHIATRIC:
#) Schizophrenia, paranoid type: Patient admitted to having
delusions of ___ telling him he was not allowed to eat.
Patient stated they started around 1 month ago. He had lost 8
lbs. Patient stated he has been compliant with medications.
Clozapine level was drawn and was: Norclozapine 148, clozapine
377. He was restarted on home meds which included Clozapine
150mg BID, Trazadone 100mg QHS and IM risperidone Consta 50mg
Q2weeks. He received and injection while in house on ___.
Patient became more coherent and less paranoid while in house.
He was eating appropriately and denied hearing any voices or had
any delusions of ___ telling him not to eat.
#) Alcohol Use Disorder: Patient had a recent relapse on alcohol
after an approx 8mo stretch of sobriety. Patient was restarted
on his home naltrexone 100mg daily.
GENERAL MEDICAL CONDITIONS:
#) CBC: Was drawn on ___ and shown a WBC count of 5.7 K/uL
and a ANC of 2.56 K/uL.
PSYCHOSOCIAL:
#) GROUPS/MILIEU: Pt was encouraged to participate in units
groups/ milieu/ therapy opportunities. Use of coping skills and
mindfulness/relaxation methods were encouraged. Therapy
addressed family/social/work issues. Patient and family were
involved in family meeting focused on psychoeducation and
discharge planning.
#) FAMILY INVOLVEMENT:
- no family involvement
#) INTERVENTIONS:
- Medications: Clozapine 150mg BID, IM Risperidone Consta 50mg
Q2weeks, Trazadone 100mg PO QHS:PRN, Naltrexone 100mg Daily
- Psychotherapeutic Interventions: Individual, group, and milieu
therapy.
- Coordination of aftercare: Appt with Dr. ___ at ___
INFORMED CONSENT: The team discussed the indications for,
intended benefits of, and possible side effects and risks of
starting these medications, 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
- Chronic Medical Illness
- Male
- Elderly
#) Modifiable Risk Factors:
- Relapse on alcohol
- Medication non-compliance
- decompensation of mental illness
#) Protective Factors:
- Current ongoing psychiatric treatment
PROGNOSIS:
Guarded: Patient has guarged prognosis because he has a severe
chronic mental illness and occasional decompensations due to his
delusions and relapse on alcohol abuse. Patient does keep appts
and take all his medications as prescribed as outpatient, which
allows him to keep him out of hospital. The most important part
is to keep him from relapsing on alcohol, which usually precedes
him coming to hospital.
***. | PSYCHOSES |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Patient was admitted to the ___ Spine Surgery Service for
infection of surgical wound. TEDs/pnemoboots were used for
postoperative DVT prophylaxis as well as aspirin. Intravenous
antibiotics, vancomycin was initially started and switched to
Nafcillin once cultures grew MSSA Patient followed by ID. Diet
was advanced as tolerated. The patient was transitioned to oral
pain medication when tolerating PO diet. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet
***. | POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURE WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
On ___, Mr. ___ was transferred from OSH with fever and
UA concerning for UTI. He also had a fluid collection at the
site of his baclofen pump and there was a small amount of clear
drainage intermittently from the incision. He was treated with
IV ceftriaxone and admitted to the neurosurgery service for
close monitoring. CT of the abdomen showed resolution of a
previously seen rim-enhancing fluid collection, and was not
concerning for infection. His leukocytosis on admission
downtrended and his antibiotics were transitioned to PO bactrim
and keflex. He was afebrile during his admission. He was
discharged home with instructions to follow-up with his PCP on
HD#2.
***. | KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
ORTHOPEDIC COURSE ___:
The patient was admitted to the orthopedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
On POD#1, the patient spiked a temp to 102.5. She was required
oxygen despite attempts to wean from the nasal cannula. Her WBC
was also 12.5. Given her pulmonary history and current smoking
status (1ppd), a chest x-ray was performed. Per the radiologist,
there was some concern for pneumonia versus a pulmonary
embolism. A CTA was performed. The CTA was negative for a
pulmonary embolism. She was found to have scattered
ground-glass opacities in the left upper and right middle lobes.
She was started on PO Levaquin 750mg once daily. Pain was
controlled with a combination of IV and oral pain medications.
The patient received Lovenox for DVT prophylaxis starting on the
morning of POD#1. The overlying dressing was removed on POD#2
and the Silverlon dressing was found to be clean and dry. Due to
continuing fever and hypoxia, the pt was started on Vancomycin
on ___ and cefepime was added ___. Repeat CXR concerning for
worsening multifocal opacities vs ARDS.
TRANSFERRED TO INTENSIVE CARE UNIT ON ___:
Patient transferred to ___ ___ with persistent fevers and
leukocytosis on day 2 of all 3 antibiotics.
She presented with hypoxic respiratory distress/failure with
increased oxygen requirement. She was treated with continued IV
antibiotics and oxygen requirement on high-flow face mask was
titrated as needed. Azithromycin 500 mg 5-day course was added
on for atypical coverage. CTA showed multifocal faint ground
glass opacities that seem most consistent with an atypical
infection. CT was redone that showed worsening bilateral ground
glass opacities, and radiology said findings were most
consistent with bacterial pneumonia, and not COP. Cultures sent
were not diagnostically helpful. Her respiratory status improved
and she was able to go back to the general medical floor.
TRANSFERRED TO GENERAL MEDICINE ON ___:
# Pneumonia: the pt presented from the FICU with 5 L NC O2
requirement. After evaluation by the pulmonary team, she
underwent VATS procedure on ___ to get tissue biopsy to
confirm a diagnosis of COP. Abx were discontinued as the pt's
clinical status improved, and when she was started on empiric
steroids following VATS, her O2 requirement decreased
substantially. Final path report showed inflammatory changes
consistent with COP. She was found to have a RF 22, CRP elevated
although this could be to general inflammatory process and an
elevated ESR concerning for underlying inflammatory process (see
transitional issues). Fungal studies were negative. On day of
discharge the pt was breathing comfortably on room air at rest
and required O2 by NC only for symptom relief while ambulating.
# Anemia: the pt had normocytic anemia and had a preliminary
workup with hemolytic labs unrevealing. Her hemoglobin was
likely decreased in the setting of infection, dilutional and
mild bleeding from surgery. There were no signs of active
bleeding.
# Right hip arthroplasty: she continued to work with ___ who
recommended home ___ on discharge. She received ___ mg
oxycodone q8h for pain.
# HTN: the pt was continued on her home metoprolol. Her
amlodipine was held given concern for hypotension.
# HLD: the pt was continued on her home ASA and simvastatin
# chronic pain: treated as above
***Transitional issues***:
- steroids: pt will take 60 mg prednisone daily until her
appointment with pulmonary. She should take Bactrim SS daily and
Calcium/Vitamin D for prophylaxis.
- Pulmonary to schedule follow up CT scan before next
appointment. Please ensure CT scheduled and performed to
expedite management at next pulmonary appointment.
- Multiple nodules (2-3mm each) noted on CT scan of lungs.
Follow-up in 12 months with dedicated CT is recommended. Dr.
___ at your primary care physician's office was notified of
this. She will report this to Dr. ___.
- the pt was noted to have an elevated ESR >130 inpatient, which
is concerning for an underlying malignancy, vasculitis, or other
inflammatory process. After resolution of COP, if inflammatory
markers persist, further workup should be considered.
- the pt's home amlodipine was held during her stay because of
concern for hypotension. This should be restarted in the outpt
setting as needed.
-patient should continue to take Lovenox 40mg SC daily as ppx
for DVT until ___
- The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity with posterior precautions.
Walker or two crutches at all times for 6 weeks.
FULL CODE
***. | MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY 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.
***
___ is an ___ y/o M hx of CAD (NSTEMI in ___,
s/p stenting), HTN, NIDDM, former smoker, who presented with one
day of cough / dyspnea after being scared by a mouse.
Presentation was concerning to atypical angina equivalent given
cardiac history. Underwent nuclear stress test with showed a
reversible, medium sized, moderate severity perfusion defect
involving the LAD territory. Subsequent cath showed an 80%
lesion in the mid LAD with DES x2 placed. 95% diagonal lesion
underwent balloon angioplasty as vessel was too small for
stenting. TTE showed an EF >55%, mild aortic stenosis, mild
mitral regurgitation, no focal wall motion abnormalities.
Carotid ultrasound for bruit on exam showed <40% stenosis
bilaterally. Diuresed with 20mg Lasix x2 days with improvement
in ___ edema. Given that TTE with normal EF and pro-BNP 440, was
not discharged on Lasix.
TRANSITIONAL ISSUES:
-S/p ___. Discharged on ASA, clopidogrel. Please
determine duration of dual antiplatelet therapy
-Amlodipine increased to 10mg daily
-Metoprolol decreased to 12.5mg daily
-Home lisinopril held on discharge as BP well controlled without
and already on valsartan
-Vitamin B12 level 189, started on 1000mcg daily, please
follow-up
***. | 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.
*** yr old male s/p liver transplant, post splenectomy with RLE
cellulitis
.
RLE cellulitis: We started him on vancomycin but his cellulitis
continued to expand beyond its initial boundaries. We changed
this to Unasyn, and his erythema retreated substantially from
prior boundaries. Throughout the admission he was not having any
systemic symptoms. The cellulitis appeared to go around joints
rather than over them, and his primary pain did not seem to be
joint associated, which argued against gout or septic joints. He
continued to have a fair amount of pain through the admission,
however. At this point we felt that it would still be most
likely that resolution of pain will gradually follow resolution
of clinically apparent cellulitic erythema, but if pain
continues unabated it might be an indication for outpatient MRI
to rule out underlying osteomyelitis or other possible nidus of
infection (though there was no evidence or focal findings that
would suggest abscess). We changed over to augmentin PO, with
continued improvement, and then discharged the patient to home.
Cultures were unrevealing. We considered the possibility of an
atypical presentation of the many possible manifestations of
cryoglobulinemia, but given his response to antibiotics we
deferred a workup for this.
.
#Leukocytosis: Chronic, associated w heme abnormalities
described below; continue to monitor.
.
#Thrombocytopenia: Hx of ITP, s/p splenectomy, but decreased
since last level. Easy bruising and bleeding. Bone marrow biopsy
during his hospitalization in ___ revealed a hypercellular
marrow (90% cellularity) with myeloid and megakaryocytic
hyperplasia. Karyotype on the bone marrow revealed: 46, XY,
21PSTK+: no clonal cytogenetic aberrations, but the well-known,
clinically insignificant chromosomal variant pstk+. JAK mutation
negative. Receives infusions of gamma globulin and followed by
heme. He received IVIG during this admission; his plts were
stable in the mid- to high-40s. Though the platelet count goal
is 50, we felt that he did not need repeat IVIG given that the
platelet count was near this goal, stable, and no procedures
were being contemplated.
.
#S/P liver transplant. Tacrolimus levels were followed and
tacrolimus was dosed by level. He was sent out on 1 mg BID, a
slight decrease from his prior dose of 1.5 mg BID.
.
FEN: regular cardiac diet, repleted lytes PRN
PPX: bowel regimen
Access: PIV
Dispo: home
.
.
***. | 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.
***
ASSESSMENT AND PLAN: ___ year-old woman with a history of DLBCL
with meningeal involvement who is s/p three cycles of R-CHOP and
three cycles of HD-Methotrexate who is presenting with poor PO
intake and abdominal pain concerning for MTX induced
mucositis/esophagitis.
#Mucositis/Esophagitis:
Significantly improved prior to discharge. Patient with poor PO
intake secondary to painful oral lesions and burning pain
extending along esophagus to epigastrium. In setting of recent
HD-MTX concerning for MTX induced mucositis/esophagitis. With
her current neutropenia, she is at increased risk for bacterial
translocation. Pain continues to improve currently and she is
able to tolerate increased PO
intake. She is having increased expectoration which is likely
secondary to esophageal mucosal irritation. She had been on a
dilaudid PCA but had no longer required it so converted to prn
oxycodone liquid for pain. Nutrition was consulted and she was
supported with TPN but this was subsequently discontinued as her
PO intake increased.
#Neutropenic Fever: Besides Urine cx showing <100,000 CFU of
alpha strep/lactobacillus, no identified source of infection.
She was empirically managed with cefepime (d1: ___ and
vancomycin (___). No fever spikes since ___.
#Headache: She describes diffuse headache which occurs when she
coughs. With hx of meningeal involvement of her lymphoma,
obtained MRI brain which shows decrease in dural thickening and
enhancement since the MR of ___. Unchanged appearance of
likely right anterior cranial fossa meningioma. Unchanged
appearance of calvarial signal intensity abnormalities
suggesting tumor infiltration.
#DLBCL: DLBCL with meningeal involvement who is s/p three cycles
of R-CHOP and three cycles of HD-Methotrexate. ___ consider next
cycle of HD-MTX at decreased
dose or alternative agent per primary oncologist. Restaging PET
scan ___ pending at discharge. She continues on acyclovir and
fluconazole. Holding Folic acid in anticipation for next dose of
HD MTX.
#Constipation: On presentation patient reported she had not had
a bowel movement in ___ days. She had bowel regimen ordered. She
had had pain with defection consistent with mucositis that may
involve entire GI tract and rectum. Continues with standing
bowel regimen and has been having daily BMs prior to discharge.
#GERD: H omeprazole in anticipation of next round of HD-MTX,
added ranitidine 150mg BID (___)
#ACCESS: Right chest POC
#CODE: FC
#EMERGENCY CONTACT: ___: ___
#DISPO: home
***. | 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.
*** y/o female who has been undergoing routine, q 3 month
exchanges of the PTC drain. She underwent successful exchange of
the the drai. A new 10 ___ internal-external biliary drain
was the placed under fluoroscopy with pigtail was formed in the
duodenum. Final images following a second contrast injection of
7 cc demonstrate good positioning of drain within the biliary
tree and duodenum with prompt clearing of contrast into the
duodenum.
The patient initially did well, however she developed a fever to
101.2 and chills, and so was admitted overnight.
The drain bag was initally left open, and she received
Vancomycin and Zosyn. The fever abated, and she remained
afebrile overnight.
Mornign labs were obtained, and the LFTs were WNL and did not
show any rise from the previous days values.
The patient was feeling well with only minimal discomfort at the
drain site.
The drain was capped, the antibiotics were discontinued and she
was discharged back to ___. She will complete a
course of Cipro on ___, all other home medications will be
resumed.
Followup for routine exchange should be in 3 months.
***. | 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 ___ yo man with CAD s/p CABG, EHF EF 35%, S/P ICD
for h/o VT here with c/o 4 months of CP, volume overload, and
concern that ICD fired.
.
#. CAD- Pt with known CAD and now with months of chest pain. Pt
reports the pain is different than his previous angina. Cardiac
enzymes were negative and ECG revealed no changes from prior.
Patient was continued on regimen of aspirin, plavix,
atorvastatin, lisinopril, and toprol xl.
.
#. Pump - Pt with EF 35% on ___. Appears volume overloaded on
exam. Pt reported non-adherence to lasix regimen. He was treated
with IV lasix and lost approximately 5 pounds while inpatient.
He continued his lisinopril and metoprolol.
.
#. Rhythm - Patien has ICD for history of VT. Recent admission
for ICD firing several months prior. Pacer was interrogated by
EP while in house. Also was changed from procainamide to
sotalol. qTC was monitored with ECG following day and there was
no evidence of prolongation.
.
#. BRBPR- Noted to have episode in ED. Anoscopy performed was
negative in ED for hemorrhoids. No further episodes while
admitted and HCT was stable. Patient told to follow up with his
PCP.
.
# Anxiety- continued regimen of diazepam.
.
# ADD- continued methylphenidate per outpt regimen
.
# Chronic Lower back pain - continued oxycontin and percocet
.
#. PPx: protonix, hep subq
. .
#. Contact: Mother, ___ ___ cell; ___ home.
.
#. Code: Full
***. | 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.
***
___ admitted for ischemic right index finger. She was started
on a heparin drip, which improved her symptoms. Her skin became
more pink, but some residual necrotic tissue was observed.
During her stay, she was evaluated for a potential autoimmune
cause for this process. To this end, and ESR and CRP were
obtained, neither of which stongly supported an inflammatory
process. She additionally had a syncope workup which included a
echo cardiogram and carotid ultrasound. The echo cardiogram
demonstrated a mildly dilated ascending aorta, but there was no
structural cardiac cause of syncope identified. The carotid
ultrasound was performed but the study was not published at the
time of discharge. The patient was in stable condition, with
her pain well controlled. She is being discharged on coumadin
and was instructed that she would need daily blood drawn to
check and adjust her INR. This was explained to the patient who
will be seeing a new PCP starting this ___ at which
time, he would take over responsibilty of checking her INR
levels. Until this time it was agreed that she would have daily
labs drawn at a local labratory and those results would be faxed
to Dr. ___. Her PCP should also follow up with her
blood pressure and heart rate as both have been mildly elevated
while in the hospital.
***. | PERIPHERAL VASCULAR 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.
***
___ with HFpEF, pulmonary hypertension, atrial fibrillation,
cirrhosis and increasing renal mass presenting with worsening
DOE over the past month despite increases in home diuretics.
# Dyspnea on exertion: Patient with multiple reasons for
dyspnea on exertion, including heart failure, pulmonary
hypertension, atrial fibrillation, deconditioning or even angina
equivalent. Recent TTE showed signs of right ventricular
pressure overload, and in the setting of weight gain (10 lbs),
lower extremity edema and elevated JVP, this makes heart failure
exacerbation the most likely culprit. Troponins were 0.02->0.01
and therefore difficult to interpret. She is on albuterol
inhalers, and exertional dyspnea especially taking a few minutes
to have symptoms, could be consistent with reactive airway
disease. However, previous PFTs do not suggest reactive airways
disease. Given her age, perhaps aspiration is a possibility. She
appears to be well-rate controlled in terms of her atrial
fibrillation, and therefore this is less likely. Patient
underwent persantine pharmacologic stress test on ___ which was
negative for reversible ischemia or filling defects. Patient was
diuresed with 100mg Lasix BID and transitioned to torsemide 60mg
BID PO. Overall, patient felt somewhat improved, however her
symptoms did not completely resolve. Patient should continue to
have an outpatient work up for non-cardiac dyspnea on exertion.
# Heart failure with preserved ejection fraction: Weight is up
to 162 lbs from 152lbs in ___. This does represent an
increase, but not an increase over a short period of time per
se. However, she has elevated JVP and 1+ pitting/spongy edema in
her lower extremities and crackles bilaterally. No clear
precipitating factor, although she does have Proteus >100,000
colonies during this hospitalization, albeit without symptoms.
Continued lisinopril and metoprolol. Patient was diuresed with
100mg Lasix BID and transitioned to torsemide 60mg BID PO
regimen.
# Acute kidney injury: Patient's ___ (Cr 1.7 from normal
baseline) likely from cardiorenal state, given that Creatinine
improved to baseline after diuresis. Patient had a Cr elevation
to 1.3 after 100mg IV Lasix BID, likely from overdiuresis.
# Urinary tract infection: Patient with pyruia and bacteriuria
and growing Proteus > 100,000 sensitive to CTX. Patient treated
with CTX for 3 days. Blood cultures remained negative.
# Atrial fibrillation: Patient rate controlled with diltiazem
and metoprolol. Warfarin was continued. Goal INR ___.
# NASH Cirrhosis: Patient followed by Dr. ___ in hepatology.
Well-compensated. No current medical therapy. LFTs within normal
limits. Alk Phos elevated 131, however has been elevated since
___.
# Renal mass: Followed by Urology with active surveillance with
interval imaging every ___ months.
# Diabetes: Diet controlled. Glucose with AM labs: 150-300
while hospitalized. A1c was 6.9% in ___.
TRANSITIONAL ISSUES
===========================
-Consider bubble study for evaluation of pulmonary shunt.
-Consider evaluation for sleep apnea.
-Follow up with Cardiology.
-DISCHARGE WEIGHT: 72.8kg.
# LANGUAGE SPOKEN: ___
# CODE: Full, discussion deferred without interpreter
# CONTACT: Name of health care proxy: ___
Relationship: daughter
Phone number: ___
Cell phone: ___
**Grandaughter: ___: ___. Per family,
___ is best point of contact for longer conversations given
she speaks ___ best**
***. | 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.
***
___ year old female with delayed gastric emptying p/w nausea and
vomitting now resolved and tube feeds at goal through J tube
placement.
.
# Nausea/emesis: Ms. ___ emesis and nausea complaints
have been occurring for over a year now. She has undergone
abdominal CT scans, EGDs, colonoscopies, ERCP and multiple lab
studies but the etiology of her chronic nausea and emesis is
still unclear. Her current acute exacerbation leading to this
admission was attributed to opioids provided after her recent
J-tube placement on ___, just days before transfer to ___.
Morphine was stopped and her emesis improved slightly although
her nausea was fairly persistent. Although she has been labeled
with gastroparesis diagnosis her two recorded gastric motility
studies are fairly equivocal on closer review. She had a
borderline normal gastric motility study on ___ followed by
subsequent gastric emptying study on ___ which only showed
mild dysmotility but the study was suboptimal and technically
limited due to non-standard meal and multiple episodes of
vomiting. Therefore, a diagnosis of idiopathic gastroparesis is
not clearly warranted at this juncture and her workup is ongoing
for the underlying etiology of her vomiting and emesis. She has
no history of diabetes and no signs or symptoms of scleroderma
in review of other differential causes of gastroparesis. Nausea
resolved with dexamethasone, dosing as per palliative care
recommendations.
.
Neurological exam was remarkable for hyperactive 3+ lower
extremity DTRs and clonus in her ankles bilaterally. She also
has generalized weakness, worse in her lower extremities. A
neurology consult was called to consider possible UMN insults
which may be causing her nausea/emesis such as hypothalamic
and/or pituitary pathology. Furthermore, she had secondary
amenorrhea for nearly ___ years that predated her GI symptoms
which also sparked concern for interplay of an endocrine or
neuroendocrinological process. A follow-up MRI of the brain and
spine was unremarkable. HTLV-1 studies sent to work-up tropical
spastic paraparesis as potential etiology of her illness.
.
Sjogrens disease antibodies and Whipple's Disease PCR tests all
sent off and results to be followed up by GI in one week at
outpatient appointment.
.
The GI team was consulted soon after her admission and continued
to follow her through her hospital course. Initial J-tube
gastrograffin plain x-ray study on ___bdomen
___ showed no SBO, no absceses, and normal placement of
J-tube and feeds were initiated. Nutrition consult called to
help adjust tube feed recommendations. Plan was to advance her
feeds q6hours very slowly at ___ intervals with end goal
50cc/hr as she had persistent nausea with attempts to advance
past 20cc/hr. By time of discharge, tube feeds at goal.
.
Initially, she was unable to tolerate PO food but taking pills
orally so most of her IV medications switched to PO. She was
continued on a wide variety of antiemetics, including standing
zofran, PRN compazine and phenergen, ativan and marinol 5 mg qid
and 5 mg q4 prn. She continued to have refractory nausea so the
palliative team was called for a consult and additional
recommendations on nausea/emesis control. She was started on 4mg
IV Decadron q6 hours and then q8 hours for 3 days. Steroids
improved her appetite and improved her nausea/emesis. Steroids
were soon weaned and she was stabilized on several PO
medications for discharge.
.
.
# Secondary amenorrhea: Patient has been without her menses for
___ months pre-dating her nausea and vomiting episodes when her
body weight was stable. Thus, cannot blame pure
malnutrition/anemia for her amenorrhea; although this is likely
a major contributor to her ongoing irregular cycles now given
her nearly 45 lb weight loss and extreme iron deficiency. As
noted, this raised concern for hypothalamic/pituitary etiologies
but her MRI brain was WNL. HCG urine pregnancy screen negative.
On further lab studies she had an elevated prolactin level of
60, but this mild elevation was felt to be from medications
rather than a prolactinoma which would typically create a much
higher prolactin level. Moreover, the brain MRI was normal. FSH
in low normal range and LH low. DHEA-S and testosterone were
low, and her estrogen levels to be followed up in GYN and
endocrine as outpatient. Patient has menstrual cycle prior to
discharge, but workup is still warranted.
.
# Weakness, gait disturbance: Unsteady weak gait most likely
from generalized malnutrition, severe anemia. Toes downgoing on
right and equivocal on left, sensation in tact, but
hyperreflexia 3+ at patellar tendons B/L noted and hyperreflexia
at upper extremities. Head CT and MRI brain and spine had no
acute process/masses to explain a clear neurological process.
Also, her B12, TSH and cortisol levels were all assessed and
WNL. She will plan to continue her home tube feeds, vitamins
and iron to help improve her nutritional status.
.
# Anemia: Very clearly iron deficiency anemia given ferritin of
4.6 and iron of 14 in ___ of this year. MCV still <70.
Repeat anemia workup on this admission showed an iron level of
19, normal folate and Vitamin B12 levels, TIBC 385 and ferritin
of 18 to re-confirm her severe iron deficiency anemia.
Colonoscopy performed in ___ was normal, leaving poor
nutritional status or mal-absorption as the etiology. She had a
prior reaction with hives to IV iron infusions at ___
___ so her PCP was contacted for details and her reaction
had been to Ferrlicet iron preparation in the past. Therefore
she was given pre-treatment Benadryl and H2B and a test dose of
iron dextran was given with no adverse reactions so she was
given additional iron infusions during her stay in attempt to
correct her low iron levels. She will plan to continue her
infusions with iron dextran with her PCP after discharge.
.
# Depression/Anxiety: Ms. ___ had a fairly flat, depressed
affect noted on arrival so a social work consult was called. No
suicidal ideation. She was also extremely fatigued, dehydrated
and malnourished which made her presentation appear more
depressed as well. Mood seemed to improve as her nausea and
emesis began to taper off. She was continued on her usual daily
Paxil and Diazepam was switched to Ativan PRN initially and then
standing Ativan for added anti-nausea effects. Given additional
Ativan during imaging studies due to increased anxiety levels.
Social work continued to follow patient for coping and
counseling during her stay.
.
# Fluids, Electrolytes and Nutrition: Monitored and repleted
electrolytes as needed. IVFs were provided throughout her
hospital course and as noted a nutrition consult called to help
with tubefeeding recommendations. She was placed on Fibersource
HN full strength tube feeds starting at 10 ml/hr and advanced
rate very slowly by ___ ml q6h with a goal rate of 50 ml/hr. By
time of discharge her feeds were at goal and she was set up with
___ and home services to assist with continued tube feeds as an
outpatient.
.
# Prophylaxis: SC Heparin given for DVT prevention and IV PPI
was switched to a PO PPI BID for GERD coverage.
.
# Code status: Patient was maintained as a full code status ;
confirmed directly with patient.
.
***. | 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.
***
SUMMARY OF HOSPITALIZATION
============================
Ms. ___ is a ___ woman with history of CKD stage V, central
retinal artery occlusion, and hypertension who presented to the
ED with whole body pruritus, found to have acute hepatocellular
and cholestatic liver injury, with CKD within baseline and a
very mild hyperkalemia that resolved after single dose of lasix.
Workup for obstructive cause by right upper quadrant ultrasound
showed stones but no obstruction or biliary dilation, MRCP
showed also do NOT show biliary dilation or
obstruction. Serologic workup was negative for infectious cause,
toxin ingestion. Recent exposure to amoxicillin-clavulanate was
thought to be the most likely cause. LFTs downtrended. Amox-clav
was added to allergies and patient was discharged.
