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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.
***
===================
Transitional Issues
===================
[ ] Follow-up Microscopic hematuria
[ ] Formal ongoing neurocognitive testing needed
[ ] Lab check in ___ weeks for anemia/leukopenia
[ ] Consider hematology follow-up for continued anemia and
leukopenia
[ ] Consider statin initiation given prolonged history type 2 DM
[ ] Consider rheumatologic workup for positive ___ and dsDNA on
admission to ___
[ ] Consider follow-up with sleep medicine for CPAP initiation
SUMMARY: Mr. ___ is a ___ male with a history of
mild cognitive dementia, chronic atrial fibrillation on Xarelto,
CHB s/p PPM, HTN, HLD, T2DM, who presented to ___ with
acutely worsening mental status, empirically treated for
bacterial meningitis there, unable to perform LP, transferred
here for ___ LP which was unsuccessful. After transfer, he
defervesced and had no clinical signs or symptoms of meningitis.
Antibiotics were discontinued on ___, after which he was
closely monitored. The patient had no fevers, WBC count or other
clinical symptoms of meningitis, and his mental status change
was deemed to be non infectious.
====================
Acute Medical Issues
====================
#Acute worsening mental status
#Mild cognitive dementia
Patient has several year history of worsening neurocognitive
function and gait disturbances, noted to have several months of
progressive neurologic decline with memory impairment, waxing
and waning mental status. He had persistent fevers at ___
and was empirically covered for bacterial and HSV meningitis;
multiple LP attempts were unsuccessful. CXR no evidence of PNA.
Tick borne illness w/u negative for lyme and anaplasma. No blood
parasites on peripheral smear. ___ LP at ___ ___
unsuccessful drawing any CSF. All antibiotics were stopped
___, and the patient had no further fevers or clinical signs
of meningitis. His mental status changes are likely secondary to
worsening cognitive dementia, given MRI brain showing global
volume loss and extensive probable microangiopathic changes,
particularly in the setting of many years of alcohol use.
#Hyponatremia
Urine electrolytes and osmolality per report at ___
consistent with SIADH. He was fluid restricted, but repeat serum
osmolality and urine electrolytes did not indicate SIADH. His
sodium self corrected while inpatient.
#Gait ataxia
#Peripheral neuropathy
#Urinary incontinence
Long-standing gait ataxia with severe peripheral neuropathy per
outpatient neurology evaluation with falls. Likely secondary to
his known T2DM and alcohol abuse. TSH and B12 normal at OSH. New
urinary incontinence but unclear if related to patient's
inability to ambulate or lack of catheter. Imaging not
supportive of NPH. As per above, neurology considering possible
EMG testing as an outpatient. Fall precautions were maintained,
and physical and occupational therapy worked with the patient.
They recommended rehabilitation after discharge.
#Anemia
Labs here show Hb 11.4, elevated LDH and normal haptoglobin. Per
report there with evidence of hemolysis with low haptoglobin and
elevated LDH. There may be a component of hypersplenism given
splenomegaly seen on RUQUS there, did not comment on any liver
pathology. Right upper quadrant ultrasound demonstrated no
evidence of liver pathology. He may also have some
myelosuppression given his chronic EtOH use. Given persistent
anemia, recommend repeat labs within 1 to 2 weeks of discharge
and considering a hematology consult.
#Leukopenia
Unclear recent baseline, not neutropenic. Could be leukopenic in
setting of occult underlying infection, also from chronic EtOH
use. Given persistent leukopenia, recommend repeat labs within 1
to 2 weeks of discharge and considering a hematology consult.
Discharge WBC 3.2.
#Polysubstance use
Per OSH, patient endorses 3 drinks/day with last drink prior to
___ presentation. Serum EtOH there was negative and the
patient was not treated for withdrawal. He also endorses smoking
cocaine several
months ago. He was treated with thiamine, folate, and
multivitamin daily.
#Positive ___
#Positive dsDNA
Noted to have positive ___ and dsDNA at OSH. Also had broad
rheumatologic panel sent there that was largely negative.
Difficult to interpret positive ___ and dsDNA in setting of
possible acute illness. Patient denies any history of joint
pain/swelling or other constitutional symptoms. Defer further
hematologic testing here given other above acute issues and can
likely repeat as an outpatient.
=====================
Chronic Medical Issues
======================
#Chronic atrial fibrillation (CHADS2VASC score 4)
On Xarelto, no longer on any rate control agents per patient.
Xarelto was initially held due to LP, but it was restarted after
the procedure.
#T2DM
Diet controlled. Consider statin initiation given history of DM
and MRI findings supporting chronic microvascular changes.
#COPD
Continued home Spiriva.
#OSA
Not on CPAP. Consider follow-up with sleep medicine for CPAP.
#CHB s/p PPM
Advanced Care Planning
Code status: Full, presumed
Contact: ___, Cell ___, home ___
(wife)
***. | DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient was admitted to the General Surgical Service for
evaluation and treatment abdominal pain. On ___ the patient
underwent CT abdomen/pelvis which showed Sigmoid diverticulitis
with evidence of microperforation, and no drainable fluids. the
patient arrived on the floor NPO, on IV fluids and antibiotics
ciprofloxacin and flagyl IV, without a foley catheter, and IV
morphine/IV tylenol for pain control. The patient was
hemodynamically stable. On ___ the patient abdominal exam
improved and his pain has resolved, his diet was advanced to
regular and antibiotics switched to PO , which was well
tolerated. The patent was discharged home on the same day on 10
days PO cipro/flagyl and follow up in clinic in 2 weeks, and
colonoscopy in 6 weeks.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. 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 very
minimum. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
***. | 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.
***SSESSMENT: The patient is a ___ y/o M with met lung CA being
cared at home admitted for placement in ___ facility.