ACUTE ISSUES ADDRESSED
========================
# Mixed hepatocellular/cholestatic injury
Presentation of pruritis found with transaminitis, elevated alk
phos, and tbili that peaked at 2.8. Right upper quadrant
ultrasound showed coarsened hepatic parenchyma, no focal lesion,
though with cholelithiasis. MRCP showed no evidence of biliary
dilation or obstruction within the limits of the study. Patient
with recent amox-clav use for sinusitis, otherwise, no recent
start of culprit meds, no toxins, no supplements. Hepatitis B
immune and Hep C antibody testing negative. Hep A Ig testing was
positive with IgM pending at time of discharge. Thyroid function
within normal limits. Normal iron saturation. Autoimmune workup
not pursued. LFTs downtrending during discharge. Amox-clav was
added to allergies and patient was discharged.
# Pruritis
Underlying CKD 5 (stable, no e/o uremia) with acute
hepatocellular/cholestatic injury; while the bili wasn't
particularly high, may have tipped over the edge. Very mild
peripheral eosinophilia, no rash, reassuring against DRESS.
Cetirizine, Sarna was started with improvement of pruritis.
Received 1x gabapentin with improvement, but was unlikely the
agent to have helped. Hydrocerin ordered and never applied.
Cholestyramine was considered but not given because of risk of
hyperchloremic acidosis in renal impairment. Her pruritis was
improved at time of discharge.
# CKD stage V
On admission, at her baseline Cr. CKD likely due to secondary
focal glomerulosclerosis ___ pre-eclampsia in ___. Also with
contribution from hypertension. Labs stable over several months,
with intermittent metabolic acidosis and mild hyperkalemia.
Sodium bicarbonate dosing was recently increased. Renal
consulted in the ED, recommended outpatient follow-up with Dr.
___ as planned and compliance with sodium bicarb and low K
diet. Already has mature AVF.
# Hyperkalemia
Related to CKD, diet non-adherence. No EKG changes at K5.8,
which normalized. She received 1 dose of lasix.
# Borderline Macrocytic Anemia
Chronic, stable, secondary to CKD. On aranesp as outpt.
CHRONIC ISSUES ADDRESSED
==========================
# HTN
Continued home amlodipine and metoprolol.
# Gout
Held home allopurinol initially with concern for contribution to
transaminitis, then resumed prior to discharge.
# Hx central retinal artery occlusion ___
Felt embolic, carotid u/s neg, hypercoagulable work up negative,
though ___ 1:160 without other e/o autoimmune phenomenon.
Treated
with DAPT for 3 months(?) and maintained on aspirin thereafter.
Continued aspirin.
TRANSITIONAL ISSUES
===================
[] repeat LFTs to ensure they continue to downtrend.
[] Pravastatin was held on admission given elevated LFTs. Would
restart when LFTs normalized.
[] Found to have multiple tiny pancreas cysts (largest 7mm).
RECOMMENDATION(S): For management of pancreatic cyst(s) between
6-15 mm in patients between 65- ___ years at presentation,
recommend non-contrast MRCP follow-up every other year up to a
total of ___ years.
[] Received 1 dose of gabapentin with improvement of itching.
Unlikely to have helped. Consider restarting gabapentin 100mg
daily if itching restarts vs cholestyramine
[] amoxicillin-clavulanate added to allergy/adverse reaction
list
[] f/u ___ IgM, pending at time of discharge
[] f/u blood cx, no growth at time of discharge
#CODE: Full
#CONTACT:
Name of health care proxy: ___: husband
Phone number: ___
***. | 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.
***
___ is a ___ yo M w/ ESRD s/p cadaveric renal
transplant in ___, CKD, hypertension, 3-V CAD s/p DES to RCA
and OMB in ___, atrial fibrillation, COPD, diastolic CHF, who
presented with chest pain and palpitations and was found to be
in an AVNRT. He was managed initially with adenosine, and then
had good continued rate control with an increase dose of his
home metoprolol. He also had a troponin increase, which was
likely from demand (type 2 NSTEMI) rather than acute plaque
rupture or stent thrombosis in setting of recent coronary
angiogram on ___ that revealed non-obstructive CAD.
Electrophysiology consult recommended Mmtoprolol succinate 25 mg
PO QAM and 12.5 mg QHS, on which the patient was discharged. He
will follow-up with EP for further evaluation.
The changes to his chronic medical issues were an increase in
his metoprolol succinate dosing, as noted above, and amlodipine
for high blood pressure. Tacrolimus and sirolimus levels were
checked and within goal ranges.
TRANSITIONAL ISSUES:
DISCHARGE WEIGHT: 68.4 kg (150.79 lb) - he remained euvolemic
here
CONTACT INFORMATION: Proxy name: ___
Relationship: Daughter Phone: ___
CODE STATUS: Full Code
[ ] Please follow up patient's symptoms and heart rate,
titrating beta blockade as needed. Higher doses were not given
due to bradycardia into the low ___.
[ ] Follow up blood pressures
[ ] Please check CHEM10 on ___ and follow up labs, especially
Cr and Phos (which was low here, patient may require some
standing supplements)
***. | ACUTE MYOCARDIAL INFARCTION DISCHARGED ALIVE 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.
***
ASSESSMENT AND PLAN:
Mr. ___ is a ___ yo male with a h/o atrial fibrillation on
coumadin, HTN and COPD, with Right inguinal hernia repair w/
mesh ___, who was referred after being found to be hypotensive
at PCP appt, improved BP with fluid resuscitation.
# Hypotension, Orthostasis: Most likely etiology was hypovolemia
from decreased PO intake, diarrhea, drainage from wound, and
antihypertensive meds. Supported by his clinical description of
lightheaded when arising from a seated position (orthostatic
hypotension), hx of increased diarrhea, poor PO intake over
weekend, as well as elevated Cr from baseline (Cr of 1.4 from
1.0). Resolved with 1L fluid bolus. Held lasix and valsartan.
Cardiogenic shock less likely given lack of h/o CHF, CXR without
increased pulm vasculature and physical exam without crackles,
no elevation of JVD ___ edema. No fevers, chills or
leukocytosis to suggest sepsis, no growth in blood cx. His
inguinal wound does not appear infected at this time; only
draining serosanguinous fluid. Hct at baseline and no h/o
bleeding to suggest hemorrhagic shock. D-dimer negative (ruling
against PE), no PTX on CXR. No h/o steroid use to suggest
adrenal insufficieency as a cause of hypotension.
- Given IVF and monitored, was asymptomatic on discharge
# Hernia Incision/Wound Drainage: Right inguinal hernia repair
incision done 2 weeks ago, staples removed last ___ since
that time, large amounts of serosanguinous drainage. N signs on
infection (no fevers, chills, leukocytosis), no purulent
drainage, no bacterial growth on wound culture so far.
-___ 3 Surgery suggested dry gauze dressings and ___ wound care
f/u.
# Atrial fibrillation: His initial trigger for A fib with RVR
may have been ___ dehydration and exertion. Well rate controlled
with HR's in the 100's-110's after fluid bolus.
-Continued home diltiazem and metoprolol.
# Coagulopathy/Supratherapeutic INR: Mr. ___ INR was
measured 4.9 on ___. Most recent INR per Atrius was 3.4, at
which time warfarin dose was changed to 6mg daily. Possibility
that patient was taking larger warfarin dose than recommended
(per ___, last filled dose was 7mg).
-Held coumadin ___ have INR drawn by ___ on ___, and
coumadin mgmt team at ___ will adjust his dose.
# Hypothyroidism: Stable, continued home levothyroxine 25 mcg
daily
# COPD: Stable; gave duonebs ___ and home budesonide.
# GERD: Stable; continued home ranitidine 150 mg qhs
#Transitional Issues:
- Stop Valsartan and Furosemide until PCP appointment on ___
- INR check on ___, with dose adjusment in light of
results
- Possible repeat echocardiogram, for PCP consideration
Blood cultures pending at time of signing.
***. | MISCELLANEOUS DISORDERS OF NUTRITION METABOLISM FLUIDS AND ELECTROLYTES WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous vancomycin was
continued in the post-operative period as continued treatment
for his chronic infection. Initial postop pain was controlled
with a PCA. Patient suffered from post-operative ileus that was
treated succesfully with methylnaltrexone on POD #3. The
patient was transitioned to oral pain medication when tolerating
PO diet. Due to his high demand for opiates, pain management was
consulted for recommendations for weaning patient off of
narcotics. Foley was removed on POD#2. Physical therapy was
consulted for mobilization OOB to ambulate, they deemed him safe
to discharge home but determined that he should receive and
in-home evaluation and participate outpatient physical therapy.
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.
***. | BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE 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 to ___ on ___. Pt was evaluated
by anaesthesia and taken to the operating room where she
underwent a laparoscopic Roux-en-Y gastric bypass. A IJ central
venous line was placed due to difficult with peripheral access.
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. Pt had some post-operative pain that was
managed with morphine PCA.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a PCA and then
transitioned to oral Roxicet once tolerating a stage 2 diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Right IJ CVL
was removed prior to admission with no issues.
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 with a
___ tube in place for decompression. On POD1, the NGT
was removed and an upper GI study was negative for a leak,
therefore, the diet was advanced sequentially to a Bariatric
Stage 3 diet, which was well tolerated. Patient's intake and
output were closely monitored. JP output remained
serosanguinous throughout admission including after advancement
to stage III; the drain was removed the day of discharge.
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
with stable vital signs. The patient was tolerating a 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. She will follow up with Dr.
___ on ___.
***. | O.R. PROCEDURES FOR OBESITY 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.
***
On ___, the patient was admitted post-operatively after
aborted segmental liver resection for large hepatoma.
Post-operative course was uneventful. Diet was advanced to
regular diet, pain was under control with IV then PO analgesics,
and she ambulated with little difficulty. On ___, she was
discharged home in good condition.
***. | HEPATOBILIARY DIAGNOSTIC 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 woman with a past medical history of
COPD (on ___ NC), bipolar disorder/schizoaffective disorder,
SCC, severe sleep apnea (noncompliant with PAP) who presented
with altered mental status and was found to have acute
hypercarbic respiratory failure.
========================
ACTIVE ISSUES:
========================
# Acute hypercarbic respiratory failure: The patient presented
with altered mental status and was found to have acute
hypercarbic respiratory failure in the setting of known COPD,
with retention (baseline CO2 ___ as well as pneumonia. The
patient was intubated in the OR on ___ she had difficult
airway with proximal tracheal stenosis. She was extubated in
the OR on ___ and trach was placed and then further
revised required on ___. Per ACS recs, the stitches are to
remain in place she should not be decannulated EVER without
consulting ___ due to significant anatomic
abnormalities. Speech and swallow evaluated the patient for
voice adaptor, however one could not be fitted given the
patient's copious secretions, so she remains NPO. On discharge,
SpO2 was 96% on trach collar with 40% FiO2.
# Hypervolemia/hypernatremia: Patient was volume resuscitated in
the setting of hypotension related to sepsis upon admission.
Patient was positive 19L by the end of her hospital stay.
Patient's sepsis and hypotension resolved and diuresis of extra
volume was attempted with IV Lasix, however patient became
hypochloremic, with a contraction alkalosis and developed
hypernatremia. Free water flushes were increased prior to
discharge with correction of her sodium on discharge, however
patient remains volume overloaded. On discharge, patient's
sodium was 143. On discharge to LTACH, sodium should be
monitored daily and free water flushes should be adjusted
according. Additionally, patient responds to 40-60 mg IV Lasix
to maintain euvolemia.
# Schizophrenia: Patient has a history of schizophrenia and
paranoia. During this admission, psych was consulted and stated
the patient had a history of chronic auditory hallucinations
that are derogatory but that do not feel threatening to her and
intermittent exacerbations of paranoia including suspicions of
her son.
Patient will require slow approach to build rapport before she
is likely to allow a
complete exam or accept any recommended treatment. Patient has
long history of marginal compliance with medical and psychiatric
treatment. Patient was continued on olanzapine 10 mg PO BID with
good result.
# Agitation and delirium: Patient was intermittently agitated
during hospitalization treated mainly with sedation during
intubation. On day of discharge, patient was evaluated by
Psychiatry. They stated she was not a harm to herself or others.
They recommended avoid benzodiazepines given hypercapnic
respiratory failure and Haldol PRN 0.5-1 mg PO BID to control
agitation.
# Palliative care: Patient has expressed wishes to eat and
drink, however she is an aspiration risk at this time and is
currently full code. Patient has lung cancer and refused
treatment. She has severe respiratory disease, is not compliant
with meds, and had a trach in the past. She would likely to
benefit from a goals of care discussion. Patient's brother is
the listed health care proxy, however was not present at
patient's bedside and difficult to reach regarding important
issues including consenting for OR procedures. Would suggest
reaching out to the health care proxy and the patient's son to
further discuss goals of care for this patient. Palliative care
was consulted, however family meeting was not able to held given
inability to reach health care proxy prior to discharge.
# Nutrition: Patient is an aspiration risk. Patient received PEG
tube on ___ with good result. Nutrition recommended tube
feeds with vital High Protein @ 65 mL/hr. They also recommended
if bloating persists to consider Glucerna 1.5 @ 40 mL/hr + 5
packets of beneprotein/day (1565 kcals, 109g protein). She was
discharged on the High Protein diet @ goal of 65 mL/hr and
tolerating the diet well.
# Sepsis and hypotension: Patient found to have right lung base
opacity concerning for pneumonia on CXR. Started on azithromycin
(___) and vancomycin/cefepime (___). The patient
was hypotensive s/p intubation and in the setting of pneumonia
as above. Propofol was also thought to be contributing to her
hypotension. She briefly required levophed to maintain her blood
pressures. Her pneumonia was treated as above. She was weaned
off pressors successfully. On day of discharge, she was afebrile
with stable pressure stable with SBPs of 110-160's.
# Toxic Metabolic Encephalopathy: Patient presented with altered
mental status. Her altered mental status worsened in the setting
of increasing hypercarbia (CO2 >100) and she required intubation
as above. Given her history of COPD and lung SCC she required
prolonged intubation and eventual tracheostomy on ___.
Sedation was weaned and patient's mental status improved.
# COPD: Patient on ___ L NC at home. She presented with slight
respiratory distress in ED, refusing BiPAP but found to be
hypercarbic (CO2 94, baseline 70's) requiring intubation. She
was started on prednisone (___) and azithromycin
(___).
# Persistent hydroureteronephrosis of the upper pole right
renal: The patient was evaluated by urology, who determined that
there was no indication for GU intervention at this time.
========================
CHRONIC ISSUES:
========================
# ___ of Lung: Patient has moderately differentiated squamous
cell cancer of the lung. Per prior Dc summary "She is not a
surgical candidate and reported that she does not wish to have
chemotherapy." Will defer workup and management of SCC as such
unless patient has change in GOC.
# GERD: Lansoprazole while intubated and switched to famotidine
on discharge.
# Status post hip fracture, chronic: Held home oxycodone while
intubated and sedated. Restarted fentanyl patch prior to
discharge. Oxycodone was discontinued as it was not needed.
========================
TRANSITIONAL ISSUES:
========================
- Patient will require slow approach to build rapport before she
is likely to allow a
complete exam or accept any recommended treatment.
- Inpatient psych consult suggested follow up with psychiatric
at ___.
- Would advise ___ to contact her caregroup visiting nurse who
may be a useful bridge, having established a relationship with
- Avoid benzodiazepines given hypercapnic respiratory failure
-Trach stitches to remain in place indefinitely. Usually come
out in ~1 week, however will stay in indefinitely given her soft
tissue thickness.
-No decannulation EVER of trach without consulting thoracic
surgeons Drs. ___ given anatomic
abnormalities.
-Code Status: Full
-Contact Information: HCP: Brother ___ ___
***. | ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PDX EXCEPT FACE MOUTH AND NECK WITH MAJOR O.R. PROCEDURE |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mrs. ___ is a ___ with end stage renal disease on
hemodialysis, type 2 diabetes mellitus on insulin,
atrial-flutter status-post ablation (___), paroxysmal atrial
fibrillation, asthma, obstructive sleep apnea on home BiPAP, who
presented to ___ with paroxysmal dizziness for 1 mo with
tachycardia/bradycardia and conversion sinus pauses of ___
seconds on outpatient Holter. She underwent uncomplicated
pacemaker placement for tach-brady syndrome on ___. She was
then transferred to CCU on ___ for hypotension and altered
mental status, found to have volume overload and likely
pneumonia/sepsis requiring norepinephrine. She recovered and was
transferred out of the CCU on ___ when off pressors.
# tachy-brady syndrome:
Patient had 1 month of dizziness and pre-syncope. On ___,
she was referred to ___ ED after her outpatient Holter monitor
showed HRs intermittently in ___, with sinus pauses ___ seconds.
In the ED, EKG showed normal sinus rhythm without ischemic
changes. Home nodal blocking agents (cardizem and metoprolol)
were held pending further electrophysiology evaluation.
Electrophysiology was subsequently consulted and determined that
her holter and telemetry data were consistent with tachy/___
syndrome with post atrial-fibrillation conversion pauses of the
sinus node lasting ___ seconds. This data appeared to coincide
with her symptoms of pre-syncope, and she was thus referred for
permanent pacemaker (PPM) placement.
Due to her complicated vascular anatomy (L fistula and R
subclavian thrombus), epicardial lead placement was considered
the best approach for PPM placement. On ___, she underwent
uncomplicated placement of right ventricular epicardial lead
placement via anterior thoracotomy.
#Atrial fibrillation: In addition to sick sinus, the patient
also had multiple episodes of atrial fibrillation while
inpatient. The patient's CHADS2-Vasc score is 4, corresponding
to a high risk of stroke (annual risk estimated at 4%). However,
she declined anticoagulation due to history of falls and
undestood her risk of stroke; she refused warfarin, heparin gtt,
and subcu heparin. She was continued on aspirin daily.
She received multiple doses of metoprolol with little effect on
her rate. She was finally placed on digoxin ___ MWF with
dialysis and amiodarone loading, which brought her rates down to
the ___. She is being discharged on amiodarone 400mg daily
for 5 days, until ___, to complete her load, and then will be
transitioned to 200mg daily as her stable dose. If she is not in
sinus rhythm by completion of her amiodarone load, we recommend
talking to Dr. ___ cardiologist) about stopping it.
# Hypotension and new oxygen requirement:
The patient was transferred to the CCU on ___ due to
hypotension of systolic BP to ___, decreased mentation, and
new oxygen requirement (requiring ___ NC). Echo on ___ did
not show evidence of new wall motion abnormality, effusion, or
increased heart failure. EKG did not show evidence of ischemia.
Her hypotension and new oxygen requirement were initially
thought to be multifactorial, secondary to (1) volume overload
from no HD for several days, (2) pneumonia (worsening productive
cough and altered mental status suggesting pneumosepsis), and
(3) atrial fibrillation and decreased cardiac output from lack
of atrial kick.
She was started on Vanc/Zosyn empirically for possible HCAP for
7 days. She received an a-line to better monitor BPs as cuff BPs
were consistently lower than arterial line BPs. She received a
femoral CVL and low dose levophed. She was also started on
amiodarone, with oral loading to rhythm control afib. She
improved, was weaned off pressors, and was transferred back to
the floor ___.
On the floor, she continued to be stable and her oxygen was
weaned to room air,with stable heartrate and bloodpressure. Her
antibiotics were stopped ___ and she continued to be stable
with no further pulmonary symptoms.
# End-stage Renal Disease
The patient was continued on hemodialysis on ___
and ___. Her creatinine remained within recent baseline. All
medications were renally dosed. She was continued on her home
nephrocaps, cinacalcet, and calcium acetate.
# Type-2 Diabetes Mellitus
The patient was continued on her home levimir and insulin
sliding scale.
# Obstructive Sleep Apnea
The patient was cotninued on her home Bipap, and a respiratory
therapist was consulted.
# Chronic Anemia
Serial hematocrits remained near her recent baseline of ___.
There were no signs or symptoms of blood loss, and she was
continued on her home Epo and Iron with hemodialisis.
TRANSITIONAL ISSUES
- Switch amio from 400mg daily to 200mg daily on ___ AM.
- Please check LFTs and TFTs in 3 months given amiodarone
- Please check EKG weekly to monitor QTc and rhythm. Please
notify Dr. ___ cardiologist) of results. If not converted
to sinus, may consider stopping amiodarone with his approval.
- Panorex images showed a gross decay in two premolars, though
not thought to present a threat of PPM infection. She should
address possible future extraction with her private dentist on
discharge.
- After many discussions about code status, we have confirmed
that patient continues to be full code
***. | 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.
***
Ms. ___ is a ___ w/ PMHx DM II, RA, HTN, possible COPD, and
ESRD on dialysis with recurrent admissions for ___, initially
presenting with worsening shortness of breath. She was treated
for COPD exacerbation, however after one dose of azithromycin in
the ED had VT arrest w/ Torsades on ___ with ROSC s/p shock x1.
Course c/b persistent MSSA bacteremia (now s/p HD line removal)
and endocarditis, CKD, and persistent hyperglycemia in the
setting of prednisone taper.
ACTIVE ISSUES:
==============
# Polymorphic VT/Long QT Syndrome:
On the evening of ___, patient went into torsades, likely in
the setting of previously undiagnosed long QT syndrome with
administration of azithromycin 500mg for possible COPD
exacerbation. Received chest compressions and defibrillation x1
with ROSC. No apparent clinical sequelae, but EKG have shown
T-wave inversions in the precordial leads raising concern for
ischemia. For long QT syndrome, patient was placed on
propranolol, then transitioned to mexiletine for better effect.
For possible ischemia, ___ Cardiology had recommended cardiac
cath, but defered in the setting of MSSA bacteremia and
endocarditis (see below). Similarly, ICD placement this
hospitalization was also defered. Patient was discharged with a
___ to wear until she can have cardiac catheterization
and ICD placement. She will also go on mexiletine, with
azithromycin added to her allergy list.
# Sepsis with MSSA bacteremia and infective endocarditis:
The patient initially met ___ SIRS criteria with blood cultures
growing MSSA bacteremia. The source was felt to be most likely
from her tunneled HD line so this was removed by ___ on ___. The
tip subsequently grew MSSA. A new tunneled line was placed on
___ for dialysis access. She was initially started on
vancomycin but pending sensitivies this was narrowed to
cefazolin, dosed after her hemodialysis sessions. TEE revealed
aortic valve vegetation, so patient will need minimum 6 weeks of
antibiotics (end date: ___. She will be followed by ___
clinic after discharge.
# COPD exacerbation:
The patient initially presented with increased cough, sputum
production, and O2 requirement. She received azithromycin in the
ED and started on prednisone. Given her episode of VT, the
azithromycin was not continued. Her prednisone was tapered by
10mg q2days given her infection.
# Hypertensive emergency:
In the ED, the patient was acutely hypertensive to 193/112, with
end organ dysfunction as evidenced by worsening respiratory
symptoms and pulmonary edema. She was initially started on a
nitro gtt that was weaned after she underwent hemodialysis in
the FICU (prior to her VTach Arrest). She was restarted on her
home labetalol, but this was switched to propranolol given
Cardiology recommendations after her VT arrest. Given recurrent
(asymptomatic) QT prolongation and asymptomatic bradycardia,
propranolol was discontinued, and the patient was started on
hydralazine and resumed her home isosorbide mononitrate. Her
pressures have been normotensive to prehypertensive since.
# Hyperglycemia:
She had DM2 with last A1C 7.1%. Pt initially reported that her
glargine had recently been increased from 5 to 10 units as an
outpatient, but later endorsed that she was still taking only 5
units at lunchtime. For markedly elevated FSBG on presentation,
she was transiently on an insulin gtt with her home lantus and
sliding scale adjusted. Prior to transfer from the ICU, she had
persistent hyperglycemia in the setting of prednisone course,
acute illness, and likely dietary indiscretions. She was given
>20u short-acting insulin prior to transfer. On the ___,
her sugars were progressively better controlled with higher dose
Lantus and meal-time insulin coverage. At discharge, glargine
was increased to 10 units standing lunchtime (from 5 units at
lunchtime) as the patient stated that she does not want to start
bolus dosing of Humalog.
# ESRD on HD:
The patient had been receiving dialysis on a ___ schedule.
She received dialysis on the day of admission (___) but given
concern for line infection, her tunneled HD line was removed on
___. Her fistula had not yet matured. In the interim, she was
kept on a strict 1L fluid restriction and low sodium diet. She
had a temporary line placed for dialysis after transfer to the
___. This line was pulled with a tunneled line placed
prior to discharge. This tunneled line will need to be replaced
after 6 weeks, at or around the time she completes her
antibiotic course for MSSA bacteremia/endocarditis.
CHRONIC ISSUES:
===============
# Hypercholesterolemia:
Continued home dose pravastatin.
# Rheumatoid arthritis:
No longer on prednisone. Had been planned for rituximab, but not
started this admission given issues above.
TRANSITIONAL ISSUES:
====================
- Azithromycin added as an allergy in OMR - the patient should
NEVER take any macrolide antibiotics.
- Though VTach was initially ascribed to QTc prolongation,
subsequent EKGs have shown T-wave inversions in the precordial
leads, so ischemia remains on differential. She will need
cardiac cath and ICD placement in the future after her infection
is treated.
- Will continue on post-HD cefazolin (end date: ___, with
follow-up with ___ clinic.
- Tunneled line will need to be replaced at the end of her
course of IV antibiotics.
- Will have follow-up with ___ to follow fistula
maturation.
- Insulin adjusted this hospitalization for hyperglycemia in the
setting of steroids, infection and shock. Will need follow-up
with primary care physician.
- 10mm solitary nodule was noted on admission CT (noted at 7 mm
last year). Recommended for 3 month radiographic follow-up.
- ___ benefit from outpatient PFTs to confirm diagnosis of COPD.
- Tunneled dialysis line will need to be replaced after
completion of antibiotic course
***. | OTHER VASCULAR 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.
***
The patient was admitted to the General Surgical Service for
surgical treatment of a gastric outlet obstruction.
Pre-operative clearance was accomplished. On ___, the
patient underwent gastrojejunostomy and jejunostomy tube
placement, 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 jejunostomy
tube to gravity in place, and IV Toradol and a Dilaudid PCA for
pain control. The patient was hemodynamically stable.
.
Post-operative pain was initially well controlled with the 3 day
course of IV Toradol in addition to the Dilaudid PCA, which was
converted to oral pain medication when tolerating clear liquids.
The NG tube was discontinued on POD#3, and the patient was
started on sips of clears on POD#4. Diet was progressively
advanced as tolerated to a regular diet by POD#5. The foley
catheter was discontinued the morning of POD#3. The patient
subsequently voided without problem. The J-tube was clamped on
POD#2; trophic tubefeeds started on POD#3. Full strength
tubefeeds were increased toward the cycled goal of 80mL/Hr
starting POD#5, but the patient experienced abdominal bloating,
discomfort, nausea and vomiting. Tubefeeds were held. The
patient was resistent to having continuous tubefeeds, despite
his poor caloric intake, but agreed to cycled trophic tubefeeds
overnight. On POD#11, the tubefeed was changed to Nutren 2.0 to
increase calories per mL, and overnight tubefeeds were increased
to 20mL/Hr x 12hours. The incision remained clean and intact.
.
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. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated. Labwork was routinely followed;
electrolytes were repleted when indicated.
.
At the time of discharge, 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 prior
to discharge. He was discharged home with ___ services. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.
***. | STOMACH ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ yo M with CAD s/p CABG, sCHF (EF 45%), mild/mod MR, afib on
coumadin, non-oxygen dependent COPD, DM2, CKD (Cr 1.7-2)
presenting with worsening dyspnea, likely secondary to CHF
exacerbation
.
# Dyspnea secondary to Acute on Chronic Systolic Congestive
Heart Failure: Patient presented with two weeks of progressive
dyspnea that worsened acutely the morning of admission. He had
no symptoms of pneumonia or laboratory evidence to support
infection. EKG was without changes to support acute ischemia or
right heart strain (additionally, patient was supratherapuetic
on Coumadin so unlikely to have a pulmonary embolism). He
completed a myocardial infarction rule out. Likely etiology of
dyspnea was acute exacerbation of heart failure, perhaps from a
recent decrease in Lasix dose and discontinuation of
Spironolactone in the setting of worsening renal function. He
denied dietary indiscretion or medication non-compliance. BNP
was elevated and CXR supported congestion with bilateral
effusions. Repeat TTE showed stable MR and mildly improved EF
(45% from 30%), although it was suboptimal quality. He did not
respond well to increasing doses of IV Lasix (up to 120 mg), so
was started on Torsemide 20 mg BID with subsequent improvement.
Cardiology Heart Failure consult was obtained and recommended
follow up in Heart Failure clinic. His supplemental oxygen was
weaned off from 3L to room air and his symptoms resolved. His
weight at time of discharge was 88.6 kg. He was discharged on
Torsemide 20 mg daily and Lisinopril 5 mg daily. He may benefit
from initiation of Spironolactone in the outpatient setting.
.
# Bradycardia/Long QTc: Patient had an episode of sinus
bradycardia to 38 on the night of admission during his sleep.
EKG revealed QTc of 521 (increased from 432 on admission).
Risperdal was discontinued. Repeat EKGs over the next few days
showed resolution with QTc in the low 400s. Electrolytes were
repleted as necessary. Telemetry was continued for monitoring.
Risperdal was held at discharge.
.
# Atrial Fibrillation on Coumadin: CHADS2 score of 6. Not on
rate-controlling agent (HR ranged ___. Coumadin was held in
the setting of supratherapuetic INR and restarted once in the
acceptable range.
.
# HTN: Amlodipine was discontinued and Lisinopril 5 mg started.
Patient remained normotensive. This may need to be uptitrated in
the outpatient setting. Renal function and electrolytes should
be monitored by his Primary Care Physician.
.
# Suspected COPD: Patient has extensive tobacco history. Once
diuresed, exam revealed occasional wheezes and patient exhibited
pursed lip breathing when tachypneic that resolved with
bronchodilators. He was started on Advair and given an Albuterol
inhaler as needed. This can be further evaluated/managed by his
Primary Care Physician in the outpatient setting.
.
# DM: Reasonably controlled. Sliding scale insulin provided
while inpatient. NPH 12 units BID restarted at discharge.
.
# HLD: Continued on Simvastatin 20 mg daily.
.
# CKD: Creatinine remained within recent baseline.
.
# Anemia: Microcytic. Fe studies reflect Fe deficiency. Hct
initially trended down (likely hemodilution in setting of
inadequate diuresis) then remained stable. Stools guaiac
negative. He was discharged on Fe 325 daily and a bowel regimen.
His anemia should be further evaluated, perhaps with
colonoscopy, in the outpatient setting.
.
# Depression: Risperdone was discontinued secondary to long QTc.
Celexa 60 mg daily was continued.
.
# BPH: Continued Finasteride 5 mg daily
.
# Full Code
.
# To Do:
-___ Fe deficiency anemia
-Optimize heart failure regimen
-Monitor electrolytes/renal function
-Monitor for PTSD symptoms (___ discontinued secondary to
QT prolongation)
-Consider PFTs
***. | 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.
***
The patient was admitted to the General Surgical Service for
evaluation and treatment. On ___ the patient underwent
minimally invasive (thoracoscopic-laparoscopic) ___ type
near total esophagectomy, which went well without complication
(reader referred to the Operative Note for details) and the
patient was extubated in the OR prior to transfer. The patient
was sent to the SICU NPO, on IV fluids and antibiotics, with a
foley catheter, and dilaudid PCA for pain control. The patient
was hemodynamically stable.
Neuro: The patient received dilaudid PCA, followed by
acetaminophen IV with good effect and adequate pain control.
When tolerating oral intake, the patient was transitioned to
oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. He remained
in rate controlled atrial fibrillation. On ___, the
patient was restarted on coumadin 5mg daily without hep gtt
bridging. At discharge, the patient's INR was 1.7.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization. The patient's chest tube
and JP drains were removed on ___ without complication, and
f/u CXR confirmed no pneumothorax.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, after swallow study
on ___ confirmed no anastamotic leak. Patient's intake and
output were closely monitored, and IV fluid was adjusted when
necessary. Electrolytes were routinely followed, and repleted
when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. The patient remained
afebrile throughout this hospitalization with a normal WBC
count.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, 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. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
***. | STOMACH ESOPHAGEAL AND DUODENAL 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.
***
SUMMARY:
___ is a ___ with Hx of presumed etoh-induced
pancreatitis (now abstinent entirely of alcohol), otherwise
healthy, presents sent to ED from clinic with severe abdominal
pain and emesis and chronic weight loss, found to have
radiographic evidence of necrotizing pancreatitis complicated by
walled-off necrosis and chronic mesenteric thrombosis.
HOSPITAL COURSE BY PROBLEM:
# Acute on chronic necrotizing pancreatitis
# Large peripancreatic fluid collections
# Walled-off necrosis
# Chronic mesenteric thrombosis
Unclear etiology of recurrent pancreatitis. He is completely
abstinent of alcohol. Triglycerides and calcium are normal. He
is s/p CCY. IgG4 is mildly elevated, however necrotizing
pancreatitis is not consistent with autoimmune pancreatitis.
He was seen by GI who recommended bowel rest and conservative,
supportive care. NGT was placed on ___ for initiation of tube
feeds.He was initially covered empirically with cefepime and
Flagyl, however as his clinical picture seemed more consistent
with acute on chronic pancreatitis rather than superinfection of
WON/pseudocysts, antibiotics were stopped on ___. They were
restarted on ___ in the setting of acutely worsened pain,
nausea/vomiting, and rising WBC count. CT abd/pelvis completed
at the time was essentially stable. After this, he was improving
and had been tolerating TFs at full strength without significant
pain med needs, but decompensated again on ___ with increased
abdominal/back pain, rigoring, nausea/vomiting, and increased
WBC count. It is not completely clear what caused these
decompensations - whether
there may be superinfection of his walled-off necrosis or if
this could just be due to natural progression of his
pancreatitis. For both decompensations, he has improved after
holding tube feeds and restarting broad-spectrum antibiotics.
After he had received 7 days of broad spectrum antibiotics, they
were stopped as the Pancreas did did not feel strongly that he
was infected. He was monitored for 48 hours after this and
continued to do well.
The chronic mesenteric thrombosis noted on CTA abdomen was
discussed with the ___ Team, as well. Because he has
sufficient collaterals, anticoagulation was not recommended.
He was discharged on tube feeds and a clear liquid diet on ___
with plans to follow up with Dr. ___ specialist)
on ___. He was discharged on as-needed Lasix for
third-spacing and was provided a few doses of Dilaudid in case
of severe pain at home.
# Hypokalemia
# Hypomagnesemia
# Hypophosphatemia
In the setting of poor nutrition and emesis. These were
aggressively repleted and closely monitored throughout his
admission. He was discharged on standing magnesium oxide due to
near daily magnesium repletion needs.
# Elevated bicarb (resolved)
Most likely ___ contraction alkalosis. Improved after IV fluids.
# Hepatic steatosis: monitor as outpatient issue
# HTN: now off meds and normotensive; monitor
>30 minutes spent on complex discharge
***. | DISORDERS OF PANCREAS EXCEPT 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.
***
Patient ___ was admitted to the urology service for ___
3-way foley catheter placement and continuous bladder
irrigation. Urine culture was obtained, no growth final. His
aspirin was continued however Plavix was held due to ongoing
hematuria. On HD3 he experienced mild chest discomfort, ECG was
obtained and reassuring, no ST changes. Bladder irrigation was
weaned by HD5. Patient was discharged home with foley catheter
in place on ASA. He was advised to continue to hold his Plavix
until discussion with Dr. ___ his cardiologist to weigh
the risk/benefit of restarting this medication given
ongoing/recurrent hematuria. He will follow up outpatient for a
voiding trial. Urinary leg bag teaching was provided to the
patient prior to discharge.
***. | 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.
***
===============
PATIENT SUMMARY
===============
___ year old man with a history of CLL recently off Ibrutinib,
CAD
s/p stenting, HTN, HLD presenting with weakness and a recent
fall, found to have pancytopenia with concern for PNA, and a
hospital course complicated by NSTEMI s/p stent placement and
ballooning and SVT/Afib (on warfarin) controlled on metoprolol
and amiodarone.
=============
ACTIVE ISSUES
=============
#Febrile neutropenia
Severe neutropenia (<500) with ANC 0.42 on admission. Reported
fever at home to ___ and fever to 102.5 in the hospital. He
also had rigors and sweats that have slowly improved. Most
likely source of infection is PNA, given CXR findings, dyspnea,
and hypoxia. Alternative dx include sinusitis (given head CT
findings), intraabdominal source such as typhilitis (although
exam and diarrhea improved), subacute LLE wound. Covered broadly
with Cefepime, Vancomycin, Flagyl, Azithromycin, and we narrowed
to ceftriaxone and azithromycin. Patient was also placed on
neutropenic precautions. His infectious workup including stool,
blood, urine CX, MRSA swab, fungal cx, beta-glucan,
galactomannan, u/a, C diff negative except for positive stool
culture for salmonella and rare staph aureus found in his wound.
#CLL
#Pancytopenia
History of CLL for ___ years. Previously treated with
fludarabine, rituximab, leukeran/prednisone, and second
fludarabine.
Started on Ibrutinib for several years until 1 month ago when
counts began dropping. CBC ___ at OSH Oncologist:
___.
Stable thrombocytopenia, but worsened neutropenia and
significant anemia.
Given initial presentation of pancytopenia including
hypoproliferation of RBCs, concern for bone marrow infiltration,
Ibrutinib treatment effect, less likely infectious BM
suppression given negative infectious workup. MDS suggested by
markedly elevated B12, teardrop cells. Increased Tbili, LDH, AST
c/w hemolysis. We repeated hemolysis labs frequently and did not
find evidence of active hemolysis. Serum antibodies indicate
hypogammaglobulinemia. Heme-Onc consulted and reported there was
no indication for IVIG, especially given his risk of clotting.
Patient received 1 unit of pRBCs.
#NSTEMI
Patient complained of chest tightness, found to have elevated
trop, tachycardia, borderline hypotension, and a stat echo that
showed LAD territory severely dysfunctional, compared to OSH TEE
___, with a
marked drop in global LV systolic function. Patient now s/p
successful placement of DES in the LAD and LMCA with kissing
balloon angioplasty of the LMCA, LAD and Cx. 2. PTCA of the
diagonal 1.
#New systolic heart failure (EF 25%)
Patient treated with IV Lasix 40mg BID, with goal net negative
-1L/day. Patient was kept on this regimen for 7 days with good
output. His initial weight was 68.9 kg at the start of diuresis
and his discharge weight was 62.4 kg.
#Afib/SVT:
Patient had various rhythms s/p cath including afib with HRs up
to 150s and likely NSVT with HRs up to 180s. For the afib,
patient was started on warfarin with goal INR ___. His dose of
metoprolol was also uptitrated. The episode of likely NSVT with
HRs up to 180s, patient need escalation of care, eventually
requiring 12mg adenosine to break rhythm. He was loaded on
amiodarone and should continue on amiodarone 400 daily.
#Anti-coagulation
Patient was not yet therapeutic upon discharge, but he will be
discharged with ___ services who will monitor his INR. He will
remain on aspirin, Plavix and Coumadin until INR >2, and then
aspirin should be held. If her INR is ever subtherapeutic, his
aspirin should be restarted asap. Patient should never be on
fewer than 2 agents.
#Fall at home
#LLE weakness
Fall sounds mechanical given history, but patient reports
several falls in recent weeks to months. Reports chronic urinary
incontinence, but no change and no significant back pain. ___
consulted.
==============
CHRONIC ISSUES
==============
___ swelling
Unclear if new or chronic issue. 2+ edema LEs. Recent med list
from ___ has him on amlodipine 5mg, unsure if taking but if he
is
this could be contributing. Recent echo ___ with some LV
hypokinesis and LVEF of 50%, and no pulmonary edema on CXR. Pt
is
mildly hypoalbuminemic and this ___ be contributing. Amlodipine
held.
#Chronic bronchitis
Continued home inhalers
#GERD
Omeprazole changed to pantoprazole given interaction with
Plavix.
#CAD
#HTN
Continued ASA, Plavix, Crestor, Lisinopril.
TRANSITIONAL ISSUES
===================
Discharge weight: 62.4 kg
Cr: 1.0
Hb: 7.5
INR: 1.8
WBC: 2.2
Platelets: 156
LDH: 433
Bilirubin, Total 1.1
Haptoglobin: 202
Trop peak 3.10
[ ] Follow up with oncologist Dr. ___ at ___ for
f/u and next steps regarding cytopenias
[ ] Patient was started on oral diuretic. His weights and BMP
should be monitored.
[ ] Please stop aspirin when INR >2. If INR ever <2, please
restart aspirin.
[ ] Patient needs to take amiodarone 200mg BID from ___.
Patient will then take 200mg daily after ___.
[ ] Consider stopping amiodarone in the future based on
conversation with your cardiologist. It was started in the
setting of atrial tachyarrhythmias (SVT, afib) in the setting of
NSTEMI and newly reduced EF
[ ] Please ensure patient has follow up TTE in ___ weeks to look
for recovery of systolic function
MEDICATION CHANGES
[ ] Discontinued omeprazole & switched to pantoprazole given
interaction w Plavix
[ ] Aspirin should be held once INR is >2.0
MEDICATIONS DISCONTINUED
[ ] Held amlodipine
NEW MEDICATIONS
[ ] Plavix 75 mg was started after stent placement. This
medication needs to be continued after leaving the hospital.
[ ] Continue aspirin daily until INR ___
[ ] Warfarin
[ ] Torsemide 20 mg PO DAILY
[ ] Amiodarone 200mg BID ___. Amiodarone 200mg daily
starting after ___.
***. | 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.
***
___ year old ___ only female with history of
polio, insulin dependent type II diabetes, and chronic kidney
disease presented with an episode of falling due to lower
extremity weakness and was found to be hypotensive on admission
with acute on chronic kidney failure and rhabdomyolysis.
## Hypotension: The etiology of her hypotension was likely
multifactorial in the setting of potential blood pressure
medication changes, sepsis, or hypovolemia from poor oral
intake. The patient was initially admitted to the intensive care
unit because of systolic blood pressure of 50 (although
reportedly asymptomatic). She briefly required levophed and was
aggressively fluid resuscitated with improvement of her blood
pressures. Unfortunately the patient developed hypoxia secondary
to pulmonary edema in this setting (see below) and required
BiPAP.
## Pulmonary edema: In the setting of aggressive fluid
hydration, the patient developed hypoxia with pulmonary edema
shown on chest x-ray and required BiPAP. With diuresis the
patient's hypoxia resolved. An echo showed a hyperdynamic left
ventricular function with increased severity of known mitral
regurgitation.
## Leukocytosis: Patient was admitted with a WBC 21K. She was
started on antibiotics for possible pneumonia or sepsis in the
setting of her hypotension. However no evidence of pneumonia was
reported on repeat chest x-ray, and blood and urine cultures
show no growth to date. On discharge patient was afebrile and
WBC was downtrending at 14.2. Patient will follow-up with her
PCP to ___ her CBC in one week.
## Vascular stenosis: Patient had uneven blood pressures in her
right and left arm (left SBP ___, right SBP 130s) concerning for
aortic dissection in the setting of her low blood pressures. An
MRI chest however showed no evidence of aortic dissection.
Vascular surgery thought this was most likely due to arterial
stenosis and recommended no intervention at this time as patient
was asymptomatic.
## Rule out hypopituitarism: MRI brain showed a partial empty
sella, which was concerning for secondary adrenal insufficiency
in the setting of her hypotensive episode. Patient received
decadron in the ED initially. Patient however had normal AM
cortisols (>20) and an adequate response to the cosyntropin
test. Other pituitary hormones (LH/FSH/ACTH/prolactin/IGF-1)
were also checked given the partial empty sella. LH and FSH were
indicative of post-menopausal status. Prolactin slightly
elevated which is difficult to interpret in the setting of
illness. TSH normal. ACTH and IGF-1 will be followed-up as an
outpatient.
## Rhabdomyolysis: Patient had mild rhabdomyolysis with elevated
creatine kinase on admission secondary to prolonged time down
after her fall. This was consistent with her urine analysis
which showed gross hematuria but only 1 RBC. Her rhabdomyolys
resolved resolved with hydration, and her creatine kinase and
creatinine normalized.
## Acute on chronic kidney failure: Patient's creatinine was
elevated on admission (3.0) from her baseline (1.6-2.1) likely
secondary to prerenal azotemia. Her creatinine returned to
baseline with fluid resuscitation.
## Lower extremity weakness/falls: Most likely this patient's
fall was secondary to an exacerbation of her left leg weakness,
which she has at baseline as a sequelae of polio. However due to
concern for cerebrovascular accident, neurology was consulted
and an MRI brain showed sequelae of chronic small vessel
ischemic disease without any acute intracranial process. MR
___ ruled out a cord lesion. Furthermore L-spine and pelvis
was negative for any fractures. Patient was seen by physical
therapy who recommended discharge with home ___.
# DM2: Patient had high blood sugars on this admission, so her
Levemir insulin was increased to 16 Units at night.
Patient was discharged on ___ to her home. She will follow-up
with her PCP. At that time, she should:
(1) get bloodwork to ensure that WBC is downtrending,
(2) follow-up final urine and blood cultures,
(3) follow-up endocrine labs (ACTH, IGF, LH)
(4) discuss medication adjustments.
Namely the medication adjustment that were made during this
hospitalization was: 1) increase Levemir to 16, 2) continue
cefpodoxime and azithromycin until ___, and 3) decreased lasix
to 20 mg.
***. | 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.
*** female with a history of diverticulosis transferred
from an outside hospital for management of a large bowel
obstruction.
She initially went to the ED at an OSH on ___ with a
3-day history of low p.o. intake, no bowel movements, emesis,
and left lower quadrant pain. While in the ED she underwent a
CT scan that showed an intramural abscess in the sigmoid colon.
She was made n.p.o. and started on IVF, and antibiotics.
Throughout her hospital stay she did not improve clinically and
her abdomen became more distended. A repeat CT scan on
___ showed no changes in her intramural abscess. She was
kept on antibiotics. On ___ a KUB with Gastrografin
enema showed Gastrografin
flows freely beyond the site of narrowing into the dilated
proximal sigmoid and descending colon. Given these results and
lack of progression, she was transferred here for possible
diverticular stricture or tumor obstructing the sigmoid colon.
At ___ she was admitted to the colorectal
surgery service and kept on clear liquids with IVF. GI was
consulted for a flexible sigmoidoscopy which was performed and
showed a narrowing of the sigmoid colon likely due to a
diverticular stricture, however the scope was able to pass the
narrowing with only mild resistance. There was also moderate
severity diverticulosis which was non bleeding. Biopsies were
taken of the inflamed area of colon and sent for pathology.
The patient's diet was advanced as tolerated to a low residue
diet. She was passing flatus and having bowel movements. Her
abdominal pain had resolved and she was deemed medically
appropriate for discharge home with close follow up in clinic.
She will likely need a sigmoid colectomy at a future date due to
her sigmoid diverticular stricture and the patient was in good
understanding of this.
***. | 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.
***
___ ___ yo F with history of dCHF, CKD, SSS with PPM in
place, and prior GI bleeds who presents to ED with SOB, DOE,
weakness, and weight gain in setting of missing several doses of
torsemide.
#Acute on chronic systolic CHF: likely due to medication
non-compliance, causing SOB, DOE, weight gain, and weakness.
Volume overloaded on exam. Initially treated with diuresis but
repeat echo showed newly low EF (25%) potentially due to poorly
controlled tachycardia. Thought was that tachycardia is causing
her low EF, fluid retention, and possibly her weakness. She was
digoxin-loaded and continued on Dig 0.0625 mcg qod in addition
to uptitration of Metoprolol Succinate XL to 200mg bid. This
provided good control of her tachycardia, and repeat echo showed
returned preservation of EF (55%). Ultimately she was
established on a diuretic regimen of Torsemide 60 mg qd with
plans for close follow up to obtain labs and a dig level at our
heart failure clinic.
#Acute on chronic kidney disease: acute injury likely
cardiorenal syndrome with background of diabetic nephropathy vs
hypertensive nephropathy. B/l Cr is ~ 1.5, and she presented
with a Cr of 2.7. Initially improved with diuresis but then
worsened, so diuresis held. Cr actually returned to baseline
once tachycardia was controlled as above. On discharge Cr
stable on Torsemide 60 mg daily.
#SSS and AFib s/p dual-chamber PPM: CHADS2 score of 3. Not on
any anticoagulation due to prior GI bleeds. Rate controlled
with digoxin 0.0625 mcg qod and Metoprolol Succinate XL 200mg
bid as above. Possible disease of thyroid causing worsening of
atrial fibrillation (described next). Of note, we discussed
possible TEE/cardioversion with family, but as this would
require anticoagulation and she has a history of GI bleeds, this
was not pursued.
#Thyrotoxicosis: Of note, she also had slightly elevated TSH and
FT4 on admission so endocrine was consulted in regards to
thyroid disease causing worsening of her AFib. They recommended
an I-123 thyroid uptake scan which showed uptake in the upper
limits of normal. Endocrine team considered MRI of pituitary to
be the next step in work up, and they will work with her
PCP/endocrinologist Dr. ___ to facilitate this.
#Weakness: no focal signs on exam, so low c/f stroke or head
bleed. Potentially related to poorly controlled tachycardia,
UTI on admission, or malignancy. Repeat CXR was obtained to
evaluate status of known pleural effusions from prior
hospitalizations, but these were no longer evident. She worked
with physical therapy while hospitalized, and ___ will visit her
at home to improve her strength.
#UTI: slightly dirty UA on admission and endorsed lower
abdominal discomfort. Treated with 3 days of ceftriaxone and
UCx was negative.
#Prior GI bleeds: prior scopes showing ileal angioectasias,
diffuse diverticulosis. Anticoagulation was held per patient
and family wishes.
#DM: sugars well-controlled while hospitalized.
#Hyponatremia: normalized s/p diuresis.
#HTN: well-controlled on metoprolol and losartan while
hospitalized.
#HLD: home simvastatin continued.
#LBP: avoided any narcotic pain medications while hospitalized.
Monitored.
TRANSITIONAL ISSUES
[] Diuretic regimen: torsemide 60 mg daily
[] Discontinued losartan given HFpEF
[] Will need outpatient ___ with endocrine for ___ work-up
[] After family meeting, discussed risk and benefits of
anticoagulation given atrial fibrillation and joint decision
made to hold off on anticoagulation
[] Will need Chem-7 and digoxin level drawn on ___ and faxed to
Dr. ___ at ___.
[] Contact: ___ daughter ___ ___
___
***Discharge weight 54.5 kg***
***. | 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.
***
1. Sepsis: Pt meets SIRS criteria with urine as suspected
source. Pt's BP responded well to fluid challenge. He required
pressors in setting of initiating HD, and was weaned off the
Phenylephrine on ___ (transitioned to ___ midodrine 10mg
prior to dialysis) Antibiotic coverage as follows: Initially
continued linezolid for h/o VRE and broadened from
ceftriaxone=>cefepime. Linezolid was discontinued for
thrombocytopenia on ___. Spiked temp to 102 on ___ with
worsening secretions, added Vancomycin and cefepime=>meropenem
for better GN coverage. Vancomycin discontinued on ___ given
worsening thrombocytopenia. He was started on
daptomycin/meropenem meningitis doses on ___ given
unresponsiveness in absence of sedation since admission and MRI
with extra-axial CSF protein noted. LP attempted on ___ per
attending and resident, unsuccessfully-pt already on meningitis
doses of Abx. Patient's femoral line placed in ED was pulled,
his L PICC line and tip were sent for culture on ___. Sputum
positive for Pseudomonas, sensitive to meropenem which was
continued for tx of VAP, to finish course of meropenem 500mg
daily, last day on ___. Daptomycin was discontinued
on ___ given absence of Gram positives in culture data.
2. Respiratory distress: Pt was initially nasally intubated due
to locked jaw and unresponsiveness at his NH and upon ED
presentation. His NT was switched over to ETT. He remained
intubated due to unresponsiveness in absence of sedation for at
east 1 week. Additionally the patient had significant amt. of
secretions with little gag. Tracheostomy and PEG on ___.
He had a trial on trach collar on ___ but had to go back on to
pressure support ventilation due to respiratory fatigue.
3. Neuro: Dementia and mobility disorder likely secondary to
severe ___ disease. He was started on Sinemet at ___
and titrated to escelating doses prior to transfer which was
continued here with some improvement. MRI (non contrast) done
with extraaxial protein noted, non-specific finding but
?meningitis. LP attempt on ___ w/attndg-unsuccessful. Sinemet
dose uptitrated to 250/50 TID. Patient should receive tube
feeds at night so that they do not interfere with Sinemet
absorption.
4. Thrombocytopenia: presumed from linezolid and sepsis.
Received 1 unit of platelets, HIT negative, and subsequently
resolved. Patient continued to receive heparin gtt for left IJ
clot until INR was therapeutic.
5. ESRD on HD: On ___ schedule at ___.
Renal following, ___ attempted on several occasions due to
hypotension. HD initially not tolerated due to hypotension, but
now tolerating with pre-treatment with 10mg midodrine.
6. Ileus: Pt started on reglan on ___ for ? ileus, which was
discontinued once the ileus resolved resolved.
7. HTN: Discontinued anti-hypertensives given persistent
hypotension and requiring midodrine to maintain this.
8. Nutrition: Tube feeds, Probalance full strength at rate of
130/hour, cycled from 9PM to 7AM, held for residuals > 150, free
water flushes q6H. Cycled at night to avoid interference with
Sinemet absorption.
9. Prophylaxis: Started on warfarin for 6 weeks for left IJ
thrombosis.
10. Code status - full code
Communication: With Daughter, ___ ___
___
***. | 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.
***
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left hip hemiarthroplasty which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight-bearing as tolerated in the left lower extremity, and
will be discharged on lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
***. | 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.
*** with history of ADD, low back pain status post L4-L5
hemilaminectomy and microdiscectomy (___), nephrolithiasis,
and cervical disc disease, who presented with right-sided
chest/back/neck pain for three days prior to presentation, and
new vesicular rash since the day prior to presentation, overall
c/f herpes zoster.