.
1) Hospice Care
Case management was consulted who found the patient an ___
___ facility. Patient was given prescriptions for pain
control (Morphine, Ativan) along with his home meds prior to
admission. He was transferred to the hospice facility on HD #2.
***. | RESPIRATORY NEOPLASMS 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.
***
Pt is a ___ yo F with ESLD ___ HBV and HCV with hx of IV drug
abuse p/w ascites, abdominal pain, N/V s/p para on ___ with
persistent leaking from site
.
#. Ascites - 1 episode of SBP one year ago, has been having
frequent paracenteses every ___ weeks for the past 6 months.
Admitted on ___ and had para with 9L removed, negative for SBP.
Has had leaking from site since discharge despite having suture
placed and dressing changes at home. Has history of persistent
leaking post-paras with several episodes requiring suturing in
the past. Fluid reaccumulating more quickly recently despite
compliance with diuretics and low Na diet. Has had discussion
about TIPS as an outpatient and told that it was not adivsable
for her. Diagnostic para in the ED was negative for SBP. A purse
string suture was replaced over the old para site and the
draining/oozing decreased susbtantially. Diuretics were held due
to ___ (see below) then restarted at half dose prior to
discharge. Tylenol and Ultram for pain control. Pt will need
scheduled paras per usual as outpatient. Did therapeutic para
before discharge and removed 7L with post-para albumin of 50g.
.
#. ___ - Cr bumped to 1.5 since baseline 1.0 on admission and
went up to 1.8. Likely ___ intravascular depletion from
persistent oozing in para site and reaccumulating ascites.
BUN/Cr ratio suggests pre-renal etiology. Cr resolved to 1.1
today with 2 days of fluid challenges (albumin 75g daily x 2
days). Diuretics were held during admission but restarted at
discharge (half of home dose).
.
#. Cirrhosis - ESLD ___ HCV cirrhosis (genotype 1, VL= 158,000
in ___ decompensated by ascites (refractory to max diuretics)
and encephalopathy - no longer on transplant list d/t poor
social supports & nonadherence. MELD is 25. Diuretics were
initially continued, but then held when Cr bumped to 1.8. These
were restarted half-home-dose prior to admission when Cr
normalized to 1.1. Thiamine, MVI, folic acid, and low Na diet
were continued.
.
#. Pain management - pt has been taking oxycodone without relief
at home, has missed previous pain clinic appt. Simethicone helps
slightly with abdominal pain and on gabapentin for peripheral
neuropathy. Will hold oxycodone for now per Dr. ___
previously. She was given Tylenol and Ultram PRN pain but
requested something stronger. Low dose PO morphine tried for one
day but caused encephalopathy. She was continued on
tylenol/ultram as needed. Pain appointment was scheduled for
outpatient and discussion was had w/pt regarding importance of
attending this appointment for her pain control.
***. | 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.
***
This is a ___ yo F with HTN, DM2, HL, but no known CAD or CHF who
presented to the ED after tonic-clonic seizure likely in the
setting of electrolyte abnormalities. The patient was intubated
for airway protection and was hypotensive after admission to the
neuro service. A bedside TTE showed ? of new systolic
dysfunction and LV hypokinesis. The patient was transferred to
the CCU for management of ? cardiogenic shock.
# Acute Systolic Heart Failure: The patient had a bedside TTE
performed by anesthesia that showed ? of new systolic heart
failure with LV hypokinesis. The TTE was initially performed due
to transient hypotension. ___ Echo results: Severe left
ventricular systolic dysfunction (estimated EF is 10%) and
severe right ventricular systolic dysfunction. Given these
findings, cardiology was consulted and recommended r/o ischemia
and IV diuresis. The patient had initial negative CE with
elevation of trop to 0.59 --> 0.55 12 hours later. EKG did not
show signs of ischemia. Other possibilities included
decompensation of undiagnosed CHF given acute illness,
hypertensive CM, tachycardia induced CM, or idiopathic dilated
CM. LOS fluid balance +6L and CXR with mild pulmonary edema at
time of transfer to CCU. The patient was diuresed with IV lasix
bolus as needed. Repeat ECHO on ___ that showed EF of ___
and mild focal wall motion abnl secondary to acute illness vs.
wrap-around LAD lesion. The patient was started on metoprolol
and lisinopril on ___ and they were titrated to control BP and
HR.
# Seizure: The patient had new onset seizure in the setting of
nausea and vomiting and low mag, potassium, calcium. The patient
was loaded with dilantin and admitted to the neuro ICU. Head CT
normal. LP bland. No other focus of seizure identified. MRI
showed small vessel disease. Most likely seizure
metabolic-related. Acyclovir and ceftriaxone were intially
started and d/c when bland LP results and no signs of
meningitis. HSV PCR also negative. Dilantin was continued with a
goal level of 15. She was transitioned to PO dilantin 100mg TID
and per neuro will need to continue for ___ months with taper if
no more events. MRA of brain and neck done prior to discharge
and normal.