ACUTE ISSUES:
==============
#Vesicular rash:
#Chest/Back/Neck pain:
#Herpes zoster:
Presented with three days of right sided chest/neck/back pain,
with subsequent development of vesicular rash over right
shoulder blade and under right arm, consistent with herpes
zoster infection. Unable to achieve adequate pain control in the
ED with PO medications, therefore patient admitted for pain
control. No risk factors for immunocompromised state, negative
HIV antibody ___ and repeat negative ___ here. No
involvement of the face, ears, or eye which would prompt urgent
evaluation/treatment. Patient endorses high levels of stress at
work, applying for MBA, which is likely the cause of his
shingles. He was started on valacylovir 1000 mg TID for 7 days
___ evening) with end date ___ afternoon, and topical
bacitracin. For pain control, he was taking tylenol ___ mg q6h,
ibuprofen 600 mg TID, PO Dilaudid ___ mg q4h prn, and IV
Dilaudid 0.25-0.5 mg q4h prn breakthrough pain. He requested a
derm consult prior to discharge, and they agreed that this is
localized shingles and recommended valacyclovir and mupirocin
prn.
#Elevated Hct:
Noted to have Hct in the ___, appears chronically elevated. Per
patient, has been worked up outpatient with sleep study and
genetic tests (presumably for hemochromatosis and PCV).
CHRONIC/STABLE ISSUES:
======================
#ADD:
Continued home dextroamphetamine-amphetamine 15mg daily.
#Chronic low back pain:
Pain relief as above.
TRANSITIONAL ISSUES:
====================
[] Continue valacylovir 1000 mg TID for 7 days ___
evening) with end date ___.
[] Ensure resolution of herpes zoster, and monitor for
post-herpetic neuralgia.
[] Discharged with 15 tabs of PO Dilaudid 2 mg. Checked PMP.
===================================
#CODE STATUS: Full code (confirmed)
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.
***. | MAJOR SKIN 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.
***
___ year old female with history of rectal cancer was admitted to
the Colorectal Surgery service on ___ and had a
laparoscopic abdominoperineal resection. The patient tolerated
the procedure well and was admitted to the inpatient General
Surgery Unit postoperatively.
Neuro: Post-operatively, the patient received Dilaudid IV/PCA
with ___ effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications.
CV: The patient was stable from a cardiovascular standpoint;
home anti-hypertensive medications were resumed on POD1. vital
signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. On POD1 patient had no nausea or emesis
and tolerated clears. Her diet was advanced to regular on POD5,
which was tolerated well. She was also started on a bowel
regimen to encourage bowel movement. Foley was removed on POD#4
at midnight. Intake and output were closely monitored.
ID: The patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge on POD#5, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
***. | RECTAL RESECTION 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.
***
# Endocarditis with valvular involvement: Diagnosed with MRSA
endocarditis in late ___, complicated by abscess,
pseudoaneurysm and microperforation, w/o evidence of tamponade.
___. ___ CT surgery did not think she was a good candidate for
surgery and she was transferred here for a second opinion with
Dr. ___. Dr. ___ did not think she was a good
candidate for surgery. Pt was monitored on telemetry without
event, until the decision was made to focus on comfort measures
and she was transferred to the hospice.
# End of life care: Discussion with family was had and it was
decided that she should be started on transition to comfort
measures only. Palliative care was consulted and a referral to a
free standing ___ center in ___ was made given the
family's preference. Labs and vitals were minimized and she was
taken off the telemetry. Patient was monitored for pain and
respiratory distress but she remained comfortable. She was
continued on tube feeds until ___ per family's wishes and her
last dialysis was done on ___ before transfer to ___
___.
# Atrial fibrillation: Report of difficult to control a-fib with
RVR, however, patient is rate controlled without medication at
the time of transfer. Her blood pressure is low at baseline, so
her digoxin and beta blocker were stopped at ___
___. She was placed on tele and continuous vital
monitoring. Given her recent GI bleed, her anticoagulation was
held. She was monitored on telemetry and remained in rate
controlled a-fib until the decision was made to start the
transitioning to comfort measures only. Then her telemetry
monitoring was stopped.
# DM: per daughter, pt is a brittle diabetic. Her long acting
insulin was held on admission as her tube feeding was
inconsistent, as to avoid hypoglycemia. She was covered with
sliding scale insulin. Her blood glucose ran high (in 200-300s)
on tube feeding without her lantus. She did not have episodes of
hypoglycemia.
# CKD from ___ nephropathy: patient with history of chronic
kidney disease from IgA nephropathy, recently started on
dialysis. ___ renal service was consulted for hemodialysis.
Patient was kept on his ___ hemodialysis schedule in the
hospital. Also, per rehab record, she had been on prednisone 20
mg daily, but it seems to have been stopped at ___ given
her infection and upper GI bleed. Prednisone was held during the
hospitalization. Hemodialysis was done on ___ and ___.
# Recent Duodenal bleed: At OSH, required 12 units of PRBCs.
Bleeding from a duodenal ulcer, per OSH EGD report. EGD was
repeated just prior to transfer and showed stable healing
duodenal ulcer. She was typed and screened on admission. Her
sucralfate and pantoprazole were continued and all
anticoagulation was held. Hemoglobin and hematocrit were checked
and remained stable. Lab draws were stopped when family started
transitioning to comfort care.
#IgA vasculitis: pt had been on 20 mg of prednisone daily at
rehab prior to admission to ___. Unclear when
prednisone was stopped during the OSH stay, but there was no
prednisone on transfer medication list. Patient does have
hypotension, but does not seem that she has adrenal
insufficiency. Prednisone was held during the hospital stay as
it could be a complicating factor with her recent GI bleed, MRSA
endocarditis and microperforation. She was monitored for
worsening rash and vasculitis.
# Dysphagia: report of dysphagia from OSH, likely from her
stroke. Patient was transferred to ___ with NGT for
tubefeeding and it was continued in house. NG tube was removed
before transfer to the ___ facility as it would only lead to
volume overload without dialysis and family was in agreement.
Patient is NPO given her dysphagia and aspiration risk.
***. | ACUTE AND SUBACUTE ENDOCARDITIS 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 PMHx significant for atrial fibrillation, HFpEF,
traumatic subdural hematoma in ___, IDDM c/b diabetic
nephropathy and neuropathy, who presents from ALF with FTT in
the setting of frequent falls with concern for home safety.
Course complicated by poorly controlled diabetes and orthostatic
hypotension.
# Failure to Thrive:
Presented from ALF after having multiple unwitnessed falls.
Trauma workup including CT head and plain film of left knee
without acute process. Suspect orthostatic hypotension driving
etiology of recurrent falls though ongoing concern for
progressive cognitive decline and inability to continue safely
living at current facility. Per discussion with patient's
daughter, he moved into an ALF about ___ years ago and has
continued to decline more noticeably over the past few months as
evident by frequent falls and inability to adhere to his
medications including insulin with several finger sticks > 500.
His poor medication adherence is likely driven by progressive
macular degeneration (and difficulty with the glucometer). Now
that he is medically stable, he is very motivated to get back
home and I think he may be able to take care of himself there
given the appropriate support.
# Orthostatic hypotension:
Noted to have orthostatic hypotension on admission-- likely
hypovolemia from osmotic diuresis. Suspect secondary to
hypovolemia in setting of Lasix use along with polyuria from
poorly controlled diabetes as well as suspected autonomic
neuropathy also from DM. Diuretics initially held and he was
given IVF. Lasix restarted at lower dose prior to discharge and
patient no longer with orthostasis.
# IDDM:
Poorly controlled. A1c 12%. FSBG > 500 (upper limit of home
glucometer) prior to admission. Normal anion gap. ___ team
consulted given complexity of regimen and difficulty for patient
to read glucometer from macular degeneration. They recommended
NPH 24U in AM (when getting glargine he was hypoglycemic in the
morning). Blood Glucose still in 100s-200s on discharge so may
need uptitration.
Seen by Diabetes educator to develop plan for patient to deliver
insulin to himself.
Patient may be able to deliver insulin at home to himself given
the following resources:
-Prodigy Voice Glucometer (speaks the BG). This prescription
was sent to his pharmacy and ___ (daughter will pick it up and
bring it to ___ to see if he can use it)
-NPH syringes pre-loaded (7 at a time by ___. Educator thinks
pt can safely deliver syringe if pre-loaded, thus weekly ___
could let this happen.
#fall with left leg bruising and swelling.
Left knee pain and swelling after falling at home. Xray with
small knee effusion and soft tissue swelling, but no fracture. .
swelling improving over admission. continue ___.
# ___ on CKD:
Cr 3.1 from baseline of ~2.6. Improved with fluids. Cr 2.3 on
discharge. can resume home candesartan.
# HFpEF:
Lasix and aldactone initially held in setting of orthostatic
hypotension. aldoctone continued. Lasix was restarted at lower
dose (40mg daily, instead of 40mg BID). euvolemic on discharge.
# Atrial fibrillation: CHADS2 = 4 (age, hypertension, heart
failure, diabetes) - Continued Diltiazem ER 120 mg PO daily.
Continued Apixaban 2.5 mg PO BID, though will need to reevalaute
risk/benefit of continuation if patient with ongoing falls.
# Hypertension: - Candesartan 8 mg PO daily held as
nonformularly and patient with orthostatic hypotension and ?___.
Continued Diltiazem ER 120 mg PO daily. Can restart candesartan
on discharge.
#PMR: was previously started on prednisone 15mg for PMR.
Symptoms seem to be improving. This should be slowly tapered by
physician who started it (?PCP). With tapering of prednisone,
insulin will have to be adjusted.
# HSV PPX: - Continued Acyclovir 400 mg PO BID
# Hyperlipidemia: - Continued Atorvastatin 40 mg PO daily
# Normocytic anemia Stable, chronic issue.
# GERD: Continued Omeprazole 20 mg PO BID
# BPH: Continued Terazosin 5 mg PO daily
# Asthma: Continued Theophylline ER 300 mg PO BID PRN -
Albuterol PRN
# Depression: Continued Sertraline 200 mg PO daily
TRANSITIONAL ISSUES:
===================
[] continue risk/benefit assessment of anticoagulation for afib
if ongoing recurrent falls.
[] Consider referral for neurocognitive testing.
[] continued insulin management (determining if he can safely
check BG and deliver insulin at home). Please note that with
decreasing doses of prednisone, his
insulin requirement will decrease and he should be closely
followed by outpatient providers to coordinate this.
[]continue to monitor left knee swelling
[] continue to monitor kidney function
[] ___ patient does not want some medical information shared
with family. I have been asking pt what information is ok to
share. Daughter, ___, is very concerned about her father and
very involved. ___ - DAUGHTER - ___- she is the
one who will bring the talking glucometer.
[] ?Dementia: patient is very involved in his care and
knowledgeable about things, however he does have some memory
problems. Per family he has "failed MOCAs" in the past but does
not want more testing. Family wants him to get an appointment
with Dr. ___ (Geriatrics) at ___ (P:
___ please look into making an appt after discharge.
***. | DIABETES 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 plastic surgery service on
___ and had a bilateral breast reduction. The patient
tolerated the procedure well.
.
Neuro: Post-operatively, the patient was given morphine IV with
good effect. When tolerating oral intake, the patient was
transitioned to oral pain medications.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. Her diet was advanced when appropriate,
which was tolerated well. Intake and output were closely
monitored.
.
ID: Post-operatively, the patient was started on IV cefazolin,
then switched to PO cephalexin for discharge home. The patient's
temperature was closely watched for signs of infection.
.
Prophylaxis: The patient was encouraged to get up and ambulate
as early as possible.
.
At the time of discharge on POD#1, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled. She had a surgibra in place with clean wrap dressing
over breasts bilaterally. No evidence of active bleeding or
hematoma.
***. | BREAST BIOPSY LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
A/P: ___ F with HTN, PVD s/p AAA repair in ___, PUD presents
with epigastric pain, dyspepsia, N/V, diarrhea, low grade temps
x 2 days. Hypertensive urgency in ED, easily controlled with
home medications.
.
# Abdominal pain/dyspepsia/emesis: Abdominal exam nonspecific;
relatively benign. Symptoms started after start of PO dilaudid,
?effect of this. Does not explain diarrhea though. Patient
does have h/o PUD as below. Guaiac negative in ED. Also with
abd aneurysmal/PVD disease but stable on CT. Patient appears to
be more affected by indigestion rather than epigastric pain.
Also considered ACS given patient's PVD, age; but ruled out for
this. Most likely was simple viral GE given concurrent diarrhea
and fever. Family members subsequently developed similar
symptoms at home, supporting this theory. She tolerated regular
diet well with no further episodes of vomiting or diarrhea. We
will send her on oxycodone as opposed to dilaudid.
.
# Diarrhea: x2 days prior to admission, associated with above
symptoms. No known antibiotic exposure. Likely represents
viral GE. No further loose stools while here.
.
# HTN: Very elevated in ED; patient had no BP meds x 2 days.
Improved to within normal range with taking home regimen. We
did increase labetalol to 200 mg daily due to persistant mild
elevation in BP and HR.
.
# UTI: U/A checked in the ED; not suggestive of UTI. Culture
with mixed flora. Had subsequent straight cath specimen with
positive UA, culture with coag neg staph, sensitive to
levofloxacin. Initially started ciprofloxacin, added vanco x 1
day; will complete course with levofloxacin.
.
# Fever: Mildly elevated temp in ED. CXR WNL in ED; U/A
eventually positive. CT neg for diverticulitis. Most likely
associated with viral GE or UTI.
.
# PVD: Stable on CT. Continued ASA, BP control. Not on statin
for unclear reasons.
.
# Back pain: h/o spinal stenosis. ALso with known lumbar
compression fracture. On lidoderm patch to low back at home.
.
# h/o PUD: Seen in ___. Guiaic negative in ED. Continued PPI
and sucralfate.
.
# Dyspnea/mild hypoxemia/Asthma: Wheezes on exam and marginal
room air sat in ED. H/o asthma, former smoker. Improved with
nebs.
.
# Cataracts/glaucoma: Continued outpatient home eye gtts.
.
# Full code
***. | 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.
***
Mrs. ___ presented to ___ ED after complaints of chronic
back pain acutely worsening. Patient was seeing a chiropractor
for her back pain however underwent aggressive manipulation and
continued to feel worsened pain for which she saw her PCP.
Patient's PCP ordered and MRI of the spine revealing a severe
T12 vertebral body fracture with extension into the pedicles and
cord compression. Patient was immediately contacted and told to
present to the ED.
#T12 fracture
Patient was subsequently admitted to the neurosurgery service
for further management. Patient underwent a CT of the T&L spine
which revealed a severe T12 compression fracture with subsequent
kyphosis and extension into the pedicle with retropulsion and
cord compression. T12 left pedicle with lucency and concern for
underlying lesion. Due to concern for underlying lytic lesion
patient underwent ___ guided biopsy on ___. Patient tolerated
the procedure well and was transferred back to the floor
post-procedure. Patient was ordered for a TLSO brace to be
delivered and fitted on ___. Patient also underwent MRI with
and without contrast of the T&L spine which redemonstration
"severe pathological compression deformity of the T12
vertebral body with complete vertebral body height loss,
kyphotic angulation
and severe spinal canal stenosis with cord compression".
Patient's pain was managed with PRN analgesics. Pathology
results pending at time of discharge and neurosurgery office
will contact patient once results are finalized to determine
surgical plan.
#Scleritis, possible anterior uveitis
Patient has h/o scleritis related to ankolosing spondylitis and
is followed by ophthalmology. She had increased acute on chronic
left eye pain while inpatient with injected sclera.
Ophthalmology was consulted and recommended labs for TB,
syphilis and lyme to rule out additional cause of scleritis -
pending at discharge. She was continued on Pred Forte drops q1h
around the clock and started on atropine bid. She was seen in
ophthalmology clinic ___ for slit lamp evaluation and atropine
drops were discontinued and prednisone drops QID. She will
continue to follow up with them outpatient.
***. | BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ was admitted to the hospital and taken to the
Operating Room where he underwent a left thoracotomy, left lower
lobectomy with bronchovascular closure, intercostal muscle flap
buttress and mediastinal lymph node dissection. He tolerated
the procedure well and returned to the PACU in stable condition.
He maintained stable hemodynamics and his pain was controlled
with an epidural catheter. His chest tube was draining moderate
amounts of serosanguinous fluid and remianed in place a bit
longer than usual due to volume.
Following transfer to the Surgical floor he was able to tolerate
a regular diet but his blood sugars were noted to be elevated
post op as high as 300. He was told a few months ago he may have
diabetes but was not following blood sugars or on medication.
He had a HgA1C of 7. His father is a diabetic. He was
evaluated by the ___ and placed on sliding scale
humalog as well as nightly Lantus insulin. He was eventually
started on Metformin and Glyburide with the hope of eventually
stopping Lantus and sliding scale. Metformin and Glyburide were
increased on ___ as his sugars were in the 180-240 range.
He met with the diabetic educator for instruction on the use of
the glucometer as well as administering insulin. His sugars will
be followed by his PCP and ___ contact the ___ service if
he has any problems.
His pre op Amlodipine was resumed post op at 5 mg daily but his
blood pressure ranged from 130/80-180/100. The increase could
be multifactorial therefore his dose remained the same and he
will have ___ services for BP monitoring and will follow up with
Dr. ___ week for re evaluation.
His chest tube was removed on ___ once his drainage
decreased and he was able to use his incentive spirometer
effectively. He did require some additional saline nebulizer
treatments to help clear his secretions and he also continued on
Levalbuteral. His thoracotomy site was healing well and his
pain was controlled with oxycodone and tylenol after his
epidural was removed. He was ambulating without difficulty and
his room air saturation was 95%.
He was discharged to home on ___ with ___ services and will
return to the Thoracic Clinic in 2 weeks.
***. | MAJOR CHEST 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.
*** female with hx of chronic pancreatitis on chronic
narcotics, c/b pseudocyst, G-tube c/b gastrocutaneous fistula
s/p takedown ___, gastric bypass, and depression/anxiety
presenting with acute on chronic abdominal pain x 3 days.
.
#Acute on chronic abdominal pain:
Pt had several year history of chronic abdominal pain controlled
at home on po dilaudid, oxycontin and fentanyl patch. She
presented with worsening of her pain and inability to tolerate
po ___ nausea/vomiting. She was treated with bowel rest, IV
fluids, and anti-emetics. Pain was controlled with IV dilaudid
in addition to her oxycontin and fentanyl patch. Laboratory
results did not reveal any etiology for abdominal pain as LFTs,
alk phos, and T.bili were normal. Physical exam was inconsistent
with any organic cause of abdominal pain. Pt insisted on
remaining NPO, complaining of worsening pain when diet was
advanced to clears. Eventually after 5 days of being NPO she
was able to tolerate clears and crackers and abdominal pain was
controlled on her home oral pain medications by the time of
discharge.
.
#Depression/Anxiety:
Pt had significant psychiatric history and reported that
emotional stressors triggered episodes of acute abdominal pain.
She was continued on her home psych meds, including buspirone,
clonazepam, seroquel, and effexor.
.
#Vitamin B12 deficiency:
No acute issues. She was continued on her once weekly
injections of cyanocobalamin
***. | 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.
***
8Ms. ___ is a ___ woman with ___ CAD, CHF (EF>55%), status post
CABG, atrial fibrillation on Coumadin who presents with
shortness of breath after recent discharge from ___,
presenting with signs and symptoms of acute on chronic diastolic
CHF exacerbation.
# Acute on Chronic Diastolic CHF exacerbation: ___ had
recent discharge on ___, presented again with signs and
symptoms of volume overload. On previous admission, weight was
64.4kg and BNP was 1815, with this admission, weight and BNP was
lower ( 60.2 kg, last discharge weight 59.6 kg, BNP 1500s).
Similar to last event, there was no clear precipitant event,
with no EKG changes and negative troponins. ___ and family
reported medication and dietary compliance, but ___ did
state also that she may have switched the diuretic medications.
She stated the ___ did not speak ___, so she was unable to
understand the medications. She was started on a lasix drip with
good urine output and symptom improvement. Her active diuresis
was held given increase in creatinine and decreased weight with
improved clinical exam. ___ received nutrition counseling
with ___ interpreter to help adhere to a CHF diet. We also
planned to do a chemical stress test to rule out possible
ischemic triggers, but ___ and her daughter (HCP) did not
want to pursue further testing given ___ symptomatic
improvement. They reported that they understood the risks of not
pursuing the testing at this time, and stated that they would
prefer to follow up with the outpatient cardiologist. ___
was off diuretics for two days with stable symptoms, breathing
comfortably on room air, and was discharged on ___,
discharge weight 58 kg. Given re-admission, ___ was
scheduled to have close follow up with heart failure clinic, as
well ___ services transitioned to ___ who provide
___ speaking nurses. ___ was instructed to resume
torsemide 40 mg (home dose) day after discharge.
Physical therapy evaluation for functional status and walking
tolerance demonstrated that she has functional independence and
has good potential for home discharge given expected improvement
with further medical management and considering baseline level
of function and social supports.
# Hypertension: ___ was noted to have systolic blood
pressures on prior admission to 190s-200s, and thus her BP
medications at the time were modified and titrated. On
admission, ___ still had elevated BPs to 160s. ___ was
continued on last discharge regimen including Lisinopril 40,
Amlodipine 10 mg, Hydralazine 50 TID and Imdur 60 with good
effect. Carvedilol was decreased to 3.125 BID given bradycardic
events to mid 35 on telemetry. HR in ___ on discharge.
# Acute Renal failure: Creatinine was 1.7 on admission, likely
secondary to renal venous congestion and intravascular depletion
from volume overload, and creatinine improved with diuresis.
However creatinine rose with continued Lasix drip, thus
aggressive diuresis was discontinued and ___ creatinine
stabilized at 1.9. She was scheduled for close outpatient
followup and resumed on home torsemide 40 mg daily.
# Bradycardia: ___ was bradycardic to the ___ on prior
admission. with diltiazem held, Carvedilol 6.25 was decreased to
3.125 BID for better rate control.
# Atrial fibrillation: Her anticoagulation was continued with
warfarin. At discharge, her INR was 2.1. Her rate control with
carvedilol was decreased as above.
# Thrombocytopenia: ___ was noted to be thrombocytopenic
(Plt 91-109), which has been noted in past results, with smear
showing no concern for acute process. This may benefit from
further outpatient workup.
# CAD s/p CABG ___ (2VD, SVG -> OM1/PDA): Continued Aspirin 81
and Atorvastatin 20 mg.
# Diabetes Type 2: Her glyburide was held and she was placed on
insulin sliding scale.
#Chest Tightness: ___ reported some chest tightness with no
acute changes on EKG and no troponin elevation, and symptoms
resolved with diuresis.
TRANSITIONAL ISSUES:
====================
-Admit Weight: 60.2 kg Discharge Weight: 58kg
-___ reported chest pain in the ED, with no EKG changes and
troponins negative x3, could consider outpatient stress test.
___ refused chemical stress test while admitted.
-___ noted to be thrombocytopenic (Plt 91-109), which has
been noted in past results, with smear showing no concern for
acute process. This may benefit from further outpatient workup.
-CONTACT: ___ (daughter) ___
-FULL CODE
***. | 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.
*** yo with history of urticaria ,Graves disease, now s/p total
thyroidectomy
complicated by hypoparathyroidism, iron deficiency anemia
admitted for fever,chills, weakness and noted to have
symptomatic anemia and pyelonephritis, as well as renal stones,
with .
#Sepsis with pyelonephritis.
Elevated WBC and fever on admission, lactate borderline of 2.2
Ua abnormal with US showing multiple stones on left side but
they are non obstructing , though evidence of mild
hydroneprosis. She underwent CT to evaluate possible
hydronephrosis - and was found to have evidence of passed stone
and evidence of infection in collecting system. She was
initially placed on ceftriaxone, then switched to ciprofloxacin
after she developed hives on CTX. Her urine culture grew out
pan sensitive E coli, and will be treated for 2 week course for
pyelonephritis.
#Symptomatic anemia, blood loss, with h/o iron deficiency anemia
and menorrhagia
s/p transfusion of one unit PRBCs. She received both one unit
of blood, as well as iv iron. Her hct remained stable. She
will require outpatient gynecology follow up for symptomatic
anemia.
#Nephrolithiaisis. She was noted to have multiple kidney
stones, with some evidence on CT of cortical thinning,
concerning for chronic kidney disease. She should see a
nephrologist as an outpatient, for workup of chronic kidney
stones.
#Epigastric pain
This improved with antibiotics. After her ultrasound showed
biliary dilatation but normal LFTS, she underwent MRCP which
showed no abnormalities, except for steatohepatosis.
#h/o graves s/p thyroidectomy complicated by hypoparathyroidism
Calcium levels were normal. She was continued on calcitriol and
calcium supplements, as well as levothyroxine.
Transitional issues:
GYN follow up for symptomatic anemia from bleeding
Renal follow up for chronic nephrolithiasis.
***. | KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mrs. ___ was taken to the operating room ___ by Dr.
___ a right thoracotomy and right middle lobe sleeve
lobectomy (anastomosis of right lower lobe bronchus to bronchus
intermedius) intercostal muscle flap buttress, mediastinal lymph
node dissection and bronchoscopy with bronchoalveolar lavage.
She was extubated in the operating room, and monitored in the
PACU. While in the PACU she was hypotensive which responded to a
fluid challenge and decrease titration of Bupivacaine Epidural
and phenylphrene. Once stable she transfer to the floor
hemodynamically stable.
Respiratory: Pulmonary toilet with incentive spirometery was
encouraged throughout her stay. She was titrated off oxygen with
ambulatory saturations of 93% on room air.
Chest tubes: 2 ___ drains anteriorly and posteriorly over the
apex were removed once pleural drainage decreased on ___ and
___ with stable postpull film revealing right apical
pneumothorax, which is unchanged on followup CXR's.
Cardiac: The patient had an episode of atrial fibrillation
___ which converted to Sinus rhythm with 10 mg IV
Lopressor. Her home dose Lopressor was continued and she
remained in sinus rhythm 60-70's with blood pressures 110-120
systolic.
GI: PPI and bowel regime continued. The patient was passing gas
on discharge but due for BM. Diet was advanced and tolerated.
Renal: The patient had normal renal function with good urine
output. Electrolytes were replete as needed.
Pain: Bupivacaine Epidural with split dilaudid PCA was used for
intitial pain management with good effect. ___ PCA was dc'd
with po vicodin ordered and managed by the acute pain service.
The epidural was removed on ___ and PO dilaudid, tylenol,
ibuprofen and neurontin were given with positive affect.
Disposition: She was seen by physical therapy and deemed safe
for home with ___. She continued to make steady progress and was
discharged to home with her family and ___ on ___.
***. | MAJOR CHEST 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. ___ is a ___ h/o GVHD involving liver, skin, lung from
allo transplant for AML, and recent admission for SOB of unclear
etiology initially presenting with worsening SOB and RLE
swelling, pain. He has a h/o thoracic spine compression
fractures, and during this hospitalization received a T3-T7
laminectomy/spinal fusion ___ ___ for acute cord compression ___
the setting of a code blue and one chest compression. He had a
FICU admission for respiratory depression thought ___ medication
sedation effect, and was called out to ___ on ___ after his pain
Rx were adjusted and his sedation had improved. On ___, he had
several episodes of SBP 70's, and later became unresponsive with
ABG's showing hypoxemia and acidemia, and the pt was transferred
to the FICU. His AMS and hypercarbia improved with CPAP, and he
was called out to the ___ floor again on ___. His Abx were
progressively stopped, and he remained afebrile. He was
continued on azithromycin for infection prophylaxis, and plan
was made to continue this at the discretion of the outpatient
physician, who can decided when or whether or not to stop.
.
ACTIVE ISSUES:
.
# Graft vs Host Disease- Involving his lungs, GI tract, eyes and
skin. On admission, the pt was complaining of persistent SOB. He
had been admitted ___ mid ___ with a similar presentation.
He was empirically treated with Vanc/Aztreonam during that
admission for a prolonged course, and his cultures were all
unremarkable. Pulmonary felt that his lung symptoms were the
result of GVHD c/w a bronchiolitis obliterans picture. It was
recommended to start Advair and Albuterol-Ipratropium as well as
pulse dose steroids. IgG level was checked and returned below
500. He was given IVIG once which also improved his symptoms.
PFTs were obtained during this admission and showed a mild to
moderate restrictive ventilatory defect with a coexisting
obstructive ventilatory defect and a moderate gas exchange
defect. He had documented PE's ___ the past and was continued on
anticoagulation. While he was on stress doses of hydrocortisone
during his ICU stays, these were changed back to his prednisone
10mg ___ AM and 5mg ___ ___ without incident.
.
# HCAP ___ setting of pulmonary GVHD: ___ an effort to elucidate
an etiology for his hypoxia, a repeat chest CT was performed.
It was negative for pulmonary embolism, but showed areas of
consolidation concerning for new PNA. As such, the patient was
restarted on IV vanco & meropenem for planned ___ut
on ___ pt was found increasingly somnolent with PCO2>100. ___
was transferred back to the FICU, was put temporarily on
positive airway pressure with improvement ___ mental status.
Blood gases showed significant improvement. He was sent to the
floor ___ on an antimicrobial regimen which included vanc,
___, voriconazole, bactrim, azithromycin. These were
progressively d/c'd, and the pt was weaned down to 0.5L NC and
continued on azithromycin for infection prophylaxis and
discharged to rehab.
.
#Osteopenia, s/p laminectomy - Pt has had multiple fractures ___
the past due to chronic steroid use. During this
hospitalization, he fractured his distal ulnar after bumping it
on a table. He fractured his R tibial plateau after bumping into
a door while ambulating to the bathroom. Ortho was consulted and
for each fracture determined that no surgical intervention was
warranted. While bending over to pull up his bed sheets, he
experienced significant pain originating ___ his thoracic spine
and radiating to his anterior chest. He had no neuro deficits on
exam. An MRI of his spine was obtained which showed new
fractures at T5 and T7. Ortho was again consulted and cleared
him for ambulation they recommended cervicothoracic brace for
comfort. He continued to have significant burning pain
occassionally with movement. Ortho was again consulted and we
were planning on performing a vertebroplasty / kyphoplasty of
both T5 and T7 for pain relief. Pt was then noted to have acute
sensorimotor loss below the level of T5-6 with complete loss of
movement ___ the lower extremities, loss of rectal tone, fecal
incontinence, and complete loss of sensation to the level of the
T5-T6 dermatome on ___. He was sent for STAT MRI which showed a
new epidural compression on T4/T5 with hyperdensity ___ that
area, and new spinal cord signal change with edema. ___ the OR a
mass was removed from his cord. It is unclear what caused this
acute cord compression, report from ortho that there may have
been a "fat pad" ___ the epidural space, or trauma from one chest
compression during his preceding code blue. He was taken
urgently to the OR for urgent T3-T7 laminectomy and fusion by
ortho spine. Endocrine was consulted for assistance with
management of severe osteopenia and recommended that we continue
to give high dose vitamin D and calcium supplementation daily.
He did not have any motor function ___ his ___, although he did
have some remaining sensation ___ b/l ___. He was discharged to
rehab.
.
# Retroperitoneal Bleed - ___ preparation for
vertebroplasty/kyphoplasty, the pt's warfarin was discontinued
and he was started on a Heparin gtt. The morning after
initiation of the drip the pt was noted to be tachycardic on
vitals and pale ___ appearance. The heparin gtt was turned off
and a stat CBC showed a 7 point Hct drop. He subsequently became
hypotensive to the ___. He was bolused 2L NS and given a total
of 5 units of blood. He was transfered to the ICU for further
management and hemodynamic stablization. On arrival to the ICU,
patient had an acute episode of LOC with BP drop to 40/doppler.
A code blue was called and abruptly cancelled after patient
awoke following one chest compression. A CT of the Abdomen and
Pelvis was obtained which showed left perinephric
retroperitoneal hematoma. Anticoagulants were discontinued and
patient remined hemodynamically stable. Given that he was no
longer a candidate for anticoagulation, ___ conjunction with a
h/o multiple pulmonary embolisms, he was taken to ___ for
placement of an IVC filter which was placed on ___.
.
# Chronic Pain - pt has chronic neuropathic pain ___ ___ and also
back pain from old compression fractures and hip / shoulder pain
from avascular necrosis as complication of chronic steroid use.
We initially continued his home doses of PO Dilaudid, Oxycotin
and Gabapentin, but due to oversedation and respiratory
compromise, his Rx were adjusted. Ultimately, the Pain service
was consulted and recommended celebrex, ritalin BID for synergy,
APAP, cymbalta, oxycontin, and small PO doses of dilaudid for
breakthrough pain.
.
# Intermittent binocular diplopia: Pt first noticed this while
___ the FICU ___ early ___. The pt had anisocoria observed ___
FICU ___ setting of nebulizers, and had head CT which was
negative. Pt had had cataract surgery ___ ___ and ___. Also has
intermittent blurry vision; has no h/o corrective eyewear.
Ophthalmology felt that the pt had significantly dry eyes and a
decompensating exophoria - they recommended aggressive lub with
artificial tear ointment BID and preservative free artificial
tears q1h. His blurry vision and diplopia improved thereafter
.
# RLE cellulitis - On presentation, his RLE was significantly
swollen and erythematous. ___ were obtained and negative for
DVT. He had a puncture wound ___ his RLE and from hitting his leg
while walking at home. It was felt that he had a cellulitis of
the RLE. ID was consulted and he was placed on Vancomycin and
meropenem for his cellulitis. He completed a two week course of
IV antibiotics with significant improvement ___ erythema and
swelling. His wounds were dressed daily per wound care
recommendations.
.
Chronic Issues:
.
#DM II- We continued twice per day dosing of NPH which required
frequent titration while on pulse dose steroid. He was also
placed on humalog sliding scale for prandial coverage. On
___ he triggered for FSG 29 (rpt 40) ___ the setting of no PO
intake for the entire day; was given 1 amp of D50; was tired but
still responsive during that episode.
.
#PE- Pt was on chronic warfarin for mult PE ___ past. Please see
above retroperitoneal bleed for adjustments made to this
regimen.
.
# HTN- continued metoprolol.
.
# GVHD PPx- Pt has been suffering from severe GVHD since his
allo transplant ___ ___. He is on chronic prednisone at home. He
was then placed on pulse dose steroids and given IVIG which
resulted ___ improvement ___ his respiratory symptoms. We
continued Acyclovir, Bactrim and Voriconazole for
immunosuppression prophylaxis.
.
TRANSITIONS OF CARE:
- cont azithromycin for infection prophylaxis
- goal O2 sat 89-92% due to patient's history of OSA and likely
chronic hypoxia at baseline
***. | OTHER O.R. PROCEDURES FOR INJURIES 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.
***
Assessment and Plan: Immunosuppressed Myasthenia ___ Pt with
FUO of 1 month who also c/o of sacral and inguinal pain.
Patient's presentation was concerning for infection given
recurrent fever and year long prednisone as well as azathioprine
treatment for MG. She doesn't demonstrate focal weakness of the
upper or lower extremities or respiratory distress that is
consistent with past myasthenic crisises.
.
#FUO: Patient presented with one month of fevers of unknown
orrigin without any grossly localizable symptoms, necessitating
consideration for infection, malignancy, and auto-immune disease
(especially given elevated ESR). Given complaints of severe
back pain, the patiet had an MRI in the ED which showed no
epidrual abcess or other acute pathology. With complaints of
nausea/vomiting, loose stool, and mild tenderness to palpation
on exam, an CT abd/pelvis was obtained on presentation showed no
abnormality.
An extensive FUO workup was planned, but the patient's blood
cultures which had been sent prior to administration of
Vanc/Cefepime in the emergency room returned positive for
Salmonella before FUO work-up was sent. She was treated with
Ceftazidime until ___ when Salmonella sensitivities came back
sensitive for ceftriaxone, ampicillin, and bactrim. Stool
cultures were negative. With complaints of 1 month of groin
pain and the high propensity for salmonella bacteremia to lead
to endovascular infections, a femoral ultrasound was obtained
which showed no evidence of infectin. Patient did not
demonstrate signs or symptoms of endocarditis and further
cardaiac evaluation was considered unnecessary. The patient was
seen by the infectious disease team, who had recommended
consideration of removal of her port. With continued negative
blood cultures and the need for continued long-term access, the
decision was made to attempt to salvage the port. The patinet
will complete a 14d course of Ceftioxone with home innfusions
through ___. Patient has only had one positive blood
culture. All other cultures have been negative (see results)
and only one is pending for follow-up.
.
#Myasthenia ___: Not currently active, but only moderatly
controlled on home regimen. Her home medications were
continued. Patient recieved IVIG treatment of 50g per day on
___, and ___ per her Neurologist for routine treatment.
Patient was noted to be slightly hypoxic in bed requiring 1L O2
to maintain O2 Sat above 90% for some of her admission. This
was noted to be her baseline as it was similar to last discharge
and she requires O2 at home which she sleeps with. On day of
discharge she was 96% on RA and breathing comfortably. She will
follow up with her outpatiet neurologist.
.
#R Inguinal pain concerning for infection or possible hernia
given steroid use and pain with cough. Ultrasound was negative
for local endovascular infection causing flow abnormality. Pain
may be secondary to pyridostigmine cholinergic effects.
.
#Diabetes mellitus. Patient was continued on home lantus dose.
Sliding scale premeal humalog was added during hospitalization.
Her finger sticks ranged mostly from the mid ___ to the mid
___. Patient was given a low/constant carb diabetic diet. She
was started on 81mg of daily aspirin given long term continued
plan of prednisone.
.
#Preventative medcine: given chronic steroid patient should
continued her Fosamax. We gave VitD/CaCO3 for concern of
osteoporosis. On the outpatient setting she should continue
this treatment if her PCP ___. Of note Calcium Citrate is
better absorbed during Proton Pump Inhibitor Therapy. She was
noted to have a mild anemia with some degree of iron deficiency,
likelly related to hemorrhoids given history of bright right
blood per rectum. Iron supplementation was started and the
patient should be scheduled for a screening colonoscopy given
her age consideration of anemia. She was guaic negative (by
stools) during her hospital stay.
.
#GERD: Continue Proton Pump Inhibitor Therapy.
***. | OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ female with history of AS s/p TAVR (___) and remote
breast adenocarcinoma s/p lumpectomy and adjuvant chemoradiation
admitted for acute-to-subacute constitutional symptomatology in
parallel with right-sided neck pain.
ACUTE/ACTIVE PROBLEMS:
#) Fever of unknown origin, night sweats, malaise: uncertain if
related to problem #2. Unifying malignant (e.g., H&N SCC,
lymphoma, etc.) or infectious diagnoses (e.g., RPA,
lymphadenitis, etc.) unlikely in the setting of unremarkable CTA
of neck/chest. Giant cell arteritis was considered in the
setting of concomitant headache/neck-jaw pain; however,
diagnostic studies not pursued in the absence of alarming
claudication or visual symptoms. Moreover, pain resolved, and
ESR was highly equivocal at 55. Chest imaging also unrevealing
in the way of recurrence of breast adenocarcinoma, new lung
malignancy, or lymphoma. (?) colorectal adenocarcinoma, given
h/o hyperplastic polyps. Alternatively, no vegetations were
identified on trans esophageal echocardiogram. Pre- and
post-antibiosis blood cultures remained negative. No occult
abscesses identified on CT abdomen/pelvis. C. diff antigen
negative. Lyme serologies negative. TB highly unlikely in the
absence of certain risk factors. No unusual animal exposures or
exotic travel. Patient was evaluated by infectious diseases. She
initially received short course of vancomycin/gentamicin, which
was transiently amended to CTX/metronidazole -> CTX, and
ultimately discontinued at discharge. Patient did not have fever
or night sweats on the eve of discharge.
#) Neck pain: vascular phenomenon ruled-out with CTA neck/chest.
No fluid collections or masses to suggest deep neck space
infection or H&N SCC/lymphoma, respectively, as above. Pain was
postulated to be a manifestation of giant cell arteritis, as
above, but diagnostic studies or empiric corticosteroids were
not pursued. No ECG changes or troponinemia to suggest atypical
presentation of acute coronary syndrome. Lastly, exam
inconsistent with spasmodic contraction or other MSK origin.
Pain spontaneously resolved by discharge.
#) ___, baseline creatinine 0.9: FeNa 0.5%, BUN:Cr >20, suggests
pre-renal, fitting with history of suboptimal oral intake and
excessive NSAID use for neck pain prior to admission. Urinalysis
with hyaline casts only. Renal ultrasound unremarkable. Resolved
with IVF. Patient received pre- and post-contrast hydration for
renal protection.
#) Acute on chronic diastolic dysfunction (HFpEF): in the
setting of AS s/p TAVR (___). Patient reports chronic
exertional dyspnea, though uncertain if onset is post-TAVR.
Minor pulmonary vascular congestion and edema on CXR. E/E' ___ on
TTE, suggesting concomitant diastolic dysfunction. TAVR team was
alerted. Home Lasix 20 mg and amlodipine 5 mg were continued.
#) Anemia, macrocytic: stable, baseline hemoglobin ___. RDW
normal. B12 low-normal. Thyroid studies and liver function tests
normal. No EtOH use. No tandem cytopenias or dysplastic forms on
smear to suggest MDS. ___ protein normal; multiple myeloma
less likely in that regard.
CHRONIC/STABLE PROBLEMS:
#) Aortic stenosis s/p TAVR (___): valve well-seated without
abnormalities on TTE/TEE this admission.
#) HTN: home amlodipine 5 mg continued. BP stable.
TRANSITIONAL ISSUES
[]Please encourage patient to avoid excessive NSAID use for
pain, given ___ on presentation
___, RF, repeat CRP, ESR pending at discharge
[]Consider repeat C. diff antigen per infectious disease
[]Consider outpatient rheumatology referral
[]Consider outpatient gastroenterology referral for repeat
colonoscopy and irritable bowel syndrome-diarrhea subtype in the
context of loose stools of non-infectious origin
[]Please evaluate small digital rash
***. | RENAL FAILURE WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient was admitted to the plastic surgery service on
___ and had a liposuction gynecomastia and inverted nipple
revision. The patient tolerated the procedure well.
Neuro: Post-operatively, the patient received Dilaudid IV with
good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to percocet with good
effect.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced when appropriate,
which was tolerated well. He was also started on a bowel regimen
to encourage bowel movement. Intake and output were closely
monitored.
ID: Post-operatively, the patient was started on IV cefazolin,
then switched to PO Duricef on POD#2. The patient's temperature
was closely watched for signs of infection.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge on POD#2, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
Patient was concerned about the appearance of right nipple at
discharge and Dr. ___ the patient to come to an
office visit immediately post-discharge. Patient was agreeable
to this plan.
***. | O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES 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 was admitted to the acute care surgery service for
RUQ abdominal pain concerning for acute cholecystitis. Due to
her ASA and Plavix she take at home, she was admitted awaiting
for plavix washout and scheduled for cholecystectomy.She
underwent laparoscopic converted to open cholecystectomy and
placement of JP drain on ___. She tolerated the procedure
well and was extubated upon completion. She was subsequently
taken to the PACU for recovery.
She was transferred to the surgical floor when hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile. She was initially given IV fluids
postoperatively, which were discontinued when she was tolerating
PO's. Her diet was advanced on the morning of POD1 to regular,
which she tolerated without abdominal pain, nausea, or vomiting.
During this admission she experienced asymptomatic A. Fib with
RVR, a flutter on POD 1 and 2. Cardiology recommended Q6H dosing
of metoprolol and she self converted on POD2 without
cardioversion.
Her foley was removed on POD 2 and she voided without
difficulty. JP drain exhibited serosanguionus fluid POD 1 that
turned more bilious in quality and a drain TBili was checked on
POD 2 which was 13.5.
She was encouraged to mobilize out of bed and ambulate as
tolerated, which she was able to do independently. Her pain was
initially managed with dPCA on POD 1 and 2 and when better
controlled, she was switched to PO pain medication. She remained
on antibiotics post operatively and will be discharged with 4
days of antibiotics (ciprofloxacin and flagyl).
She was ready to be discharged on POD 3 at the time of discharge
her vital signs were stable, she remained afebrile, tolerating a
regular diet, ambulating independently, pain adequately
controlled on PO pain medication. She is to be discharged with
JP in place and to be removed at her follow up appointment in
the Acute Care Surgery Clinic.
***. | BILIARY TRACT PROCEDURE EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is ___ y/o male who was recently discharged s/p
laminectomy of C5-T1 for tumor resection, presents today with
sudden back pain with loss of sensation and and
paralysis BLE.
#Spinal Hematoma
Stat MRI revealed a epidural collection at levels of previous
surgery which was causing cord compression and cord signal
change. He was taken emergently to the OR for C5-T1 posterior
cervical exploration. Please see operative note for full
surgical details. Hemovac drain was left in place.
Postoperatively, he was monitored in ICU where he required
pressors to maintain MAP goal of >70. Hemovac drain was removed
on ___. His MAP goal was liberalized and he was transferred
to the floor on ___ where he remained neurologically
stable.
#Heme
Hematology was consulted to evaluate for coagulation disorder.
Per Hematology/Oncology , the patient does not have any
identified bleeding disorder.
#Respiratory
The patient had an episode of mucous plugging on ___ with
desaturation to the 80's; he recovered with suctioning. He
required frequent chest ___ and respiratory therapy continued to
follow the patient during his admission.
___
Nephrology was consulted for elevated creatinine on admission.
He responded well to fluid boluses and his ___ was determined to
be pre-renal. His creatinine normalized during his
hospitalization.
#Urinary Retention
Foley catheter was placed in the Emergency Department for
urinary retention. Foley was rmoved on ___ and the patient
was straight catheterized Q3H. Foley was replaced on ___ due
to high urine output with straight cath.
#Psychosocial
The patient was noted by staff to have difficulty coping with
his new diagnosis. Social Work was consulted for coping and
support.
***. | OTHER O.R. PROCEDURES FOR INJURIES 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 to the acute care service after a fall
out of bed. Upon admission, she was made NPO, given intravenous
fluids, and underwent imaging. She was reported to have a mild
elevation of the white blood cell count to 13. Head cat scan
was reported as normal. An x-ray of the chest showed acute left
lateral rib fractures ___ with underlying effusion. No
pneumothorax was seen on the chest x-ray. Oxygen saturation was
reported as 90% and increased to 95% on 1.5 liters. The oxygen
saturation was closely monitored and the patient was encouraged
to use the incentive spirometer. The rib pain was controlled
with oral analgesia.
Because of the fall, an x-ray of the pelvis was done which
showed no displaced fracture, but a subtle lucency in the region
of the greater trochanter of the left femur. The patient was
evaluated by physical therapy and recommendations made for
discharge to a rehabilitation facility. The patient was
reluctant to pursue this avenue, but later conceded and
prepartions were started for discharge to an extended care
facility. To help further assist us in the patient's
management, the Geriatric service was consulted and provided
recommendations for her care.
The patient's vital signs remained stable and she was afebrile.
She was tolerating a regular diet and voiding without
difficulty. A urine specimen was taken upon admission and
showed alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus. The patient was started on a 3 day course of
ciprofloxacin.
The patient was discharged to the rehabilitation facility on HD
# 6 with stable vital signs.
***. | MAJOR CHEST TRAUMA 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.
***
IMPRESSION: ___ with a PMH significant for chronic A.fib (on
Coumadin), chronic lower extremity edema, celiac enteropathy,
hypothyroidism, obstructive sleep apnea (on BiPAP), non-insulin
diabetes mellitus who presented following right lower extremity
trauma with development of a rapidly-expanding hematoma that
auto-released on ___, who is s/p debridment and evacuation
(___) and who remained hemodynamically stable.
.
# AUTO-RELEASED RIGHT LOWER EXTREMITY HEMATOMA - The patient
presented with evidence of traumatic right lower extremity
injury with swelling, mild erythema and ultrasound showing an
evolving hematoma without DVT or clot burden. She initially
remained afebrile without leukocytosis. Her hematoma appeared
stable, but given some concern for surrounding infection, she
received Unasyn IV x 1 in the ED and Doxycycline with
Ciprofloxacin in the MICU, despite an exam without purulent
cellulitis. Overnight on ___, the hematoma auto-released and
she required urgent operative intervention for evacuation. She
was transferred to the MICU post-operatively given some
hypotension and acute blood loss anemia that responded to IV
fluids and blood products. Overall, she required 5 units of
fresh frozen plasma (and vitamin K PO for a supratherapeutic INR
to ___ and 3 units of packed red cells. Her hematocrit nadir
was in the 24% range and responded to blood products; on
discharge her hematocrit was 28%. She required bedisde
re-debridement on ___ to remove necrotic debris. Following
operative intervention, her hematocrit stabilized and she
required no further transfusions. She did require intermittent
IV Lasix given her blood product requirements, likely this was
mild acute pulmonary edema in the setting of possible diastolic
dysfunction; these issues resolved with IV Lasix. Her wound was
managed with wet-to-dry dressings (per General Surgery) and
began to show improvement. Prior to discharge, Plastic Surgery
evaluated her wound and felt reconstructive options were
feasible in the future. They recommended Zinc and vitamin C
supplementation to promote healing, and we performed daily
dressing changes with Xeroform and dry gauze overtop to promote
granulation. She was able to ambulate with physical therapy
prior to discharge.
.
# SUPRATHERAPEUTIC INR - Long-standing A.fib on Coumadin as an
outpatient. Home dose of Coumadin remains between 2.5 and 5 mg
daily. INR on admission supratherapeutic in the setting of
recent poor PO intake and antibiotic dosing. Coumadin was held
given these concerns, and given her hematoma concerns. The
patient received a total of 5 units of FFP and vitamin K for
reversal, following admission. In discussion with her outpatient
Cardiologist and PCP, we resumed her Aspirin and her Coumadin at
the time of discharge.
.
# ATRIAL FIBRILLATION - Long-standing and chronic atrial
fibrillation. Rate controlled with Diltiazem and Digoxin.
CHADs-2 score of 3 and has been anticoagulated with Coumadin.
INR on adission supratherapeutic and with hematoma concerns (see
above). Continued rate control with Diltiazem. Coumadin was
resumed at the time of discharge; her lower extremity should be
monitored closely.
.
# DIABETES MELLITUS, TYPE 2 - Last HbA1c 7.6% and
well-controlled on no oral hypoglycemic regimen or insulin.
Fingersticks in the ___. She was maintained on an insulin
sliding scale while hospitalized.
.
# OBSTRUCTIVE SLEEP APNEA - Remained on BiPAP and home oxygen
via nasal cannula.
.
# HYPOTHRYOIDISM - Continued Levothyroxine 150 mcg PO daily.
.
# HYPERLIPIDEMIA - Continued Pravastatin 10 mg PO QHS. Will
continue Ezetimibe 5 mg PO daily.
.
TRANSITION OF CARE ISSUES:
1. Assistance with medication administration.
2. Resume Coumadin (cautious given recent leg hematoma), in
discussion with PCP. INR goal was ___. Previous Coumadin dosing
was 2.5 to 5 mg PO daily; resume at 2 mg PO daily with daily INR
check.
3. Will need physical therapy and assistance with ambulation
(walker or cane device). Heart rate occassionally in the 130-140
bpm range when ambulating (given deconditioning). Continue rate
control with calcium-channel blocker.
4. Wean supplemental oxygen as tolerated; no home oxygen
requirement.
5. Monitor fingerstick glucose.
6. Dressing changes to right lower extremity daily: place
Xeroform over wound base. Then apply 4 x 4 dry gauze and ABD
gauze overtop. Then wrap RLE with kerlex and elevate.
7. At the time of discharge, the patient had blood cultures
pending, but these were no growth to-date.
***. | SKIN DEBRIDEMENT 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 transferred from an outside hospital on ___ for abdominal pain and concern for bowel
intussusception, therefore, she underwent a repeat abdominal CT
scan, which was negative and unrevealing as a source of the
patient's pain. However, given her pain, she was admitted to
the ___ for ongoing work-up and monitoring.
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, however,
following a normal UGI series, her diet was advanced and
tolerated. 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 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
ambulate.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance.. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan, which includes
her bariatric program, primary care provider and Dr. ___
___ incidental finding of an adrenal mass.
***. | 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.
***
___ year old male with history of morbid obesity who presented
with dyspnea and cough found to be hypoxemic with obesity
hypoventilation syndrome, obstructive sleep apnea, hypertension
and severe pulmonary artery hypertension complicated by right
heart failure.
# Pulmonary hypertension with right heart failure: Likely
secondary to longstanding and severe OSA and obestity
hypoventilation syndrome with subsequent severe pulmonary
hypertension complicated by right heart failure. He was
initially treated for CAP with ceftriaxone and azithro given a
RML infiltrate seen on CT chest. CT chest also demonstrated a
pulmonary artery of 4.5cm. Echo revealed an extremely high TR
gradient of 56 and right heart dilatation. He was profoundly
volume overloaded on initial presentation. Aggressive diuresis
was started with furosemide 20mg IV TID with a large response.
Acetazolamide was added to counteract an increasing contraction
alkalosis with good effect. This was stopped without issue
after a few days as it caused his pCO2 to rise. Then his
furosemide was uptitrated to 40mg IV TID and spironolactone 25
mg PO daily was added. He walked the halls multiple times per
day and wrapped his legs tightly with ACE wraps. His weight
upon admission was 418 pounds, and his weight prior to cardiac
catheterization was 348lbs. His creatinine was stable at
0.8-1.0 during this time. Repeat echo revealed a higher TR
gradient of 70, unchanged right heart dilatation, with abnormal
septal wall motion and position. He went for right heart cath
on ___ which revealed severe pulmonary hypertension with a
PASP of 54, a normal wedge of 12, and a failed vasodilator
study. ___, HIV, and TSH were all negative. He was followed
closely by cardiology and will follow up with Dr. ___ as an
outpatient. He will participate in ___ rehab as an
outpatient.
# OHS/OSA: CPAP was initiated on the floor on the second night
of his hospital stay but he desaturated to the 50's with this
mask on. This is felt secondary to severe OHS despite CPAP
being able to stent open his airway. He had initiated on BiPAP
in the MICU with continued desaturations. He was transferred
back to the floor the next morning. His Bipap settings were
titrated to ___ with a back up autoset rate of 12. His
desatturations improved with this I:E of 10. He takes
approximately 10 breaths per minute for an overall rate of
approximately 22. He was followed closely by the
sleep/pulmonary consult and will follow up with Dr. ___ as an
outpatient. He was set up for home Bipap, oxygen, and O2
monitoring.
# Hypertension: Initially presented with diastolic hypertensive
urgency with DBP's in the 120's. He was short of breath and
agitated. His blood pressures quickly improved with afterload
reduction including amlodipine, lisinopril, diuresis, and BiPap.
# Thrombocytopenia: Thought secondary to sequestration with
splenomegaly evident on CT. RUQ u/s confirmed splenomegaly and
a liver with a coarse heterogenous echotexture. Needs liver
follow up to rule out and/or treat cirrhosis.