# Blood culture positive for coag negative staph: The patient
was hypotensive with elevated lactate and WBC 30K and was
temporarily on phenylephrine. Blood cultures returned positive
for GPC in chains and clusters, however all subsequent cultures
have been negative to date. Vanc discontinued on ___, and
patient had been afebrile and hemodynamically stable after
weaning from phenylephrine on CCU service.
# Diabetes: The patient has DM2 and was on insulin gtt in neuro
ICU. Pt was transitioned back to ___ upon coming to CCU service.
# Crohns: Seen by GI team on ___ on previous hospitalization
where pt had abdominal pain and N/v/d for many months associated
with weight loss and failure to thrive with repeat endoscopy
showing inflammation and suggestion of granulomas. Crohn's
disease was the most likely diagnosis given granulomas found in
GI tract biopsies. Pt was maintained on prednisone 20mg BID
during course and per GI team, would like pt on this dose for
next ___ months. CCU team started pt on Bactrim for PCP
prophylaxis as well as Vit D and calcium supplementation. Pt is
to followup with GI as outpt.
# Hypothyroidism: Continued levothyroxine. TSH within normal
limits on this admission. Remained clinically euthyroid.
Transitional issues:
-Pt is to followup with PCP
-___ is to followup with Gastroenterology
-Pt is to followup with Cardiology
-Pt is to followup with Neurology
-Dilantin: should be on PO Dilantin for ___ months and can taper
as outpatient if no seizure activity
-Prednisone: per GI, continue prednisone 40 mg daily for Crohn's
disease. Pt started on PCP prophylaxis with ___ and
VitD/Calcium
-C. Diff culture pending - will call patient with results.
***. | 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.
***
Mr. ___ was admitted to the inpatient Colorectal Surgery
Service with obstructive symptoms. A CT scan was obtained prior
to transfer which showed loops of small bowel dilatation with no
specific transition point. The patient was stable without nausea
and vomiting at the time of admission so placement of NGT was
delayed with the intention of placing one if continued nausea
and vomiting. All laboratory values were stable.
On ___, the patient was discharged to home. At discharge,
he was tolerating a regular diet, passing flatus, voiding, and
ambulating independently. He was instructed to call Dr. ___
office to discuss a surgical date in approximately 1 month. This
information was communicated to the patient directly prior to
discharge. Educated about warning signs.
***. | G.I. OBSTRUCTION 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. ___ was admitted to the Vascular Surgery Service directly
from clinic. On admission, he was started on IV antibiotics and
a heparin drip . Home medications were resumed. He was
originally planned for an angiogram to assess his ability to
heal the chronic ulcerations on his left leg. However, given the
severity of disease and per wishes of his daughter (health care
proxy), his disease would be better treated with a below knee
amputation. He was taken to the operating room on ___ and
underwent a left BKA. He received 2 units of blood
intra-operatively given the amount of blood loss (300 mL) but
otherwise tolerated the procedure well. He was admitted to the
Vascular Intermediate Care Unit after close monitoring in the
PACU.
His hospital course is summarized by systems below:
Neuro: Post-operatively, the patient's pain was controlled on
standing Tylenol, oral narcotic analgesic with IV breakthrough.
He was also on his home gabapentin. The patient was also
intermittently agitated and exhibted sundowning.
CV: Given his cardiac history, the patient's vital signs were
closely monitored. He was hypertensive post-op but was
well-controlled once all of his home anti-hypertensive
medications were resumed. He did require increased dosage of his
home diltiazem 240 mg. The patient was started on a heparin gtt
on admission, which was held prior to the OR. He continued
Plavix and resumed Lovenox on POD2. Coumadin was started on
POD19 coumadin was started given patient/patient family concerns
with difficulty obtaining Lovenox upon discharge. However, this
issue was resolved on POD20 when coumadin was discontinued and
patient was restarted and discharged on lovenox anticoagulation.
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/Her diet was advanced when
appropriate,
which was tolerated well. He did have urinary retention post-op
and required Foley insertion. It was removed on POD3 and
replaced with a condom cath. Intake and output were closely
monitored.
ID: The patient was started on IV antibiotics on admission.
These were discontinued on POD2 since amputation served as
source control. The patient was afebrile thoughout the hospital
course.
Endocrine: The patient's blood sugars were well-controlled on
his home insulin regimen.
***. | AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE 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 male with HCV/ETOH cirrhosis c/b ascites, encephalopathy,
SBP SBP s/p TIPS; dCHF; HTN; COPD; morbid obesity; and OSA (not
on transplant list due to morbid obesity), who was recently
discharged from ___ with volume overload and anemia due to GI
bleed readmitted for acute blood loss anemia due to upper GI
bleeding of uncertain source and ___. Hospital course notable
for HCAP s/p treatment ___, hyperbilirubinemi due to
transfusions vs drug-induced cholestasis vs progressive liver
disease. Hospital course further complicated by exacerbation of
diastolic ___ failure causing fluid overload and pre-renal
acute kidney injury.
# Acute blood loss anemia / upper GI bleed: Source of anemia
likely due to GI bleed. Patient underwent EGD ___ on admission
to the MICU, which showed a duodenal bleed. The patient was
extremely agitated during this procedure despite sedation and
required intubation for airway protection. EGD was repeated
after intubation and they could no longer identify a source of
bleeding. EGD on the following day had similar results. H-H has
been stable since the last EGD on ___. Capsule endoscopy was
held off given crit was stable and unclear if bleeding source
could be found. There was no further evidence of GI bleed.