# TRANSITIONAL ISSUES:
-Outpatient sleep study with MD
-___ liver evaluation with potential biopsy
-Repeat Echo ___ weeks to evaluate improvement and consider
potential repeat cardiac cath to retrial vasodilators
-Code status: Full
-Contacts: mother, brother
***. | 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.
***
___ is a ___ woman, status post resection and
radiation of an atypical meningioma who presents with seizures
and was intubated for a total of 10 days for airway protection.
On ___ patient was transferred to the OMED floor in stable
condition. While in ICU her course was complicated by delayed
waking raising concern for anoxic injury. EEG showed diffuse
encepahlopathy (though initially concern for persistent seizure)
and after a prolonged trial after propfol the patient awoke.
She has been maintained on levetiracetam, phenytoin, and
dexamethasone for seizure prophylaxis and has not been noted to
have further seizure activity. Also had a fever in the ICU
during prolonged intubation so was started on cefepime and
vancomycin.
(1) Seizures and Altered Mental Status: She was admitted to the
FICU with seizures thought to be secondary to subtherapeutic
levels of levetiracetam, however serial EEGs showed no
electrographic evidence of seizure. Patient was intubated for
several days for altered mental status and seizures. She is
also status post high-doses of lorazepam for seziure and
sedation was continued with propofol. She was weaned off of
sedation and was extubated
(2) Health Care Associated Pneumonia: Cefepime/Vanc started on
___ due to leukocytosis, fever, and question of infiltrates
on chest radiograph leading to presumed diagnosis of health care
associated pneumonia. Plan is for a fourteen day course from
___ to ___. We are transitioning from cefepime to
ceftazidime for formulary issues at discharge. Therapy to be
adminstered through PICC placed during this hospitalization.
(3) Meningioma: There was no acute issues other than above. We
will defer to Dr. ___ from neuro-oncology for further
management
(4) History of DVT: She is status post 6 months of effective
anticoagulation with warfarin. There was no bleed on current
imaging. It is unlikely to be contributing to the present
illness. She was monitored for DVTs while inpatient and given
heparing SQ TID.
(5) Patient is to follow up with Dr. ___ for management
of her meningioma and seizures.
***. | SEIZURES 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 ___ y/o female with COPD (on home O2), dementia,
and schizophrenia who presented with severe sepsis due to
pneumonia.
ACTIVE ISSUES:
=====================
# SEPSIS from Health Care Associated Pneumonia: the patient
presented with fevers, tachycardia, and tachypnea. CT chest
showed consolidation in both lower lobes consistent with
pneumonia. Due to extensive antibiotic allergies she was treated
with vancomycin and meropenem. Early in the hospitalization, the
patient refused to have an IV, and so an attempt was made to
treat with PO bactrim and doxycycline. However the patient had
recurrent fevers and therefore an IV had to be replaced to
resume vancomycin and meropenem. A PICC line was placed and she
will complete a 7 day course of Vancomycin and Meropenem. The
etiology of the patient's recurrent pneumonias was discussed.
She did demonstrate silent aspiration on video swallow exam
however dietary modification was not felt to help. More likely
this represents the end stage of her severe COPD.
# Schizophrenia: throughout the admission the patient exhibited
significant paranoia. She intermittently refused treatments and
would cite concern that she was being used as a ___ pig".
She lacked decisional capacity and her ___ who is her health
care proxy was involved in her decision making. The ___ does
not have formal guardianship over the patient and therefore the
patient was able to refuse treatments. She required a few doses
of haldol during bouts of extreme paranoia when interfering with
her care. She will continue her previous home psych regimen
after discharge. She will need to follow-up with her
psychiatrist.
CHRONIC ISSUES:
====================
# COPD: Pt has severe emphysema and possible pulmonary HTN.
- Cont home meds
#) Low Back Pain
- Cont home APAP, gabapentin
TRANSITIONAL ISSUES:
===========================
# Patient tolerated TMP/SMX during this admission without signs
of allergy. Sulfa should be removed from her allergy list.
# Levofloxacin allergy was confirmed during this admission
(rash)
# CONTACT: ___ ___
***. | 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.
***
___ h/o DM, HLD, depression, colonic polyps p/w dark stool,
BRBPR, diverticulosis on colonoscopy. Still with bloody bowel
movements and Hct drop.
.
# GI bleed: Dark stool and recent aleve use at high doses would
suggest upper GI source such as from bleeding ulcer ___ NSAID
use. Also on differential given h/o diverticulosis on
colonoscopy, BRBPR in ED would be diverticulosis. Patient's Hct
is gradually trending down. Upper GI endoscopy and colonoscopy
___ identified gastric ulcerations and bloody stool in colon,
but no definitive source of bleeding. Patient received blood
transfusion, and had a few more episodes of BRBPR with melena.
However, his melena/BRBPR resolved and Hct stabilised by the
time of discharge. He had a capsule endoscopy, which showed no
evidence of small intestine pathology. Bleed is thguht to be
likely secondary to diverticulosis. Continued protonix IV BID
and started oral PPI for home use once discharged. He was
monitored on telemetry. He is to f/u with his OSH
gastroenterologist Dr. ___.
.
# DM: held PO DM meds, continued home insulin regimen.
Metformin was restarted at the time of discharge.
.
# HLD: continued home simvastatin.
.
# Depression: continued to hold citalopram in the setting of
dropping plt and bleeding
.
# BPH: continued home tamsulosin.
.
# HL - continued simvastatin
.
TRANSITIONAL ISSUES:
1. Patient will need to followup with Dr. ___ home
PCP.
2. He will require serial hematocrits to monitor blood counts,
and may require further blood transfusions if Hct<25.
3. Final report of capsule endoscopy was not yet available at
the time of discharge.
***. | 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.
***
Ms. ___ was admitted to the neurosurgery for close monitoring
in the setting of a complex C2 fracture. MRI demonstrated no
spinal cord edema to indicate cord contusion; ligamentous injury
could not be entirely excluded. The patient's spine injury was
discussed with Dr. ___ she was maintained in a
cervical collar at all times. On ___ she underwent CT thoracic
spine for reproducible midline point tenderness in the mid to
lower thoracic region which was negative for fracture or
malalignment. The findings of this CT should be reviewed at a
later date with her primary care provider.
Medicine consult was initiated for syncope workup and on further
investigation the patient complained of exertional chest pain
and Cardiology was consulted given her hx of CAD. Upon their
evaluation there were no acute findings, and no changes made to
her medication. The patient was scheduled for a stress test
this week. Given her functional status, LVH, & baseline ST
abnormalities this patient would not be a candidate for an ETT.
A nuclear study would be the most appropriate test,
if indeed the test is indicated. Her last ETT was in ___
reportedly showed partially reversible anterior and inferior
defects (although we do not have
the report).
On her ___ it was noted that the patient had a slight increase
in her Crreatinine from 1.2 to 1.7. Her lasix were held and she
was started on IV hydration. On the morning of the ___ her labs
indicated that her Creatinine showed an improvement to 1.5. We
recommend close monitoring of her Creatinine and to restart her
Lasix once she reaches her baseline of 1.2. in this time, please
monitor the patient for development of pulmonary edema and CHF
given her cardiac history.
***. | MEDICAL BACK PROBLEMS 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.
***
PSYCHIATRY:
P.t. admitted to Deaconess 4. Admits to ___ with plan to OD on
HTN medications. States he had to pills in his hand but decided
not to take them. States the acute precipitant for these ideas
is a troubled interpersonal relationship with his friend
___. Agreed to increased Celexa dose of 20mg daily. On
hospital day 2, very tearful, wanting to go home. Signed 3-day
notice. Agreed to stay over weekend, but "I'm going home
___ Isolative to room over weekend per nursing report. On
day of discharge mood and affect were much improved. P.t. admits
that staying over the weekend was a "good idea". At the time of
discharge the patient denies any SI or HI. Was referred to the
___ day treatment program by ___ prior to discharge and he
___ be seen there at 9AM on ___. A follow up appointment
was made for the patient with his outpatient therapist for
___ prior to discharge. The patinet's friend ___ was on
the unit for a meeting with the team prior to the patient's
discharge. The patient verbalized understanding that he is to
call his outpatient psychiatrist for an appointment within the
next 7 days. Discharged to home with script for low dose
Seroquel PRN for anxiety.
MEDICAL:
The paitent had no medical issues during this hospital stay.
***. | 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.
***
ASSESSMENT AND PLAN:
Mr. ___ is a ___ year old male with hx of abdominal DLBCL s/p
C6 R-CHOP who presents from OSH with lower abdominal pain,
fever, chills, slight leukocytosis, and signs of colon and ileal
inflammation on OSH CT a/p.
#Colitis/Jejunitis: Initiated on Zosyn (___) at OSH and
continued on admission, fever spike on ___ prompted initiation
of meropenum and discontinuation of zosyn. Patient does have
evidence of rising leukocytosis, trending down but slightly
elevated today. CT ___ at ___ showed inflammatory changes
within the right lower colon which could be related to
perforated appendicitis. Peritoneal enhancement is suggestive of
peritonitis. No definite extraluminal air is identified to
localize source of perforation, however, perforation is not
excluded. Surgical consulted ___ but holding surgical
intervention as no free air or evidence of free perforation.
-Diet changed to clears ___, transitioned to BRAT diet ___
-Now off IVF in anticipation for discharge
-Morphine 2mg-4mg Q2hrs PRN pain, not using as much
-Urine culture negative, blood cultures NTD
-Lactate stable, repeat ___
-C-diff and stool cultures negative, norovirus ___ negative
-Surgery following
-Transitioned to oral antibiotic regimen (cipro and flagyl) x
14D (D1 = ___ as patient remains stable
#Diarrhea: Onset of diarrhea starting ___ afternoon, no
abdominal cramping. Etiology likely due to his acute abdominal
inflammatory process and initiation of diet. Abdominal pain
remains but on RLQ alone w/o rebound tenderness. Denies nausea
and vomiting. Transitioned to BRAT diet ___ and ADAT as
tolerated. Norovirus obtain ___ (negative) for further
evaluation although unlikely to be positive, all other stool
cultures negative as above. Since negative, initiated imodium
prn. This diarrhea could also be a side effect of his antibiotic
regimen.
#Hypokalemia: Likely due to diarrhea above, repleting lytes prn.
Repeat lytes now normalized, was 3.2 on ___
#Diffuse Large B-Cell Lymphoma: s/p C6 CHOP and Rituximab. PET
after 2 cycles showed significant reduction in disease burden
-Plan for restaging PET scheduled ___
-No infectious prophylaxis, will defer to outpatient provider
___: Grade 1 in fingertips, no involvement of
lower extremities. Continue vitamin b complex
#GERD: Stable, continue daily omeprazole
#Constipation: Now having diarrhea, Colace held.
#ADD: Continues home dose methylphenidate
#Smoking Cessation: Continues on nicotine patch
Prophylaxes:
# Access: PIV
# FEN: NPO/IVF/Repleting Lytes PRN
# Pain control: Morphine PRN, see above
# Bowel regimen: Holding colace BID with diarrhea
# Contact: HCP: ___. Relationship: mother. Phone number:
___
# ___: discharged ___ after observation ~ 24hrs on
po abx
# Code status: Full
***. | 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.
***
___ year old male status post slip and fall ___ feet found to
have cervical stenosis.
#Cervical Stenosis
The patient presented electively as scheduled on ___ for
C3-C7 laminectomies and C3-C6 posterior fusion with Dr.
___. The patient was taken to the operating room. The
procedure was uncomplicated. Please see ___ Record
for further intraoperative details. The patient was extubated in
the operating room and recovered in the post anesthesia care
unit. He was then transferred to the floor for close neurologic
monitoring. The patient remained neurologically stable
postoperatively. Postoperative x-rays of the cervical spine
showed no evidence of hardware complications. A surgical drain
was left in place postoperatively and was subsequently removed
on postoperative day two without complications. On ___, the
patient was afebrile with stable vital signs, ambulating with
assistance, tolerating a diet, voiding and stooling without
difficulty, and his pain was well controlled with oral pain
medications. He was discharged to rehabilitation on ___ in
stable condition. He will continue in his hard cervical collar.
#Disposition
Physical Therapy was consulted, evaluated the patient, and
recommended discharge to rehabilitation. The patient was
discharged to rehabilitation on ___ in stable condition.
***. | CERVICAL 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.
***
___ y/o M with hx of Low-grade (grade I) follicular B-cell
non-Hodgkin's lymphoma, cerebral amyloid angiopathy and
Multiple prior intraparenchymal hemorrages (R fronto-temporal,
R occipital) with residual L side neglect, presents for left
sided weakness and AMS. Found to have ___, thrombocytopenia,
and orthostatic hypotension.
ACTIVE ISSUES
=============
#Left sided weakness
#Cerebral amyloid angiopathy
Multiple prior intraparenchymal hemorrhages (R fronto-temporal,
R occipital) with dense left sided neglect. He has great care
at home and he has been able to regain his ability to walk and
regain some functional ability in ADLs. Prior to presentation
his wife noticed that he was having difficulty walking and
worsening functioning on left side. On exam he was noted to
have full strength in left side but pronator drift, extinction
to DSS, decreased proprioception, and possibly worsening gait
apraxia. CT scan showed no acute intracranial abnormalities.
Neurology saw him and felt that he was slightly off his
baseline and recommended MRI because CT could not fully rule
out new ischemic stroke or mass as cause of his symptoms. Mr.
___ wife refused MRI as there would be no acute
intervention. She spoke to his outpatient neurologist who
agreed and felt this could be done as an outpatient. Mr. ___
endorsed symptoms of viral URI with increased sinus congestion,
sneezing, and "dry" throat. He remained afebrile without
leukocytosis. No consolidation on CXR to suggest PNA. UA was
not consistent with UTI but patient was on TMP/SMX prior so
could have sterilized urine. It was felt that this likely
represented a recrudescence of prior strokes in setting of
dehydration and Acute kidney injury. Pt was aggressively
rehydrated and Bactrim/ACE were held. His symptoms improved
rapidly in house and pt was back to baseline by the time of
discharge. He was evaluated by ___ who felt he would need rehab
placement but as patient has 24 hr care at home and home ___ in
addition to his wife feeling comfortably taking him home he was
discharged to home with ___. He will follow up with his
neurologist and get MRI as an outpatient if symptoms persist or
recur. At time of discharge his exam was much improved with
better functioning of left arm.
___
#Orthostatic Hypotension: Cr on presentation up to 1.7 from
baseline of 0.9. Most likely pre-renal as patient was also
orthostatic on admission. Cr improved to 1.1 with IV fluids.
His lisinopril and carvediolol were held during admission d/t
reduced kidney function and orthostatic hypotension. At time of
discharge patient was no longer orthostatic and Cr had improved
to 0.8. His blood pressure was normotensive off carvedilol and
lisinopril so these were held. He was discharged off these
medications and should follow up with his PCP prior to
restarting.
#Thrombocytopenia: Platelets on admission 89 down from 160 on
___. Likely secondary to Bactrim, although patient does
have a history of non-Hodgkin's lymphoma. He denied all B
symptoms with normal LDH and uric acid. He had not received any
heparin recently. There was no evidence of hemolysis as cause
of thrombocytopenia. His TMP/SMX was stopped d/t low suspicion
for UTI and plts were monitored. At time of discharge platelets
were
improving spontaneously at 92.
#Dysuria: Per patient and his wife he has been experiencing
dysuria, increased frequency, urgency, and intermittent
incontinence for about a year now. He has a history of BPH but
no recent issues. He was started on TMP/SMX prior to admission
by his PCP for his dysuria but did not get UA or urine culture.
His symptoms did not improve on TMP/SMX. He denied any blood in
urine or change in symptoms prior to admission. On exam there
was no evidence of prostatitis and ua with out evidence of
infection however iso taking TMP/SMX. His antibiotics were
stopped d/t low suspicion for infection. UA did have few RBCs
raising possibility of interstitial cystitis as cause of
prolonged dysuria. He will follow up with his urologist for
evaluation of dysuria.
#Restless legs: Per wife, gabapentin was recently started for
restless legs. It was initially held in setting ___ and AMS.
#Chronic low back pain
- Continued lidocaine patch
#Normocytic Anemia
- Hb stable in the ___ during this admission, which is his
baseline.
#Insomnia: Prior to him presenting she restarted his Seroquel
after speaking to his Neurologist. He was continued on Seroquel
at night.
Transitional Issues
====================
MEDICATIONS STARTED: Polyethylene Glycol 17 g PO/NG DAILY:PRN
Constipation
MEDICATIONS HELD: Carvedililol, lisinopril, loratadine
[] Follow up with PCP
[] Follow up with Neurology
[] Follow up with Urology
[] Repeat Cr at f/u appointment. Admitted w/ a Cr of 1.1 but
improved to 0.8 w/ IVF and PO intake.
[] Consider cystoscopy for dysuria to evaluate for interstitial
cystitis
[] Consider MRI brain as an outpatient to evaluate for new
ischemic infarct or mass
[] Should check plts at PCP appointment to ensure these do not
remain low. They were as low as 77K while in the hospital but
improved to 92K at the time of discharge. Thought to be ___
Bactrim prescribed for presumed UTI(which was discontinued
during this admission).
[] Held antihypertensives at the time of discharge as his SBP
was in the 110s during most of this admission while they were
held in the setting of orthostatic hypotension. Would f/u
whether he needs these restarted as an outpatient.
#CONTACT: ___ (wife) ___
***. | 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.
***
Patient was admitted from clinic on ___ for right upper arm
wound dehiscence. A VAC was placed to the area on HD 1. The VAC
was replaced on HD 3 and the wound was found to be adequately
healing. The patient was also seen by the renal team who
dialyzed her on ___ and ___. A home vac was ordered for
the patient which was placed before she left on ___. The patient
will be discharged home with ___ to change the vac
every 3 days. She will also have home physical therapy and
social work follow up. Upon discharge the patient was afebrile
with stable vital signs, she was tolerating a renal diet and had
good pain control.
***. | COMPLICATIONS OF TREATMENT WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***SSESSMENT:
___ year old male with hx CAD s/p CABG, Afib on warfarin, PR
prolongation s/p CCY and more recently ERCP with sphincterotomy
for 1.5cm CBD stone, now presenting with syncope and
hypotension, likely secondary to GI bleed.
BRIEF HOSPITAL COURSE BY PROBLEM:
ACTIVE ISSUES:
# GI bleed: He was initially admitted to the ICU with concern
for active upper GI bleeding with evidence of a HCT drop and
melena. The ERCP service was consulted and recommended
consulting the GI service for upper endoscopy before attempting
a repeat ERCP. While awaiting this study, he received the
following infusions: 6L NS IV, 4 units pRBCs, 1 units FFP, and
10mg vitamin K in order to reverse an INR of 2.4. Due to a prior
history of a transfusion reaction, he was pre -treated with
diphenhydramine and transfused at a slower rate. His hematocrit
was followed closely and continued to trend up over the course
of his MICU stay so he was transferred to the floor. Had EGD
with side viewing scope which showed cratered ulcer at Duodenal
bulb. Biopsies were taken, GI rec'd: 1. following up in 4 weeks
for rescope to evaluate for healing of ulcer; 2. if H Pylori
positive, will need treatment; 3. continue PPi.
.
# Hypotension: Due to a presumed ongoing GI bleed, he was
admitted to the MICU for observation of his hypotension without
tachycardia. He was felt to be hypovolemic from the GI bleed and
was resuscitated as above. He did not appear to be septic. His
blood pressure remained stable throughout his MICU stay.
# Bradycardia/Syncope- His EKGs were initially concerning for a
high-degree AV block, but review of the EKGs with the Cardiology
service revealed atrial flutter with variable conduction
(usually 3:1) as well as known PR prolongation. TTE was done
and showed stable EF and no effusion. Troponins trended
downward. EP consulted who felt no acute intervention was
needed.
# Atrial fibrillation/flutter: INR was supratherapeutic in
setting of coumadin at presentation .Patient appears to have
slow atrial flutter, per EP, and does not require EP
intervention at this time. Reversed with FFP and 10 vitamin K
for EGD. Patient was instructed to restart coumadinon ___ if
no signs of bleeding/melena. Plans to have INR drawn the week of
___ with results sent to his nurse at his anticoagulation
___ in ___. They will manage his dosing from there.
INACTIVE ISSUES:
# CAD s/p CABG: Patient was w/o chest pain throughout. Troponins
negative. No evidence of active/acute ischemia on EKG. Home
statin was continued.
# Portacaval lesion: First noted on CT in ___. Appears stable.
Being followed by PCP in ___ with MRI and surgical referral.
# Diabetes: On metformin, saxaglipitin and Januvia at Home. He
was given insulin sliding scale while in house.
# Hypothyroidism (s/p thyroidectomy): Patient was maintined on
home dose of levothyroxine. No issues while in house.
TRANSITIONAL ISSUES
- Full code
- f/u pending EGD biopsies
- f/u H Pylori, treat if positive
- Repeat EGD in 4 weeks to evaluate healing and rule out
malignancy
- Re-initiation of coumadin on ___ - goal INR ___
- Continued workup of portocaval mass
***. | RED BLOOD CELL DISORDERS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient was admitted to the Orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
Patient had intermittent episodes of delirium in the post op
period. The Geriatrics team followed along for co-management.
Infectious work up negative, electrolytes wnl, and patient's
pain was well controlled. Baseline delirium.
Otherwise, pain was controlled with a combination of IV and oral
pain medications. The patient received lovenox for DVT
prophylaxis starting on the morning of POD#1. His Coumadin was
started in the evening of POD#0. The Lovenox was discontinued
when INR was >2 on POD#5. The foley was removed and the patient
was voiding independently thereafter. The surgical dressing was
changed and the SIlverlon dressing was removed on POD#2. The
surgical incision was found to be clean and intact without
erythema or abnormal drainage. The patient was seen daily by
physical therapy. Labs were checked throughout the hospital
course and repleted accordingly. At the time of discharge the
patient was tolerating a regular diet and feeling well. The
patient was afebrile with stable vital signs. The patient's
hematocrit was acceptable and pain was adequately controlled on
an oral regimen. The operative extremity was neurovascularly
intact and the wound was benign
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity. Please use walker or 2
crutches at all times for 6 weeks.
Mr. ___ is discharged to rehab in stable condition.
***. | 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.
***
The patient is a ___ female with ___ syndrome s/p
splenectomy with multiple relapses, multiple admissions, poor
adherence to appointments and treatments who was admitted with
relapsed ITP as well as vaginal bleeding.
#Thrombocytopenia
#Blood loss anemia
___ syndrome with AIHA
#Vaginal bleeding
#Epistaxis - patient presented with heavy vaginal bleeding,
epistaxis. Platelets <5, hbg<7, low haptoglobin, elevated LDH
and high reticulocyte count on admission. Heme was consulted and
patient received IVIG x 1 in the ED on ___. Patient continued
to have vaginal bleeding and Hgb down to 6.7 therefore patient
given additional dose of IVIG as well as romiplostim and 1 unit
PRBC. She was continued on PO prednisone. With this her platlets
improved to 183. Her bleeding was completely resolved on
discharge. She has heme follow up in two days where she will
have her CBC rechecked.
#Acute on chronic pelvic pain
#Ovarian cyst- Pelvic pain present for weeks, not associated
with menstruation. Hcg negative. Prelim ultrasound read showing
ovarian cyst and nonspecific small volume fluid as well as
endometrial polyp. Gyn was consulted and was not concerned for
ovarian torsion, recommended outpatient follow up.
CHRONIC/STABLE PROBLEMS:
#Hepatitis B Core Positive - Last HBV VL checked was ___,
negative. Serologies c/w previous infection. Patient on
entecavir given likely initiation of Rituximab in the future.
Plan to continue treatment for one month before initiation of
rituxtimab and six months following.
#Depression - Patient says she stopped prior bupropion after
last admission
because she felt like she didn't need it.
>30 minutes spent on complex discharge
***. | 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 neurology stroke service for
right cerebellar stroke. Throughout the hospitalization, her
symptoms of mild scanning speech and for mild saccadic ataxia,
mostly on right and up-gaze, improved. Her evaluation included
CTA head/neck which showed mild posterior circulation
atherosclerosis
and an MRI brain which showed a large right SCA territory
cerebellar stroke as well as another focus of ischemia which
might be either very
distal SCA or alternatively right ___ territory. The team
favored the
latter. This implied an embolic etiology as the mild
atherosclerosis seen in the basilar artery would have have
caused
___ insult.
The patient was started on atorvastatin 40 mg daily due to an
elevated LDL of 115 and was instructed to continue her home
aspirin 81 mg daily (had been non-compliant for two months). Her
A1c returned at
6 but since she is making good progress with weight loss and
exercise, we did not prescribe metformin. Her TTE did not
demonstrate a PFO or obvious intracardiac source of thrombus.
Her
telemetry did not reveal any atrial fibrillation.
Transitional issues:
-TSH pendng
-Follow-up Dr. ___ in stroke neurology on ___
-review her ___ of Hearts data (outpatient eval for AFib)
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
7. 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
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
***. | 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.
*** year old male who presented to ___ on ___
reporting about a ___ min episode of chest pain across his
upper chest, radiating from right to left that woke him up. ___
was found to have ST depressions with a Troponin-T of 0.5. ___
was transferred to ___ for further evaluation. At ___ ___ was
sent for a cardiac catheterization where ___ was found to have
left main disease. ___ was then referred to cardiac surgery for
revascularization. ___ had the usual pre operative work up and on
___ ___ was brought to the operating room for coronary artery
bypass grafting. Please see operative report for details in
summary ___ had: Coronary artery bypass grafts x4 (LIMA-LAD,
SVG-PDA, SVG-D1, SVG-D2) Endovascular saphenous vein harvest
of left lower extremity. ___ tolerated the operation well and
post-operatively was transferred to the cardiac surgery ICU in
stable condition. In the immediate post-op period ___ remained
stable, his anesthesia was reversed, ___ weaned from the
ventilator and was extubated. On POD 1 ___ transferred to the
step-down floor for continued post-op care and recovery. All
tubes, lines, and drains were removed per cardiac surgery
protocol without complication. Once on the step-down floor ___
worked with nursing and physical therapy to increase strength
and mobility. ___ progressed along and on POD #4 ___ was ready for
discharge home with visiting nurses. ___ is to follow up with Dr.
___ in one month.
***. | CORONARY BYPASS WITH CARDIAC CATHETERIZATION 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.
***
Mrs. ___ is a ___ year old female with multiple myeloma s/p
7 cycles of RVD in ___ admitted for HD CTX mobilization in
preparation for autologous SCT.
ACUTE CONDITIONS
=========================
#Multiple Myeloma:
#Encounter for Chemotherapy:
Initially presented with low back pain, found to have marrow
signaling on MRI. At that time, she was noted to have anemia and
a normal creatinine. An SPEP demonstrated a 1.6 g of IgG kappa
monoclonal protein. She was started on RVD ___ in
___. She presents for HD CTX mobilization chemotherapy in
preparation for stem cell mobilization. Today is day 3. She
developed CINV and some electrolyte imbalances but otherwise,
tolerated her regimen well. She started on first dose of
neupogen and levquin inpatient and will continue per her
transplant calendar. Continues on acyclovir for HSV prophylaxis.
Follow up appointment on ___.
#CINV: Improved. Suspect ___ HD CTX. She received zofran,
ativan, compazine and phenergan inpatient. She is now able to
eat and drink fairly. She was discharged on zofran and
compazine as needed.