He required a total of 5U PRBCs and 1U FFP this hospitalization
and had an intermittent pressor requirement. He has remained
hemodynamically stable without transfusion requirement since
___ EGD. Initially held beta-blocker in the setting of his
acute kidney injury, ___ failure exacerbation, and diuresis,
but this was restarted upon discharge. He was continued on BID
PO pantoprazole.
- Consider capsule endoscopy if recurs
# HCV and EtOH Cirrhosis: MELD of 27 on last admission. He has
a history of complications of ascites, encephalopathy,
coagulopathy and hx of SBP (in early ___. He has been sober
for almost 12 months and he was scheduled to see Dr. ___ to
initiate transplant work-up. Bilirubin and INR continued to
rise during hospitalization, and MELD on discharge was 32.
Patient is not a transplant candidate given morbid obesity,
diastolic ___ failure, and COPD. We explained that his life
expectancy is ___ months, and that while his cirrhosis is not
reversible, he can help to improve his quality of life and
reduce his complication risk by taking supportive medications
and having regular follow-up.
- Continued lactulose and rifaximin for hepatic encephalopathy
- Restarted ciprofloxacin for SBP prophylaxis after completing
course for HAP
# Intubation: the patient was intubated during an EGD as
described above. He self-extubated on ___ after passing an SBT
and was monitored. He maintained an SaO2 of 100% on shovel mask.
However patient was altered in the setting of sedatives and
cirrhosis (for which he was given lactulose).
# Volume overload ___ edema, ascites, pulmonary edema): ___,
___, cirrhosis all contributing. Very mild intravascular
overload exhibited by elevated JVP, vascular congestion on chest
x-ray, but not clinically significant (oxygenating well,
asymptomatic).
# Acute kidney injury: Baseline creat 1.0. Admitted with
creatinine of 2.7, likely due to pre-renal insults and mild ATN
in the setting of GI bleed and aggressive diuresis as an
outpatient. Creatinine improved with a diuretic holiday, then
uptrended again, likely due to fluid overload. Feurea = ___
suggestive of pre-renal etiology. He was restarted on
diuretics, and creatinine continued to improve as he diuresed.
He was discharged on torsemide 60mg / spironolactone 100mg
(changed from prior home dose of bumetanide 8mg daily and
spironolactone 50mg daily). Urine sediment with hyaline casts
but no muddy brown casts.
# Diastolic ___ failure exacerbation: Patient has severe ___
requiring intermittent IV diuretic infusions as outpatient. CHF
was consulted and helped to guide diuresis. As above, he was
discharged on torsemide 60 and spironolactone 100mg, and was
diuresing net negative ___ liters daily. Discharge weight was
124.3kg (recent discharge weight 124.8kg). Recommended wrapping
his legs. Emphasized the importance of adhering to low salt,
fluid restricted diet. Discussed changes with his outpatient
CHF NP, ___: ___, who will see him in
follow-up on ___, and will repeat labs and adjust diuretics
accordingly.
# Hyperbilirubinemia: Continued to uptrend throughout
hospitalization. Possible etiologies include blood transfusions
early in this hospital, drug-induced cholestasis (received
course of zosyn), and progressive cirrhosis. He states he has
not had an alcoholic beverage for ___ months, so not
clinically consistent with alcoholic hepatitis. Abdominal
ultrasound showed biliary sludging but CBD dilatation.
Well-appearing so sepsis is unlikely. See discussion of
cirrhosis
# Hospital Acquired Pneumonia (new multifocal opacities on
___: Patient febrile to 100.3 on ___, complained of cough,
and was found to have new multifocal opacities ___ in the
setting of prolonged hospitalization and intubation. Patient
received vanc and zosyn ___.
# Hepatic encephalopathy: Exacerbated by upper GI bleed,
stopping of lactulose/rifaximin in setting of intubation, as
well as pneumonia. Resolved completely with lactulose,
rifaximin, and treatment of underlying medical conditions.
# DM2: Insulin sliding scale. Metformin recently dced at ___,
minimal insulin requirement while in house.
- Consider starting lantus as outpatient, metformin is not
recommended in end-stage liver disease
TRANSITIONAL ISSUES
=============================
CARDIOLOGY AND HEPATOLOGY:
[] Check CBC, chemistry panel, and LFTs on follow-up the week of
___
CARDIOLOGY:
[] Adjust diuretic medications as needed for fluid status, renal
function, and electrolytes
[] Dry weight on discharge is 124.3kg
[] Mr. ___ Clinic: ___:
___.
HEPATOLOGY:
[] If patient has recurrent GI bleeding, consider capsule study
PCP:
[] Consider starting long-acting insulin given history of
diabetes and recent discontinuation of metformin (metformin
should not be restarted because he has advanced liver disease)
***. | G.I. HEMORRHAGE WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ y/o M with history of provoked PE, s/p IVC filter, not on
anticoagulation, who presents with acute b/l ___ pain, swelling,
and weakness and imaging concerning for IVC thrombosis.