#Hypocalcemia, hypokalemia, & Hypophosphatemia: Suspect ___
chemotherapy effect
(HD CTX) combined with decreased PO and CINV. She was repleted
accordingly. Continues on vit d and calcium supp.
#FVO: Asympatomatic, up ~9lbs from admission weight, likely ___
aggressive IVF in s/o HD CTX. Holding off diuresis as not
symptomatic and expect auto-diuresis at home
as expect auto-diuresis.
___: Per outpatient provider notes, ___
started after initiation of Velcade; therefore, now receiving
weekly Velcade. ___ is stable but requires close
monitoring outpatient.
CHRONIC/RESOLVED CONDITIONS
==============================
#Chronic Lower Back Pain: No acute exacerbation. Patient has had
chronic lower back pain since diagnosis in ___. She is s/p
Kyphoplasty to L1 in ___. Pain is currently well managed on
Robaxin, Oxycodone and Tramadol.
#Peripheral Neuropathy: Likely ___ RVD, not affecting ADLs.
Trend sxs
CORE MEASURES
===============
#CODE: Full
#EMERGENCY CONTACT: ___ (husband)
Attending Note:
Ms. ___ is a very pleasant ___ year old physician with
multiple myeloma s/p 7 cycles of RVD in ___ admitted for HD
CTX mobilization in preparation for autologous SCT
Her course was complicated with severe chemotherapy induced
nausea and vomiting and hence was hospitalized for another day
and treated with antiemetics and IV fluids. Her nausea and
vomiting has now subsided and she is able to tolerate all diet
and medications
Clinically her vitals are normal, HEENT is normal, no palpable
nodes, chest, cardiac and abdominal exam is normal. Gross exam
of CNS was normal, did not perform sensory exam.
Blood tests are recorded above, she has mild hypokalemia and
elevated LFT's which are trending down and likely from
chemotherapy
She will be discharged home today and start G-CSF injections for
mobilization as instructed and follow in clinic. Her other
comorbidities are stable and plan is outlined above with no
changes.
This is a comprehensive and detailed visit with high
complexity medical decision making.
___ MD
___/ ___
***. | CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
SUMMARY:
=========
Mr. ___ is a ___ male with ___ CAD s/p CABG x4
(RIMA-RCA, VG-diag, VG-OM3, VG-RPDA) in ___, HTN, HLD who
presented to ___ with 2 hours of substernal chest pain
and dyspnea. He was found to have STEMI and transferred to ___
for coronary angiography and PCI. Patient is s/p PCI to LAD and
was admitted to CCU for post-STEMI monitoring, course
complicated by in-stent thrombosis requiring second stent
placement.
# STEMI
# CAD s/p CABG
# Mechanical hemolytic anemia
Pt was taken to cath lab and 2 stents placed to proximal LAD and
he was transferred to CCU. He started to c/o new CP and new EKG
showed anterior STE, returned for repeat coronary angiography
showing stent thrombosis of LAD s/p re-stenting w/ overlapping
of prior stents distally and proximally. EDP ~40, Impella placed
L groin. He was started on aspirin and atorvastatin. Continued
on Ticagrelor, and started on low dose captopril. He was
diuresed, impella repositioned. Given newly developing ___ his
captopril was held, placed on nitro gtt for map<75. However, he
developed worsening chest pain on ___ and was taken back to the
cath lab here he was found to have an LAD in-stent thrombosis.
He was placed on an Impella for ___omplicated
by hemolytic anemia. A repeat stent was placed with normal flow
and 0% residual stenosis. Impella removed ___, and he was
started on ticagrelor 90mg BID, and 6.25mg captopril as renal
function improved.
#HFrEF
Most likely cause secondary to ischemic cardiomyopathy and acute
STEMI, recent TTE with EF of 26%. He was given IV diuresis and
started on captopril. RHC on ___ after Impella removal
showed RA 11 PA ___ PCW 17, SVR 912, CVO2 60%, CO 4.2, CI 2.3.
Started metop tartrate 6.25mg q6 and titrated as tolerated. He
was euvolemic at discharge requiring no diuretics.
# Lack of insurance
Patient met with social work and financial services. He applied
for ___. He was given a month free of Ticagrelor as well
as 30-day supply of other medications with plan to follow up
with financial services.
CHRONIC PROBLEMS:
=================
# HTN:
Started on captopril for afterload reduction.
# HLD:
Started atorvastatin 80 mg PO QHS
# Tobacco use disorder: Currently smokes 6 cigarettes per day.
-Smoking cessation encouraged
TRANSITIONAL ISSUES:
====================
[] Continue to encourage tobacco cessation upon discharge
[] Ensure follow up with financial services within two weeks of
discharge to continue to work on ___ application and
Ticagrelor coverage.
[] Consider OSA evaluation given polycythemia on admission
ADVANCED CARE PLANNING:
======================
#CODE: Full code (presumed)
#CONTACT/HCP: ___, Phone: ___
***. | OTHER HEART ASSIST SYSTEM IMPLANT |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient is a ___ year old man with previous hypertension, and
morbid obesity who presents with hypertensive emergency. He
reports that prior medications included atenolol and an ACE
inhibitor, but that he lost a significant amount of weight
several years ago and had been tapered off these medications. He
initiated his care with Dr ___ has since been trying to
lower his blood pressure again with lifestyle changes, as he had
gained a significant portion of his weight back. He was noted to
have elevated blood pressures on a visit to ___ several months
ago, and was nearing medication initiation. He presents with
several days of worsening visual changes with difficulty with
near vision, as well as ongoing escalating headaches in the
weeks prior to admission, which he was managing with ibuprofen.
He later mentioned that his headaches had likely been escalating
for months prior to admission. He denies chest pain, shortness
of breath, or syncope at any time.
During his hospital course, he is tolerating blood pressure
regimen without dizziness or chest pain. BP control improved but
aiming for better control prior to discharge given retinal acute
disease in setting of extreme hypertension. Visual changes
stable.
Active Issues:
# Hypertensive urgency/emergency, with end-organ damage in eyes
(retinopathy). Previous history of HTN at young age, off meds
(labetalol and benazepril) x ___ years. Poor monitoring of BP
recently, as he notes he had not followed closely with his
internist and had gained significant weight back. He was noted
to be HTN at last PCP office visit over ___ year ago. Likely
progression of untreated primary HTN. In absence of chest pain
and with even BP's bilaterally, aortic dissection unlikely. No
evidence of renal or cardiac end-organ damage, however visual
changes concerning for HTN retinopathy, although visual changes
are currently stable.
No subsequent evidence of cardiac injury, with normal troponin
as well. Monitoring on telemetry, monitoring renal function Goal
BP ___ reduction each day, with maintainenance of this
reduction. Given end-organ damage, will require stability prior
to discharge. Now on labetalol 200mg tid, and started lisinopril
10mg daily ___. Suspect this will achieve intermediate goals,
but may require further titration. Will need very close
outpatient PCP ___. TTE showed mild symmetric LVH and
mildly dilated LA.
#Hypertensive Retinopathy with numerous retinal findings on
opthalmology ___. Monitor BP and will need ___ as
suggested both with general and retinal opthalmologists.
# Hyperlipidemia, previously diet controlled. Will recheck
fasting profile and LFTs ___. Trigs 122, Cholesterol 146, HDL
34, LDL-c 88. Would recheck as outpatient, as can be an acute
phase reactant, but no indication for therapy at this time. A1c
5.4%
# Nicotine dependence. Patient was counseled on smoking
cessation. He declined the nicotine patch. Has tried Wellbutrin
in the past. Is considering ___ f/u with PCP.
Continue to encourage cessation while inpatient. Once BP control
slightly improved, can consider nicotine patch if desired.
# Obesity. Discussed with patient that he will need BP control
before starting aggressive exercise regimen, and can discuss
timing with Dr ___ likelihood of raising BP further.
Checking HbA1c, given weight gain and patient report of strong
family history, as well as random BG of 101 this admission which
is unclear if fasting or not.
I spoke with PCP ___ ___ and also with patient about plan that
he can check his BP at home and if SBP>170 or DBP>100 then he
can call office to discuss uptitrating lisinopril to 20mg or
further increase in labetalol.
***. | 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.
***
___ y/o F with hypertension, hyperlipidemia, anxiety, presenting
with new diagnosis of acute myelogenous leukemia, admitted for
7+3 induction chemotherapy. Hospital course complicated by
fever, neutropenia, and sepsis secondary to fever and
neutropenia (likely etiologies VRE bacteremia,
diverticulitis/typhlitis) and pulmonary nodules noted on Chest
CT.
# AML: Pt is newly diagnosed with AML, possibly M4/M5 subtype
given monocytic predominance on flow cytometry and BM biopsy.
Patient underwent 7 + 3 induction chemotherapy (7 days ara-c, 3
days idarubicin) and tolerated it well. However, blasts were
still present in her bone marrow biopsy and CBC differential
after completion of chemotherapy, indicating residual disease.
She had a repeat bone marrow biopsy the day before discharge,
the results of which were pending on the day of discharge. She
was scheduled to follow-up with her outpatient oncologist on
___, and have another round of chemotherapy on ___ pending
the results of the bone marrow biopsy.
#VRE Bacteremia: Hospital course complicated by Vancomycin
resistant enterococcal bacteremia ___ bottles). Patient briefly
required ICU admission. Followed by ID during admission. Central
line was removed. Patient was treated with daptomycin,
meropenem, and voriconazole/micafungin during her neutropenic
phase. Surveillance blood cx's were negative for four days,
after which a PICC was placed. TTE showed mildly worsened mitral
regurgitation, but TEE showed ___ evidence of endocarditis,
mitral valve or otherwise. Patient was hemodynamically
stabilized and was treated with a 14 day course of daptomycin
and meropenem starting from ___ (the day she was ___ longer
neutropenic.)
# Diverticulitis/Typhlitis: Treated with 14 day course of
meropenem after patient was ___ longer neutropenic.
#Pulmonary Nodules: Pt noted to be short of breath and hypoxic
with a new oxygen requirement, improved with diuresis with IV
lasix. Patient briefly required ICU admission for her hypoxia.
Chest CT showed pulmonary nodules concerning for fungal vs.
viral infection. Treated initially with albuterol/ipratroprium
nebulizers and voriconazole, which was later d/c-ed due to LFT
abnormalities and changed to micafungin. Nodules were slightly
worsened on repeat Chest CT, but patient clincally improved.
Pulmonary followed patient in-house. Decision was made not to
bronchoscopy/BAL as she clinically improved. Anti-fungal were
eventually d/c-ed. Patient should have repeat Chest CT I- high
resolution 1 week after discharge to assess for
stability/interval change of pulmonary nodules.
# Hypertension: Poorly controlled on patient's home regimen of
metoprolol 25 mg PO BID, with SBPs into the 170s-190s. Once
patient was hemodynamically stable, increased metoprolol to 50
mg PO TID and added amlodipine 5 mg daily, bridged with PRN
doses of IV hydralazine. Patient's blood pressure was 148-150s
systolic on discharge with the initiation of calcium channel
blocker and increase in beta-blocker.
# Anxiety: Pt has baseline anxiety, which has been augmented by
this new diagnosis. Pt may experience decreased PO intake with
nausea during chemo course, so would like to wean her off
Lexapro for now and address anxiety with PO/IV meds. Tapered
celexa to 20 mg by mouth daily, and controlled anxiety with
Ativan IV/PO as needed. Discharged patient on tapered celexa
dose with PRN oral ativan, as she may likely need chemotherapy
to treat her residual disease and may have difficulty with oral
medications (requiring IV meds for anxiety).
# Silicone breast implant: Noted to have silicone breast implant
leakage, stable on mammogram/ultrasound and Chest CT. Patient
may follow up with the outpatient breast surgeons once
chemotherapy is completed.
***. | ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURE 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.
***
A/P: ___ M with history of asthma, DMII presents with asthma
exacerbation in the setting of recent viral syndrome, as well as
hyperglycemia and lactic acidosis.
# Asthma exacerbation, acute: Patient was treated with steroids
(prednisone 60mg daily and then a taper) and nebs with
improvement in his symptoms. His home medications were
continued. He had f/u scheduled with Dr. ___ in pulmonary.
# Hyperglycemia, DMII, poorly controlled with complications: Pt
reported difficulty getting the right # of novolog pens. ___
was consulted and recommended increasing glargine to 38u. Pt's
sliding scale was adjusted. The PACT team enrolled the patient.
# Lactic acidosis: Likely related to hyperglycemia. Resolved
with improvement in blood sugar.
***. | 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.
***
The patient was admitted to the Acute Care Trauma Surgery
service and was taken urgently to the operating room for
suspected ruptured spleen. He underwent an exploratory
laparotomy and splenectomy, 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 and remained NPO with an NGT, on IV fluids, and an
epidural and PCA for pain control. The patient was mildly
hypotensive and tachycardic but otherwise hemodynamically
stable.
The patient spiked a fever on POD1 and POD2; fever work-up
(chest x-ray, blood cultures, urine cultures) was negative. On
POD3, the nasogastric tube and Foley catheter was discontinued
and the patient was started on a clear liquid diet. WBC was
monitored daily and trending down.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
.
At the time of discharge, 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. The patient was discharged home without services.
The patient received his vaccinations at the time of discharge.
The patient and his family received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. He had follow-up scheduled
with his PCP and in the ___ clinic.
***. | SPLENECTOMY 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 a PMH notable for hepatitis C/cirrhosis transferred
from OSH in renal failure with septic shock.
# PEA arrest: Patient s/p PEA arrest in the ED with ROSC after 5
minutes of CPR + epinephrine. He was not a candidate for
therapeutic cooling given the SDH found on CT head. He was
admitted to the MICU and monitored closely with the post arrest
team. The patient ultimately went into an escape rhythm leading
to asystole on ___.
# Septic shock secondary to aspiration pneumonia: The patient
presented hypothermic, tachycardic and with bandemia. This was
likely secondary to septic shock from an aspiration pneumonia.
He was intubated for hypoxemic respiratory failure and given
fentanyl for sedation. His blood cultures grew coagulase
negative staphlococcus and diphtheria. He was maintained on
broad spectrum antibiotics, steroids, and maximum hemodynamic
support with fluids, multiple pressors. Despite aggressive
efforts, he remained persistently acidemic. He ultimately
expired from sepsis secondary to pneumonia.
# Metabolic acidosis: Due to overwhelming lactic acidosis
ranging from ___. He was treated by maximizing his minute
ventilation on the vent. He was also started on a bicarb drip in
addition to starting CVVH with a 32 bicarb bath. Despite these
efforts, he continued to remain persistently acidemic with pH
around 7.0.
# Subdural hematoma: Noted to have a 6 mm left, frontal, acute
subdural hematoma. He was evaluated by neurosurgery who
recommended no urgent neurosurgical procedure. His coagulopathy
was treated with vitamin K, FFP, and platelets. He eventually
developed DIC. He was started on Dilantin which was switched to
keppra in the setting of his liver disease for seizure
prophylaxis. Repreat imaging showed a stable hematoma.
# Acute on chronic liver failure: Patient had evidence of
cirrhosis and portal hypertension on imaging studies. Per old
records, patient has HCV cirrhosis (genotype Ia, VL 595,500
___ and history of significant alcohol abuse. Patient likely
decompensated in the setting of septic shock and hypotension.
Initially there was some concern for dark material on OG output
concerning for a bleed and he was started on a PPI and
octreotide gtt.
# Rhabdomyolysis - Patient noted to have blood in urine with
only 2 RBCs and found to have CK elevated to 1200 at OSH all in
the setting of being found down in the woods for an unknown
period of time. He was given fluid resuscitation but ultimately
required CVVH.
# Hypoglycemia - Noted to be hypoglycemic in the field, at OSH,
and in ___ ED. He was started on D5 in fluids to maintain
normoglycemia. Hypoglycemia likely from hepatic/renal failure
and sepsis.
# Atrial fibrillation - Patient noted to be in Afib with RVR in
the ED s/p arrest. He underwent a synchronized cardioversion
with 200J in the emergency department with conversion to sinus
tachycardia.
# Acute renal failure - Most likely secondary to ATN from
hypotension and hypovolemic from poor po intake for days. Urine
output diminished. Renal was consulted and patient was started
on CVVH.
TRANSITIONAL ISSUES
*******************
None
***. | 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.
***
On ___ presented for induction of labor for
oligohydramnios at 40w4d after being found to have an AFI of 2.7
on routine post dates testing. She advanced to 7cm dilation at
which time she had recurrent late decelerations and a prolonged
deceleration to 70 BPM at which point she underwent a stat
cesarean delivery for nonreassuring fetal heart tracing. Please
refer to Dr. ___ report for details of the
operation. Her pre-operative HCT was 29.3, intraoperative HCT
was 25, and EBL was 1500cc.
Post-operatively, her HCT nadired at 20.7 with symptoms of
anemia, so she was transfused 2 units of pRBCs for symptomatic
blood-loss anemia. Her post-transfusion HCT was 24.2. Her vital
signs were stable, her symptoms resolved, and she had no
clinical evidence of ongoing blood loss. The remainder of her
postpartum course was uncomplicated. By postpartum day 4, she
was tolerating a regular diet, ambulating independently, voiding
spontaneously, and pain was controlled with oral medications.
She was then discharged home in stable condition with outpatient
follow-up scheduled.
***. | CESAREAN SECTION WITH CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ male w/PMHx including well-controlled bipolar d/o, COPD,
chronic back pain s/p laminectomy, HTN, HL, severe AS ___
0.8cm2), w/recently diagnosed Stage 4 lung cancer on last
admission (___), s/p endobronchial mass intervention by
IP, who presented with hemoptysis and respiratory distress
progression of metastatic lung cancer, ultimately receiving
antibiotics for post-obstructive PNA, undergoing bronchial
artery embolization by ___, and transitioning to comfort measures
only as his dyspnea worsened and the family reflected on the
limited available options for his refractory symptoms in the
setting of advanced cancer. Patient ultimately expired on ___
after family elected to remove high flow oxygen apparatus.
=================
ACTIVE ISSUES
=================
#NSCLC, stage IV
#Malignant Pleural effusion:
#Hypoxic respiratory failure
Patient had an unfortunate diagnosis of poorly differentiated
adenocarcinoma (MOC31 and TTF positive; B72.3, Napsin A, and p40
negative).
Patient presented to the hospital from rehab with symptoms of
recurrent hemoptysis in the setting of his advanced stage lung
cancer. Patient had a known extensive pulmonary burden from lung
cancer w/interval imaging showing significant worsening of
disease w/additional loculations of pleural effusions likely
significantly contributing to dyspnea. Patient also had a known
history of COPD w/o obvious symptoms of flare. Patient had also
received 5 fractions of XRT ___ to lung masses and
mediastinum. His presenting symptoms were felt to unlikely be
due to acute sequelae of xrt. Anemia and severe AS were felt to
be likely contributing to extent of dyspnea. Patient presented
with an EKG reassuring for absence of ischemia or signs of
tamponade. His most recent discharge had been on 4L NC for
persistent hypoxia. His goal O2 during admission was a goal O2
of 88-92 given known COPD.
He ultimately on presentation required ___ NC to maintain O2
92% upon his admission to the MICU. Interventional pulmonary was
consulted, Chest Tube was placed on the right on ___ to
drain the fluid collection seen on CT from ___.
He was also treated with antibiotics for a post-obstructive PNA,
as pleural fluid analysis indicated that patient's posterior
fluid collection as consistent with hemothorax. He was
transfused 1 u PRBCs on ___ for Hb 6.8. Initially MRI brain was
planned, but patient did not have the ability to lie flat. He
was started on broad spectrum antibiotics with
vancomycin/ceftazidime on ___. Heme/onc was consulted and the
patient was transferred to the oncology service for further
management. On the oncology service the patient experienced
ongoing hemoptysis so ___ was consulted for bronchial artery
embolization, which the patient underwent on ___. The patient
had access via the right groin, which was closed following the
procedure with an angioseal.
There was marked difficulty ventilating the patient during the
embolization procedure, after which the patient was transferred
to the MICU, intubated, and sedated on ___ for further
monitoring. Chest tubes were removed by IP on ___ and he was
extubated, experiencing minimal further hemoptysis. He continued
to receive intermittent blood transfusions and was started on
high flow oxygen for worsened oxygen sats. Patient was treated
with flagyl as well for empiric anaerobic coverage. After repeat
consultations with oncology, pt was deemed not a candidate for
chemotherapy. Family meetings were held with the extended group
to convey impression regarding limited treatment options.
Patient was able to verbalize his understanding that he was
dying. Family and son also acknowledged that he was "on his way
out." As family meetings occurred, initially plan was to utilize
pleurX catheter for MWF drainage, though many attempts to remove
fluid were unsuccessful. Patient was seen by palliative care,
who recommended narcotics and anxiolytics to treat symptoms of
air hunger. Patient was transitioned to CMO on ___ after
experiencing progressive shortness of breath and discomfort. On
___ patient was transferred out of the MICU to the medical floor
on high flow oxygen and heart rate telemetry in the company of
his family. He remained on high flow oxygen with prn Dilaudid,
transitioning to a Dilaudid gtt on ___. Patient's RASS on the
day of expiration was approximately -3 for much of the day.
After congregating family, the family made the decision to
perform removal of the high flow oxygen device. The patient
expired at 17:16 on ___.
#Goals of care:
In the setting of general decompensation and failure to improve
clinically due to the below, goals of care were discussed
___ much of the patient's hospitalization, and patient was
transitioned to comfort measures only. Once this was decision
was made on ___, medications not contributing to comfort were
discontinued, in consultation with the palliative care team,
patient, and his family.
#Hemoptysis:
#Acute blood loss anemia:
Patient presented with a Hb 6.5 from 6, s/p 1unit prbc at ___.
Pt originally presented on last admission w/similar sx I/s/o new
dx metastatic lung cancer. Patient presented to ___ from rehab
w/recurrent hemoptysis found to have extensive progression of
disease. Anterior and posterior chest tubes were placed on
___ draining 200 and 800 cc respectively. Hct of the
posterior right lung fluid with 30% consistent with a
hemothorax, as above. H/H remained stable and output from the
chest tube while to water seal was minimal. ___ was consulted
and performed embolization on ___. H+H received intermittent
blood transfusions, as above, but H/H was remaining subsequently
stable following resolution of hemoptysis prior to transitioning
to comfort measures
#Encephalopathy:
Pt had ongoing waxing and waning mental status during admission,
which was largely attributed to hypoxia and delirium. Given that
patient was on valproate chronically, toxic metabolic
encephalopathy was considered from rx. The possibility of mets
to the brain was considered, though MRI could not be obtained,
as above, due to patient's inability to lie flat. While
admitted, valproate level was appropriate.
# Hypotension
Presented to the ED with SBP in the ___ in the setting of
metastatic lung adenocarcinoma, hemoptysis with blood loss and
concern for adrenal insufficiency given hyperkalemia on
admission. Cortisol level was within normal limits.
# Bipolar disorder: He was continued on home divalproex and
fluvoxamine initially, later discontinued as patient
transitioned to CMO.
====================
CHRONIC ISSUES:
====================
# Severe AS: ___ 0.8cm2. Moexipril was held ___ bleeding.
# COPD: patient received nebulizers throughout his hospital
course.
# HTN: home moexipril was held as above.
# HLD: Continued home simvastatin, Held home ASA in the setting
of bleeding.
# GERD: Continued home ranitidine
# Chronic back pain s/p laminectomy: Pain was initially
controlled with oxycodone/lidocaine patch, then patient was
transitioned to Dilaudid as he transitioned to CMO.
# Glaucoma: Continued home brimonidine.
***. | 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.
***
___ year old male with ___ disease who presented
electively on ___ for bilateral deep brain stimulation,
stage I.
___ Disease
Patient was taken to the OR on ___ for bilateral deep brain
stimulation, stage I. Patient was intubated for the procedure
due to his difficulty managing his secretions. The procedure was
uncomplicated. Please see separately dictated operative report
by Dr. ___ further details. Patient was extubated and
taken to the PACU to recover before being transferred to the
floor for neurological monitoring. Patient remained
neurologically intact on the floor. He returned to the OR on
___ for bilateral stage II DBS. The procedure was
uncomplicated. On day of discharge, his pain was well controlled
on oral medications. He was tolerating his tube feeds (running
continuous but cycled). He requires some assistance with
ambulation. Rehab options were discussed with case management
but patient & family preferred discharge home. Home services
were scheduled. His vital signs were stable and he was afebrile.
He was discharged to home with home services.
#Dysphagia
___, patient experienced increased difficulty
managing his secretions. A nasogastric tube was placed for
patient to receive his home ___ medications. Speech and
Language Pathology was consulted to evaluate his swallowing and
noted patient to have orophayngeal dysphagia. Patient was made
NPO, and cleared only for the trials of nectar thick liquids
after medications with nursing. Speech and Language Pathology
continued to follow. Acute Care Surgery was consulted for PEG
tube placement. On ___, he underwent placement of PEG. The
procedure was uncomplicated. For further procedure details,
please see separately dictated operative report by Dr. ___.
The PEG was cleared for use by ACS on ___. He underwent video
swallow ___ and ok for nectar thick liquid trials. Swallow
recommends repeating a video swallow after his device is on. He
was started on cycled tube feeds prior to discharge.
#Urinary retention
The patient had urinary retention requiring straight
catheterization x 3 on ___. Foley was placed for bladder rest
with plan to reassess in one week. With the foley, patient was
putting out good urine output.
***. | CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is a ___ woman with COPD on 3L home O2, afib on
rivaroxaban, diltiazem and digoxin who was referred from her
endocrinologist's office for hypotension.
# Hypotension: The etiology thought secondary to hypovolemia and
resolved with IVF bolus and increased PO intake. Her history was
notable for poor PO intake and recent attempts at weight loss.
There was no evidence of sepsis/distributive pathology. There
was no evidence of CHF, cardiogenic shock, PE, or MI on EKG or
physical exam. There was no evidence of hemorrhage/active
bleeding on exam. She remained asymptomatic throughout her
hospital stay, maintained good mentation and good urine output.
Her Lasix and diltiazem were held during her hospitalization.
Her heart rate remained in the ___. She is discharged with
instructions to continue to hold off on Lasix and diltiazem
until PCP follow up.
# Anemia: Unclear what the patient's baseline H/H is, given care
at outside facility and it is unclear what tests have already
been performed. Acute drop during her hospitalization likely
secondary to dilutional effect in the setting of IVF and
increased PO fluid intake. There were no signs of active
bleeding on exam, and no report of melena per nursing staff. The
patient refused rectal exam. The patient's PCP was called and we
discussed this issue of anemia and further workup after
discharge, as well as the other issues noted here. The PCP ___
___ with the patient.
# ___: The patient presented with Creatinine of 1.6, which
improved to 0.9 on discharge after IVF and increased PO intake.
# COPD: The patient is on 3L 02 at home. She notes that she does
not take any other medications for COPD as she has difficulty
using the inhalers. She was started in-house on albuterol
inhalers, tiotropium, advair. In addition, given leukocytosis
and findings on CXR she was also treated for suspected pneumonia
with levofloxacin. Her leukocytosis resolved on discharge. She
is discharged to complete a 5 day course of levofloxacin. She is
also discharged on her in-house COPD regimen with ___ services
to assist with medication management.