ACTIVE ISSUES
# Phlegmasia cerulea dolens: Initially suspected IVC thrombus
distal to IVC filter. Patinet started on heparin gtt and
symptoms started to improve. Vascular consulted and recommended
heparin ggt and frequent pulse checks every 1 hour which is why
he was transferred to ICU. Patient underwent repeat CTA that
showed clot above the IVC filter. Vascular discussed the case
and the patient was taken to the operating room for suprarenal
IVC filter placement & bilateral iliocaval percutaneous
mechanical thrombectomy on ___. Post-operatively,
fibrinogen levels were closely monitored. A hematoma at the
right neck access site was also closely monitored for evolution,
but it remained soft and unchanged. On ___, a lysis check
was performed. The patient had some oozing from his right groin
sheath site that stopped with digital pressure. On ___ the
patient was started on Xarelto and his heparin drip was
discontinued. On ___ the patient was ambulating, voiding,
tolerating a regular diet, and worked with ___ who recommended
home without services. On ___ the patient was discharged
with an appointment for follow up in 3 weeks, compression
stockings, xarelto, and pain medication.
#Pain- treated with Tylenol and oxycodone
# HTN: BPs slightly low in 110s. Held chlorthalidone.
# Asthma: continued inhaler PRN
TRANSITIONAL ISSUES
========================
# Communication: HCP: ___ (brother) ___
___ (son) ___
# Code: Full code, confirmed
***. | OTHER MAJOR CARDIOVASCULAR PROCEDURES W CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is a ___ yo F with HTN and DM on insulin presenting
with neck and arm pain, initial concern for NSTEMI, found to
have hypertrophic cardiomyopathy with severe resting LVOT.
ACUTE ISSUES
==================
#HCM. TTE consident with HCM with severe LVOT gradient at rest.
She was started on metoprolol tartrate 25 mg BID, which she
tolerated well. She did have transient hypotension with
lisinopril given once, so is sensitive to minimal afterload
reduction. She was counseled extensively on need for outpatient
followup with cardiology, importance of hydration, and risks of
sudden strenuous exercise.
#HX neck/arm pain. Neck/arm pain appears chronic and MSK in
nature. Initially concern for NSTEMI however only minimally
elevated troponin that normalized, lack of chest pain and given
severe LVOT gradient, held stress test on this admission.
Patient can benefit from further risk stratification as an
outpatiuent with cardiac MRI, holter monitor and repeat echo
after initiation of medical therapy. She was given Tylenol and
lidocaine patch for neck pain, normal neurological followup,
consider pain follow up as an outpatient.
CHRONIC ISSUES
===================
#Dyspnea
#?COPD: Pt reported baseline dyspnea on exertion with reported
hx of COPD. Lungs clear on exam with no crackles or wheezing.
BNP elevated on admission at 4190 however she appeared euvolemic
on exam and reported no worsening of dyspnea compared to
baseline. Possibly multifactorial given underlying reported
history of
lung disease, with mitral regurg and newly diagnosed HCM on
Echo. Nuo-nebs ordered for patient however she declined. Patient
can benefit from further pulmonary evaluation with possible
outpatient PFT.
#Diabetes on insulin: continued home ___/30 regiment with Levemir
#HTN: home HCTZ held given addition of metoprolol as above.
#Leg pain/peripheral neuropathy- continued home gabapentin.
#Active smoker-counseled re. smoking cessatio, and patient was
provided nicotine patch
TRANSITIONAL ISSUES:
=====================
-HOLDING hydrochlorothiazide 25 mg daily
-NEW MED: metoprolol tartrate 25 mg BID, please uptitrate as
allowed
-Repeat outpatient labs on PCP visit, please check K
(potassium), was 5.2 on discharge, without EKG changes
-Patient given Rx for glucometer, needs outpatient insulin
titration
-Patient needs outpatient risk stratification of severe resting
LVOT with MRI, Holter study and follow up ECHO
-Outpatient smoking cessation
-Patient can benefit from further pulmonary evaluation with
possible outpatient PFT.
***. | OTHER CIRCULATORY SYSTEM DIAGNOSES 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.
***
#) Hospice discussion: The medical team discussed with multiple
family member, including ___ (son- ___ proxy), regarding
code status upon his initial admission. His full code status was
changed to DNR but ok to intubated. The family feels patient's
quality of life is poor and would prefer to keep him as
comfortable as possible. The patient desires to be home and the
family echoes that desire. They mention also that patient's
insurance is no longer for his facility fee but are willing to
pay regardless. After stabilization of his acute infection,
further discussion regarding how to best transfer him to home
with nursing service is warranted.
#) UTI: Patient has hx of MSSA, pseudomonas sensitive to
cefepime/cefaz/cipro and VRE. Given his recent hospitalization
with intubation, an antibiotic covering ESBL (extended spectrum
beta lactamase resistant) organisms is reasonable. Broader
coverage is favored in setting with the episode of hypotension
and being tachypneic and poorly responsive on the floor. Urine
culture ___) was negative. Patient was covered with
meropenem and discharged with 7 days remaining of a 10 day
course.
#) Hypoxemia: Upon admission, patient had an oxygen requirement
that was gradually weaned. Upon discharge, his O2 saturation was
in the mid ___ on ambient air. We continued his
Albuterol-ipratropium inhaler PRN wheezing.
#) Hypotension: Patient was hypotensive to 78/57, responsive to
fluids. Patient's lopressor was held during hospitalization. His
blood pressure and heart rate remained stable (120-140s/50-70s,
HR 60-80s). Patient received NS at rate of 100cc/hr. Lopressor
was restarted upon discharge.
#) Altered mental status: Patien'ts acute delirium secondary to
most likely to infection, source UTI. We held his tramadol and
trazadone since the patient was poorly responsive and somnolent.
His mental status returned to baseline on hospital day two. We
restarted his tramadol, which seems to be effective with minimal
side effects to treat his pain.
#) Anemia: He has a stable microcytic anemia. Not iron
deficient.
#) Resolving PNA: On the admission chest XR, only a small
opacification is found on CXR, which most likely is an
improvement from his previous state, which involved bilateral
lower lobes. During hospitalization, he had no signs and
symptoms of continued respiratory infection. A follow-up chest
xray is needed to document full resolution of the pneumonia in
___ weeks.
#) Seizures: we continued his Keppra
#) Dementia: we continued his donepezil
#) Depression: on citalopram: continue.
#) FEN: Patient has G-tube. He was started on Fiber replete 80
cc/hr starting 1700-0800, however, it was stopped early for
residuals > 60cc. Nutrition saw him and left recommendations:
Nutren 2.0 cal 60cc/hr 1200-0600 (18 hours) 2160 kcal 86g
protein. Keep head of bed at greater than ___ degrees.
#) Prophylaxis: Patient was given the following for DVT,
constipation, pain and ulcer prophylaxis.
- Heparin 5000U TID
- Bowel regimen
- Acetaminophen PRN for fever/pain
- Omeprazole was switched to lansoprazole 30mg BID (increased
easy for administration via the G tube)
#) Code: His code status was discussed with family and
healthcare proxy: DNR but ok to intubate during this admission,
with a plan to transition eventually to hospice care.
***. | 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.
***
Patient was admitted for surgery on ___. Surgery was
complicated by a retroperitoneal hematoma of approximately 200cc
that was stable but necessitated conversion to an open approach
(refer to ___ operative note). Patient was transferred
extubated to the PACU with an NG tube in place and remained
hemodynamically stable. Pain control was initially difficult but
eventually was managed on a Dilaudid PCA. Patient was kept
overnight in the PACU for observation. HR was noted to be in the
___ at rest but increased to the 120s with motion due to pain.
Blood pressure and urine output were stable, and post-op
hematocrits were 34.5, 35.5, 33.3, and 32.3. On POD#1 patient
was transferred to the floor in stable condition. NGT was
removed, although patient remained NPO. Pain and tenderness was
significantly improved. On POD #2 patient was advanced from
bariatric stage 1 to stage 2 diet, which he tolerated. On POD #3
patient was ambulating and tolerating a stage 3 diet. On POD #4
HCT was 30.6, stable from 29.9 the previous day. Patient was
tolerating a full liquid diet, ambulating, and receiving good
pain control on PO Dilaudid. He was discharged home and will
follow up with Dr. ___ on ___.
***. | OTHER O.R. PROCEDURES FOR INJURIES 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 is a ___ with history of HFpEF, COPD, CAD, and DM who
was initially transferred to ___ from ___ ED iso
acute on chronic heart failure exacerbation, incidentally found
to have new metastatic abdominal mass seen on CTA chest.
# Hypoxemic Respiratory Failure
# Heart Failure with persevered EF
# COPD
Patient was first on the CHF service for aggressive diuresis iso
acute on chronic diastolic heart failure exacerbation. Etiology
of exacerbation was unclear, trops NEG, BNP>2800. By report,
patient was gaining weight and accumulating fluid over past
several weeks prior to admission. TTE ___ showed LVEF >55%; mild
RV dilation and RV free wall systolic dysfunction; mild
symmetric left ventricular hypertrophy with normal LV
regional/global systolic function. His course was complicated by
acute abdominal pain, and upon being sent down for CT A/P he
became acutely hypotensive to ___ and hypoxic to ___,
transferred to the MICU for close monitoring. Etiology of acute
event was unclear, though hypoxia was thought to be exacerbated
by atelectasis and volume overload, sats improved with ongoing
diuresis and once he was up and walking around. For diuresis,
patient was placed on a Lasix gtt (up to 20mg/hr) along with
intermittent dosing of metolazone. While in the MICU, patient
was also treated for CAP and COPD exacerbation given his tenuous
respiratory status. He was intermittently placed on BiPap, then
transitioned to high flow O2. Patient was eventually -14.7L
throughout MICU stay. His oxygen requirement prior to transfer
to general medicine was 4L NC. Aggressive IV diuresis was
continued after call out from the MICU, patient eventually >30L
net negative by time of discharge. O2 requirement decreased to
___ NC, patient qualified for a prescription for home O2.
Patient was started on spironolactone, uptitrated to 100mg qd
due to hypokalemia. He was transitioned to oral diuretics
(Torsemide 80mg qd) prior to discharge.
- Discharge weight: 108.09 kg
- Discharge Cr: 1.5
- Heart failure regimen:
***Preload: Torsemide 80mg qd
***NHBK: Carvedilol 12.5mg BID, Spironolactone 100mg qd
***Afterload: Amlodipine 10mg qd
# Abdominal mass with hepatic and omental mets, concerning for
peritoneal carcinomatosis
For work-up of newly discovered abdominal mass, patient
underwent CT torso (wo contrast due to ___, most likely
cardiorenal as Cr improved with diuresis), which showed large
12.5cm abdominal mass in the lesser sac with numerous liver
mets, extensive LAD, and omental caking concerning for
peritoneal carcinomatosis. CEA and CA ___ were elevated.