# Leukocytosis: Likely related to pneumonia. The patient had a
leukocytosis and CXR suspicious for pneumonia, though denies
worsening cough or sputum production. Her leukocytosis resolved
with treatment with levofloxacin. She is discharged on
levofloxacin to complete a ___trial Fibrillation: The patient is on rivaroxaban, digoxin,
and diltiazem at home. She was continued on rivaroxaban and
digoxin in-house. Diltiazem held in-house in the setting of
hypotension and her HR remained in the ___. She is
discharged with instructions to continue to hold diltiazem until
her PCP follow up.
# Restless leg syndrome: Continued on ropinirole
# Depression: Continued on home sertraline
TRANSITIONAL ISSUES:
- Patient discharged with ___ services to assist with COPD
inhalers
- Patient instructed to hold off on restarting Diltiazem and
Lasix until PCP follow up in the setting of hypotension
- Patient noted to be anemic in house with no active signs of
bleeding, though she refused rectal exam. Unclear what studies
have already been done to evaluate the etiology. Recommend iron
studies/colonoscopy if this has not already been performed
***. | MISCELLANEOUS DISORDERS OF NUTRITION METABOLISM FLUIDS AND ELECTROLYTES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ y/o woman with known AF on AC presenting s/p cardiac arrest,
found to have multiple C-spine injuries and significant
neurologic deficits concerning for spinal cord injury.
#) Syncope: Based on history, it is unclear whether patient
truly had PEA arrest vs. VT/VF vs. syncope ___ arrhythmia. As
detailed in HPI, she was treated as if she were s/p cardiac
arrest with CPR, epix1, and shock with stablization in
hemodynamics. Original differential included ischemia, supported
by possible lateral ST depression on EKG. Repeat EKG did not
show any ST abnormalities and cardiac enzymes initially
uptrended to 0.07, but downtrended thereafter. Structural heart
disease was considered but thought to be unlikely given normal
echocardiogram in ED, confirmed by formal TTE on ___.
Possible arrest also could have been result of toxic/metabolic
insult. On admission, K and Mg were normal but calcium was low
at 6.7 (ionized calcium of 0.8). Additionally, she had elevated
WBC of 11 (trending up to 19), which could be ___s T103.3F shortly after admission. To r/o infection, BCx x2,
UCx, and sputum gs and cx obtained, all NGTD.
Upon review of EKG's, patient appeared to oscillate between
tachy- and brady-arrhythmias. Post-resuscitation efforts, EKG
showed what appears to be atrial fibrillation with high grade
conduction block and ventricular escape beats. Following
transfer to SICU, she continued to be tachy-brady, alternating
between afib w/ RVR to 140's and sinus brady to the 30's, albeit
with stable blood pressures.
-Given her presumed syncope ___ high grade conduction block, she
will likely need a pacemaker as well as initiation on
antiarrhythmic medication. From a cardiac perspective, she will
need follow up with EP following discharge.
#) C-spine injury: Imaging on admission showed a sub-galeal SDH,
C1/dens fracture with associated hematoma, and soft tissue
density at c6/c7 compressing spinal cord - ?hematoma or
traumatic disc herniation. All of these injuries were thought to
be related to her fall. Clinically, she presented with complete
loss of motor and sensory function below the C6 level. She was
placed in a C-collar and evaluated by spine, who felt her to be
in spinal shock. Full spine MRI showed no obvious signs of cord
compression and spine felt there was no need for surgical
intervention. She was monitored clinically with frequent neuro
checks and throughout the hospitalization, her neurological
function did not improve and she remained quadriplegic
throughout her cource, ventilator dependent and on pressors for
cardiovascular support.
#) Atrial fibrillation: Has known AF on anticoagulation,
presumably with warfarin given INR >2 on admission. As discussed
above, Ms. ___ atrial fibrillation may be in the setting of
more complex conduction block. During hospitalization, she was
not started on beta blockade given her frequent conversion to
sinus brady with soft systolic BP's (~100). Anticoagulation was
also held given her supratherapeutic INR and potential need for
surgery.
-pacemaker
-antiarrhythmic
#) metabolic acidosis: patient initially with anion gap
metabolic acidosis per VBG and chem panel with bicarb of 16 and
VBS showing 7.30/52/58. Lactate, however, was normal at 1.6. On
repeat labs, chem panel showed normal bicarb of 26 with
resolution of gap and lactate still 1.6. ABG showed 7.33/47/191
on 100% FiO2. Patient's acidosis likely due to hypoperfusion.
Resolved with supportive measures.
#) Transaminitis: LFTs mildly elevated on admission with AST
326, ALT 371 and uptrending INR (2.5 on admission to 2.8). In
setting of cardiac arrest, likely for hepatic hypoperfusion. INR
could be multifactorial from presumed use of warfarin in
addition to reduced hepatic synthetic function.
#) Hypocalcemia: Patient was admitted with hypocalcemia as
described above. In setting of elevated phos and low PTH,
suggestive of primary hypoparathyroid state. Unclear about
patient's PMH due to limited available information.
After it became clear that her neurologic status was not likely
to improve, and as her hemodynamic status became more tenuous, a
family meeting was held with the patient, the ethics department,
the ICU and the ACS team to discuss goals of care. The patient
was lucid, deemed to be able to make her own decisions and
requested terminal extubation and CMO status. She was
disconnected from the ventilator and pressors were stopped on
___, and she was pronounced deceased at 14:05.
The family was in the room at the time of death. An autopsy was
offered, which the family accepted.
***. | OTHER MULTIPLE SIGNIFICANT 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.
***
Mr. ___ is a ___ year old man with a past medical history of
ischemic cardiomyopathy (LVEF 25%, ___ CAD (3-vessel CAD
s/p anterior MI felt too high risk for PCI), HTN, DM2, currently
undergoing heart transplant evaluation, admitted with
decompensated systolic heart failure with hospital course
complicated by milrinone-dependence, hyponatremia, pleural
effusions, transaminitis (likely secondary to congestive
hepatopathy), severe protein malnutrition (requiring period of
tube feeds), and acute kidney injury. He was deemed to not be a
candidate for heart transplant and transitioned to hospice care.
ACTIVE ISSUES
=============
#) ACUTE ON CHRONIC SYSTOLIC HEART FAILURE:
Pt has a history of ___ Heart Association Class II-III,
stage C ischemic cardiomyopathy with an LVEF 25%. Prior to
admission, pt was on Torsemide 80mg BID and weekly metolazone
2.5mg with persistent volume overload. On admission, pt appeared
volume overloaded with elevated JVP and lower extremity edema
consistent with decompensated systolic heart failure. Pt was
diuresed with lasix drip and Diuril 250mg IV daily, in addition
to holding home Metoprolol for decreased cardiac output. He was
started on Milrinone and Digoxin, the latter being discontinued
due to intolerance with PVCs. Pt was not started on an ACEi
given intolearnce in the past. Further neurohormonal blockade
was not well tolerated. Pt underwent right heart catheterization
on ___ (while on milrinone), which showed: mild pulmonary
hypertension; moderate-severe right ventricular diastolic heart
failure; moderately elevated PCW consistent with moderate left
ventricular diastolic heart failure; and preserved calculated
cardiac index. Following RHC, diuresis continued with Lasix drip
___ mg/hr and intermittent Metolazone 5mg. He was transitioned
to torsemide 100 mg BID. Workup for heart transplant was
initiated early, however based on his worsening heart failure
(Stage D, ___ class IV) and poor functional/nutritional status,
he was deemed to not be a candidate for transplant. After
discussion with the patient and wife, he made DNR and
transitioned to hospice.
Discharge weight 42.8kg with a creatinine of 1.0.
Milrinone Weight 50.3kg
#) Behavioral Disturbance (dementia vs bipolar vs prior CVA) / :
Patient noted to have previously had episodes of dramatic
exacerbation of personality traits including hyper-religiosity
and fixation of note-taking/organization. Initially he was
continued on his donepezil, divalproex and keppra without
incident. However, towards the end of his hospitalization,
particularly after no longer being a candidate for heart
transplant, patient developed more agitation and paranoid
thoughts. Seroquel was made standing with some benefit. Patient
occasionally has episodes of stuttering/word-finding
difficulties usually in association with agitation. At first,
there was concern for seizures, however patient remained
conscious throughout without automated movements. EEG had no
areas of cortical irritability. CT head without acute stroke. An
additional echo did not reveal LV thrombus. He was discharged on
seroquel 25mg BID, keppra 1000 BID, divalproex ___ ER QHS, and
donepezil 5mg QHS.
#) RIGHT PLEURAL EFFUSION:
On admission, pt found to have new right pleural effusion.
Underwent right chest tube placement with removal of 2L
serosanguinous fluid. Pleural fluid consistent with
pseudoexudate from CHF effusion (BNP elevated to 9000, met ___
Light's criteria with protein ratio 0.6, and uncomplicated with
pH 7.45). Chest tube was removed ___, but pleural effusion later
re-accumulated on subsequent chest x-rays, likely secondary to
decompensated heart failure.
#) TRANSAMINITIS/ASCITES:
During admission, pt had fluctuating LFTs that was felt to be
secondary to congestive hepatopathy. Pt was also noted to have
moderate ascites on CT scan. Underwent paracentesis that was
negative for SBP. Ascites fluid culture showed Bacillus species
that was felt to be a contaminant.
#) SEVERE PROTEIN CALORIE MALNUTRITION:
Pt has severe malnutrition in the setting of chronic illness.
Given severe malnutrition and BMI too low for heart
transplantation, pt underwent Dobhoff placement and started on
tube feeding for nutrition support. However, patient expressed
that tube feeding was not within his goals of care. His tube
feeds and NGT were discontinued.
#) ANEMIA, CHRONIC:
Baseline Hgb ___, hypoproliferative normocytic anemia (RI
0.8%). On iron supplementation and B12 supplementation at
baseline. Iron studies normal. No B12 or folate deficiency.
Hemolysis labs negative. SPEP without specific abnormalities.
Hematology/oncology consulted. Bone marrow biopsy with
hypocellular marrow at ___ without evidence of
myelodysplasia. Cytogenetics and flow cytometry on the bone
marrow were negative. Pt was continued on B12 and iron
supplementation during hospitalization.
#) DMII:
Pt has a history of DM on Metformin at home, Hb A1C 6.4%. During
admission, home oral regimen was held. Managed with Glargine and
Humalog insulin sliding scale during admission. Pt developed
hyperglycemia requiring high insulin requirements during
admission. Pt discharged on 10units of glargine morning and
bedtime and humalog ISS.
#) Three vessel CAD: Poor surgical targets. Continued on aspirin
and plavix. Atorvastatin reduced to 20mg daily
#) Goals of Care: As patient is not a candidate for heart
transplant, his goals of care have shifted to more symptom
control. He is now DNR/Ok to intubate per MOLST. Tube feeding is
not within his goals of care. He prefers to continue his
previous medications in hospice.
TRANSITIONAL ISSUES
======================================
-Pt found on CT chest to have a cluster of small nodules at the
left base, likely infectious or inflammatory given their rapid
onset. A follow-up CT is recommended if within goals of care
-Patient's episodes of stuttering/word-finding difficulty are
not suspected to be seizure or stroke. Prior EEG negative, prior
CT Head negative.
-Heart Failure Medications: Milrinone 0.5 mcg/kg/min IV DRIP
INFUSION. Torsemide 100mg BID. Neurohormonal blockade and
antihypertensives were not well-tolerated. Further adjustment of
diuretic dose may be symptom based. ___ need metolozone 5mg PRN
weight gain/shortness of breath.
-Electrolytes: Potassium 40meq daily in setting of 100mg
torsemide BID. Electrolytes should be checked at least weekly to
ensure normokalemia, normomagnesemia.
-Although patient is transitioning to hospice, he would prefer
to take all his previous medications
-New Medications/Changes: Keppra uptitrated to 1000mg BID,
Seroquel 25mg BID started, with additional 12.5 mg PRN insomnia.
Atorvastatin decreased to 20mg daily.
-Discharge weight 42.8kg (bed weight) with a creatinine of 1.0.
-Milrinone Weight 50.3kg
# CODE: DNR/OK to intubate (MOLST on file)
# CONTACT: ___ (wife/HCP ___
***. | NON-EXTENSIVE O.R. PROC 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.
***
___ female with a history of cirrhosis, hemochromatosis,
myelodysplasia, type 2 diabetes, chronic pancreatitis presented
in decompensated liver failure likely secondary to alcoholic
hepatitis.
# Alcoholic hepatitis: Patient presented in decompensated liver
failure with significant ascites and jaundice with elevated LFTs
and t-bili of 16. RUQ ultrasound showed possible thrombus
formation but subsequent MRCP read negative for portal vein
thrombosis. On admission patient had refused any recent alcohol
intake however after further questioning patient admitted to
recent alcohol binge few weeks ago resulting in acute hepatitis.
Patient's LFTs showed AST: ALT >2 consistent with alcoholic
hepatitis. AFP 2.8. Given discriminant function of 50,
prednisone 40mg daily was started ___ and t-bili continued to
down trend. Nutrition service was also consulted for high
calorie diet and patient encouraged to increase po intake with
supplements. Given her clinical and laboratory response, she
will continue prednisone for one month duration.
# Hepatic Encephalopathy/AMS: Patient was intermittently noted
to have levels of confusion without any asterixis during initial
course of hospitalization. She was started on lactulose and
rifaximin with clearing of her mental status. She was
encouraged to continue lactulose and titrated to ___ BMs per
day.
# Ascites: She underwent therapeutic/diagnostic paracentesis
___. Peritoneal fluid was negative for SBP by cell count and
culture. She was started on lasix however patient developed
hypotension as result of volume depletion therefore lasix was
discontinued. Patient continued to complain of abdominal
distention however repeat abdominal ultrasound did not show any
pocket of ascites. Her weight on discharge was 62.6 kg. She
should be restarted on lasix as outpatient if she starts to
retain fluid and develops worsening ascites.
# BRBPR: Patient reported 1 episode of BRBPR several days prior
to admission. EGD ___ showed no evidence of bleeding or
varices, only mild portal hypertensive gastropathy. Underwent
colonoscopy ___ which showed hemorrhoids, small rectal
varices, 2 less than 5 mm colon polyps, diverticula in the
cecum, but no brisk bleeding. Her hematocrit remained stable
through rest of her hospital stay without any further episodes
of hematochezia.
# Cirrhosis: Patient states that her cirrhosis is secondary to
hemochromatosis. Cirrhosis is complicated by ascites, jaundice,
varices, hepatic encephalopathy. She is being followed by Dr.
___ as an outpatient. She apparently was diagnosed about ___
years ago. She will continue to follow up with Dr. ___ as
outpatient. MELD score of 19 on discharge
# Hyperglycemia: She has history of DM2. Her home glipizide and
metformin was held on admission. With prednisone and high
calorie diet, her blood sugars persistently remained in the 400
range despite being on Lantus and HISS. ___ was consulted
who recommended aggressive Lantus and insulin sliding scale.
Metformin and Glipizide discontinued. She will need close
monitoring of her blood sugars especially when she finishes her
one month course of prednisone.
# Hypertension: Patient blood pressure mainly ranged in the 100.
Patient's atenolol was switched to nadolol for variceal
prophylaxis.
#CODE: Full
#CONTACT: Patient, Daughter ___: ___
.
___ of Care:
- Patient was also found to have incidental finding of 1.1cm
anterolateral chest wall lesion on MRV of abdomen; outpatient
follow up with CT chest is recommended.
- will need social work f/u and relapse prevention
- please refer for nutritionist follow-up
- if patient stays sober and remains decompensated after 3
months please refer to ___.
- please get labs as per script on ___.
- please closely follow DM monitoring and adjust insulin dosages
especially once off prednisone.
- Discharge weight of 62.6.
***. | CIRRHOSIS AND 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.
***
___ yo F with chronic obstructive asthma, RA, esophageal
dysmotility, and oropharyngeal dysphagia who is here with
subacute dyspnea likely due to exacerbation of her underlying
lung disease. Pt now improved with steroids, nebs.
# Dyspnea, ___
# Chronic obstructive lung disease w/ mild exacerbation
-Has responded well to prednisone and has gotten 40mg po x 3
days. On discharge will give short taper: 30mg po x 2 days, 20mg
po x 2 days, then 10mg po x 2 days for total 6 more days.
Continue advair and Spiriva, nebs. Azithromycin for anti
inflammatory effect, 250mg po x 2 additional days to complete 5
days.
-Back to her home o2 requirement of 2L and has o2 set up at home
already
-F/u with PCP and pulmonologist within ___ weeks. She inquires
about CPAP, will need outpatient sleep study. Already has
appointment in sleep clinic ___.
# Hypothyroidism
- continue home levothyroxine
# GERD/gastritis
- continue home pantoprazole
# FEN
- ground solids with thickened liquids per prior SLP recs
Time spent: 45 minutes
***. | CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
*** year old male with h/o asthma, depression, and substance
abuse transferred from ___ for evaluation of
citalopram intoxication.
ACTIVE ISSUES
# Citalopram overdose: He presented with suicide attempt and
citalopram overdose along with other substances (tox screen
positive for cocaine, benzos, opiates). He had a mild serotonin
syndrome with agitation and mental status changes. He did not
have hyperthermia but did have ocular and inducible clonus. He
was admitted to the ICU and ECGs were monitored closely without
significant QRS prolongation. He was given IV benzos for
agitation. He was given one dose of cypoheptadine without
effect. Head CT was negative for acute process. His mental
status changes resolved and he was transferred to the medical
floor. He was given MVI, thiamine, folate as well. Citalopram
was held on discharge to inpatient psych facility.
# Suicide attempt/depression: He was evaluated by the psychiatry
team after his mental status improved. His suicide attempt was
in the setting of his brother's recent death due to overdose.
His antidepressants were held and he was on a 1:1 sitter. He is
to be discharged to an inpatient psych facility. The pt was
written for low dose hydroxyzine 12.5mg POQ4HR PRN for anxiety
prior to d/c.
INACTIVE ISSUES
# H/o substance abuse: Tox screen positive for cocaine, benzos,
opiates. Seen by social work. Suboxone was initially held
during admission. His outpatient dose was confirmed to be 3 tabs
(___) daily. He was restarted on 2 tabs on ___.
# Decreased skin integrity: Patient was noted on admission to
have a repaired laceration on the right arm that was recently
sutured due to trauma per his reports. It remained clean, dry
and intact.
# Hypoxemia: He was noted to have a mild oxygen requirement in
the ICU and upon callout to the floor. CXR showed no infiltrate
or aspiration. He was continued on his home PRN nebs. He was
discharged on home albuterol MDI.
# Elevated CK: Trended down to normal.
TRANSITIONAL ISSUES
- Discharge to inpatient psych facility
***. | 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.
***
___ with hx of CKD stage IV-V related to severe interstitial
nephritis from PPI superimposed on reduced kidney function, who
presents as a planned admission for dialysis catheter and
initiation of dialysis.
ACUTE ISSUES:
=============
.
#CKD IV-V
#Initiation of dialysis
Patient has clotted fistula in the right upper extremity which
was never used. He has not previously received dialysis. He
was admitted for planned initiation of dialysis as inpatient.
He received tunneled line placement and received three
successive HD session without issue. PPD was placed and was
negative. X ray was performed and did not show evidence of TB.
The patient will continue HD as follows:
___
Phone: ___
Nephrologist: Dr. ___ dialysis schedule will be every ___, ___ & ___ at 4:00pm.
The patient was started on nephrocaps per renal recommendations.
He should continue Torsemide daily.
Sodium bicarbonate was discontinued as it is no longer indicated
in patients on HD.
CHRONIC ISSUES:
===============
#IDDM/DM2
Patient has history on prior admission of becoming hypoglycemic.
His endocrinologist followed the patient while in the hospital.
He should continue the following regimen:
NPH 5 Units Breakfast
Regular 4 Units Breakfast
Regular 4 Units Dinner
#CAD
#HLD
s/p NSTEMI with distal RCA stent placement in ___
- Continue atorvastatin 40 nightly
- Continue aspirin 81 daily
- SLN PRN for chest pain
#Discontinuation of Plavix
In discussion with outpatient cardiologist, Plavix can be
discontinued as is no longer indicated in patient as stents were
placed in ___.
-Discontinued Plavix
# HTN
- Continue home losartan,
- Continue amlodipine 5 mg nightly
# Hypothyroidism
- Continue levothyroxine 25 mcg daily
# GERD:
- Continued ranitidine 75 mg PO BID
# Psoriasis:
Patient will bring in Humira. Due ___.
- Continue adalimumab 40 mg/0.8 mL subcutaneous EVERY 2 WEEKS
# Hypovitaminosis D:
- Vitamin D ___ UNIT PO 1X/WEEK due ___
Transitional Issue:
=============
Asses patient volume status for need to continue torsemide
daily.
Follow up patient blood sugar for further insulin titration
***. | OTHER KIDNEY AND URINARY TRACT 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.
*** M w/a PMHX of IDDM, ESRD on HD ___, CAD s/p PCIx3
who presented to the ED as a transfer from an OSH for
nausea/hematemesis, anemia, and hyperkalemia i/s/o missed HD
sessions.
# Nausea/Vomiting
Patient reported having multiple episodes of nausea and
hematemesis for past 3 days; he initially went to ___
___ and was transferred to ___ on ___. Of note, was
previously hospitalized at ___ in early ___ for
intractable nausea and vomiting w/blood, which was diagnosed as
viral gastroenteritis. At the ___ ED, patient's had WBC 11.1,
Hgb 7.5 (baseline ~9), negative guaiac test; he reported that he
no longer had any episodes of nausea/vomiting since ___
was consulted during his hospitalization; they had low concern
for a GI bleed given resolution of his symptoms, negative guaiac
test, and stable Hgb, and believed an EGD to be unnecessary.
However, they did recommend a trial of PPI, so patient was
started on 20mg omeprazole. At the time of discharge, the
patient was doing well and was asymptomatic. The etiology of his
nausea and vomiting is likely ___ uremia and hyperkalemia in the
setting of missed HD sessions, or a possible gastroenteritis.
Given that his vomiting had resolved by time of hospitalization,
it is unclear whether his vomit was blood-tinged or bile-tinged.
# Anemia of chronic disease
Patient was found to be anemic with Hgb 7.5 (baseline ~9). This
was likely secondary to his ESRD. His anemia remained stable
throughout the course of his hospitalization. At the time of
discharge, his Hgb was 8.8.
# Coagulase negative staph bacteremia
Patient was found to have GPC bacteremia on blood culture from
___. He was given 1 dose of vancomycin. His blood cultures
returned as coag-negative staph, and was thought to be a
contaminant. Patient will be notified if subsequent blood
cultures are positive.
# Hyperkalemia, ESRD on HD ___
Patient has ESRD on HD ___ but missed last 2 sessions due to
nausea that
prevented him from tolerating HD. On presentation to ED, patient
was hyperkalemic to 6.6, for which he was given calcium
gluconate and insulin +D50 and sent immediately for HD.
Throughout the remainder of his hospitalization, he was
continued on his home HD regimen. His diuretics were held upon
admission. His furosemide was restarted at the time of
discharge. He will require follow-up with his outpatient
nephrologist for further management of his diuretic regimen.
# Elevated troponin i/s/o hx CAD s/p multiple PCI
Patient has extensive cardiac history with multiple
interventions (most recently, DES to LAD in ___. Last TTE
___ EF 45%. Upon his presentation to ___, he was found
to have an elevated troponin to 0.28. Following transfer to the
___ ED, this was down to 0.12. In the ED, EKG demonstrated
sinus rhythm with possible ischemia in the infero-lateral leads,
which appears consistent with prior EKGs (as viewed on ___.
His troponins continued to fluctuate throughout his
hospitalization, but he was complete asymptomatic. At time of
discharge, his troponin was stable at 0.24, and his EKG was
similar to his baseline. He was continued on his home aspirin.
# Hypertension
Patient was initially continued on his home amlodipine and
carvedilol. He was hypertensive throughout his hospitalization
to the 180s-200s, so his amlodipine was increased to 10mg with
improvement of his SBPs 160s. He will follow-up with his PCP for
further management of his anti-hypertensive regimen.
CHRONIC ISSUES
==============
# Nutrition: Patient was given nephrocaps daily, placed on a low
phosphorus and low potassium diet, and given sevelamer carbonate
with meals
# Chronic pain ___ prior surgical interventions
Patient was continued on his home oxycodone and cyclobenzaprine
# Diabetic neuropathy
Patient was continued on his home gabapentin
TRANSITION ISSUES
=================
[] On admission, patient was filling scripts for both furosemide
and torsemide; per patient, he was no longer taking the
torsemide. He was discharged on his home furosemide. He will
require follow-up for further management of his diuretics
[] Coagulase negative staph grown from 1 culture, likely
contaminant. Hospitalist will follow-up for any additional
culture growth.
[] Patient started on one month trial of PPI. Please trial
stopping the medication after this and assess for improvement.
[] Patient will require follow-up with GI for routine
colonoscopy, given that his last one was back in ___.
***. | RENAL FAILURE WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Patient was admitted to ___ on ___. His hospital course per
system is summarized below.
Neuro: pain was initially controlled with IV medications. Given
the extent of his rib fractures he was evaluated by the acute
pain service for possible epidural placement, however, he
continued to be able to breathe adequately and was continued on
narcotic pain medication. He was also given a lidocaine skin
patch for rib pain. Given his history of heavy etoh consumption
he was started on a phenobarbitol taper. When appropriate he was
switched to po pain medications.
CV: He was hemodynamically stable. His admission HCT was 31 this
fell to 21 and then 20 on the morning of ___. He was transfused
2 units on ___ and his hematocrit bumped appopriately. The HCT
drop was felt to be secondary to hemodilution and intra-op blood
loss. He remained stable throughout the remainder of his
hospital course.
Resp: Patient had small hemo/pneumothorax. He remained stable
from a respiratory standpoint. This was followed with daily
xrays. He used incentive spirometry throughout admission.
GI: Patient was initially NPO. Between OR cases with ortho and
plastics he was given a regular diet which he tolerated well.
He was maintained on a bowel regimen.
GU: Patient had a foley catheter. When appropriate this was
discontinued and the patient was able to void without
assistance.
Heme: Patient was given SC heparin prophylaxis for DVT.
Transfusions as above.
Endo: No issues
ID: Patient was given cefazolin perioperatively for his initial
surgery. Due to concerns of possible infection with unknown
organisms after the gastroc flap and STSG on ___, the
patient was placed on vanc/zosyn. He returned to the OR for
irrigation and debridement on ___ with VAC placement and on
___ he had his RLE graft reconstructed. Cultures from tissue
samples showed no growth at which point antibiotics were
switched back to cefazolin. This was discontinued at discharge
when his wound VAC was removed.
MSK: Patient was taken for reduction of tib fib by orthopedics
on ___. His acetabular fracture was placed under traction he was
taken back to the OR on ___ with the Orthopaedics team
where he underwent an ORIF of the transverse posterior wall
acetabular fracture and examination under anesthesia with stress
radiographs right hip. The patient tolerated this operation
well. After an uneventful recovery in the PACU, the patient was
transferred to the step-down surgical floor.
On ___, the patient underwent radiation therapy treatment
to the right hip to
prevent heterotopic bone formation.
On ___ he had a gastrocnemius flap to anterior shin and
split thickness skin graft.
On ___ he underwent irrigation and debridement of anterior
shin with VAC placement.
On ___ he had a right lower extremity skin graft
reconstruction.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating with crutches though NWB to RLE, voiding without
assistance, and pain was well controlled. He worked with
Physical Therapy and Occupational therapy who recommended his
discharge to home with services and ongoing ___. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
***. | OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC |
Subsets and Splits