Interventional radiology performed bedside peritoneal biopsy
___. Pathology showed poorly differentiated carcinoma, most
likely of gastric vs. pancreatic origin. Immunohistochemistry
revealed the following: POSITIVE CDX-2 and GATA3 (focally) and
TTF-1 (focally); NEGATIVE CK7, CK20, PAX8, synaptophysin,
chromogranin. For additional work-up, patient subsequently
underwent thyroid ultrasound (which was unremarkable), and MRI
abdomen (which showed (14.6 x 9.4 x 7.6 cm mass centered in the
lesser sac concerning for primary gastric adenocarcinoma; no
findings of primary pancreatic malignancy). Oncology was
consulted and recommended outpatient oncologic evaluation after
stabilization of acute cardiopulmonary issues as above. There
was no indication to initiate chemotherapy while inpatient.
Patient has been scheduled to follow-up with Dr. ___
___, ___) ___, he was provided with histology slides and
discs containing all imaging studies performed while at ___.
# Leukocytosis - WBC count increased 10->~14 during admission.
Patient was treated for CAP and given prednisone for COPD
exacerbation as above. Leukocytosis persisted throughout
admission, he did not develop any localizing symptoms.
Leukocytosis related to malignancy is very likely.
# Normocytic Anemia - Iron studies c/w iron deficiency, likely
component of ACD given mass, should consider Fe supplementation
as an outpatient
==============
CHRONIC ISSUES
==============
# T2DM - Home glipizide/metformin were held throughout
admission, not restarted at time of discharge. Patient was
continued on home insulin regimen at time of discharge. HbA1C
9.4%.
# CAD - Moderate triple vessel disease of LAD, RCA, Cx
(reportedly non-intervention on it after cath ___ years ago),
more recent stress which was reportedly reassuring.
- Continued home carvedilol, dose was decreased from 37.5mg BID
to 12.5mg BID
- Continued home atorvastatin
- Home ASA 325mg qd was decreased to 81mg qd
# HTN
- Continued home carvedilol, amlodipine, carvedilol dose was
decreased from 37.5mg BID to 12.5mg BID
- Held losartan iso ___, not restarted at time of discharge
# GERD
- Continued home omeprazole
TRANSITIONAL ISSUES
=================
- Discharge weight: 108.09 kg
- Discharge Cr: 1.5
- Diuretic regimen: Torsemide 80mg qd
- Patient will have oncology follow-up with Dr. ___ ___
- Patient will have cardiology follow-up with ___ ___
- Patient should have repeat Chem-10 drawn ___ at primary
care visit with Dr. ___ to check kidney function/electrolytes
with ongoing diuresis
- Patient may need potassium supplementation iso diuresis
- Abdominal mass is most likely of gastric origin, should
consider sending Her2neu given potention to use Trastuzumab
- Given patient's functional status, he is likely ineligible for
clinical trials
- In treatment decisions, oncologist assuming care will need to
be cautious with gemcitabine (given dCHF and fluid retention)
- Patient noted to have persistent leukocytosis during admission
(___), infectious work-up negative, most likely related to
malignancy
- Patient noted to have normocytic anemia (Hb 10.5-11.5), iron
studies consistent with Fe deficiency, consider Fe
supplementation
- CT torso revealed indeterminate 1.5 cm left adrenal nodule,
further evaluation with adrenal mass protocol may be helpful
- Follow up final MRI read
NEW MEDICATIONS
- Torsemide 80 mg PO DAILY
- Spironolactone 100 mg PO DAILY
CHANGED MEDICATIONS
- Aspirin 81 mg PO DAILY
- Carvedilol 12.5 mg PO BID
STOPPED MEDICATIONS
- Valsartan 320 mg PO QPM
- GlipiZIDE-metformin ___ mg oral 3 daily
======================
# Code Status: Full (confirmed)
# Emergency Contact: HCP: ___ (wife) ___
>30 minutes spent coordinating discharge home
***. | DIGESTIVE MALIGNANCY WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is an ___ woman with a history of asthma,
CHF (diastolic heart failure), angina, and NIDDM who presents
with a one-month history of productive cough and an episode of
nausea and dizziness.
ACTIVE PROBLEMS:
# Presyncope: Given her history of recent illness with possible
decreased oral intake and physical exam with no evidence of
volume overload, the etiology of dizziness is most likely
orthostatic hypotension due to dehydration. The differential
included hypoperfusion secondary to worsening CHF (this is less
likely given BNP 191), and cardiogenic syncope (less likely
given unchanged EKG and neg TropT). We rechecked orthostatic
signs which were negative, however this was after Ms. ___
received IV fluids in the emergency department. We held her
diuretic and encouraged her to drink to thirst in order to
replete volume.
Ms. ___ reported that her nausea and dizziness improved
after rehydration with IV fluids. She remained asymptomatic
while on the medicine floor. We encouraged her to take her Lasix
only as prescribed, as she has a history of sometimes
self-treating with extra Lasix.
She has been hospitalized several times previously for
dizziness/nausea in the setting of dehydration which sometimes
is precipitated by her self-medication with Lasix. We discussed
her medication management with her daughter. At present, Ms.
___ her own medications. It might prevent future
hospitalizations if she can purchase a medication organizer, or
get her daily meds pre-packaged in bubble-wrap by the pharmacy,
in order to more closely monitor her diuretic use.
# Hyponatremia: Given her history and exam, this was likely
hypovolemic hyponatremia to 132 due to decreased PO intake vs
less likely CHF exacerbation. Urine lytes did not provide a
clear picture of prerenal volume depletion, however they were
likely drawn, again, AFTER the patient received IV fluids in the
emergency department.
# Abnormal CXR: Ms. ___ history of productive cough and
inconclusive chest Xray could suggest pneumonia, however she was
afebrile with a normal white count, history of improving cough,
benign lung exam and good O2sats on room air. Her clinical
presentation did not support a diagnosis of pneumonia and we
chose to hold off on antibiotic treatment. We treated her cough
symptomatically with Guaifenesin and Benzonatate and she
reported improvement. She remained hemodynamically stable with
good O2 sats and benign lung exam throughout her
hospitalization.
INACTIVE PROBLEMS:
# Diabetes Mellitus Type 2. We held her sulfonylurea and
metformin while she was on the inpatient floor. We monitored
her blood glucose QID and managed her glucose levels with an
insulin sliding scale.
# Hypertension. We continued Ms. ___ home regimen of
Metoprolol.
# Asthma. We continued Ms. ___ albuterol nebulizers and
her fluticasone spray.
# Hx fall with head trauma. She is on seizure prphylaxis
following a head trauma one year ago. We continued her home
regimen of Levetiracetam.
# Hx DVT/Thrombophlebitis. She received subcutaneous heparin
5000units TID.
PENDING TESTS AT DISCHARGE:
None
TRANSITIONAL CARE ISSUES:
-continued volume management as an outpatient
***. | 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.
***
Mr. ___ hospital course was uneventful. He received two
infusions of HiDaC per his chemo provider's orders and one pRBC
transfusion. No adverse reaction to cytarabine or packed red
cells was noted. He denies nausea/vomiting. His cerebellar exam
remained within normal limits throughout his stay. Mr. ___
was given his home medications in the morning on the day of
discharge. He was discharged with PrednisoLONE eye drops to use
three times per day for 48 hours.
***. | CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SDX 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. ___ was admitted for right recurrent apical pneumothorax
on ___. He was taken to the operating room by Dr.
___ on ___ for a right Video-assisted thoracoscopic
right apical blebectomy and mechanical and chemical (1 gram
doxycycline) pleurodesis. He was extubated in the operating
room and transferred to the PACU. While in the PACU he
desaturated to the mid 80's his PCO2 was 77%. He transferred to
the intensive care unit for observation. He was slightly
confused, with two chest tubes to wall suction for over 48
hours. The patient was transferred to the floor on ___.
Below is a systems review of his hospital course.
Neuro: The patient's ___ medications were continued. His
PCP and geriatrics followed him while in house. He developed
delirium in the ICU. Geriatrics was consulted followed him
throughout his hospital course and recommended, continue his
home dose of Ativan 0.5 BID and Seroquel 12.5 for acute
agitation. No Haldol since would make his ___ worse.
Ultram and acetaminophen, Lidoderm patch for pain. No morphine
secondary to confusion with this narcotics. His delirium
improved.
Pulmonary: Pulmonary toilet with incentive spirometry,
nebulizers, and mucolytics were continued. The patient had a
good productive yellow cough. The patient's oxygen saturations
were kept in the low 90's initially with shovel mask transition
ed to 4 L Nasal cannula. On ___ his saturations decreased
a Chest CT was negative for Pulmonary Embolism.
Chest-tubes: On POD 3, the anterior chest tube was discontinued
with posterior chest tube kept to water seal. CXR was stable,
however small leak persisted. gram right talc pleurodesis and
chest tubes to wall suction for 48 hours. The chest tube was
clamped on ___ follow-up chest film showed no pneumothorax.
The chest tube was removed.
Serial chest films: see above report.
CV: He was found to tachycardic in the ICU and low-dose
beta-blocker was started. He converted to PO with HR 70-90's.
Once stabilized the beta-blocker was titrated off given his
history of severe COPD. His home dose of felodipine of 5 mg was
continue on admission but decreased to 2.5 mg to allow BP
greater than 110 for cerebral perfusion.
Abd: Stool softeners were given throughout his stay. The
patients diet was advanced and tolerated, however he had poor
appetite. Ensure supplemental shakes were continued. The patient
had adequate bowel movements.
GU/renal: Foley was removed following surgery. Initially he had
low urine output responded to fluid bolus. Hyponatremia with
Na+ 131. monitored closely.
ID: no fevers or leukocytosis.
Heme: HCT stable ___.
Prophylaxis: SCD's and SQ heparin were instituted for VTE
prophylaxis.
Disposition: he was followed by physical therapy who recommended
rehab. He was discharged to ___ Rehab in ___
___ on ___. He will follow-up with Dr. ___ as an
outpatient.
***. | MAJOR CHEST PROCEDURES WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
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 ___ were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.
Initial postop pain was controlled with oral and IV pain
medication.
POD#1, Ms ___ was lightheaded and dizzy in the morning and
when she mobilized for the first time and had an "assisted
fall". She became unresponsive for ___ seconds. Upon exam she
was alert and oriented. Upon review, she was given am blood
pressure meds as well as her pain medications and had just
received IV morphine for additional pain control. Further blood
pressure monitoring and mental status checks were normal. She
was treated with IVF's and hold parameters were given for her
blood pressure medications. It is recommended to hold any IV
pain medication administration. She should avoid high dose
narcotics for pain control.
Diet was advanced as tolerated. Nutrition Service was consulted
for poor po intake and risk for delayed healing. Nutrition Recs:
1 Packet of Beneprotein with Carnation Instant Breakfast TID
Foley was removed on POD#2. Physical therapy and Occupational
therapy were consulted for mobilization OOB to ambulate and
ADL's.
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.
***. | CERVICAL SPINAL FUSION WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ was admitted to the gynecology oncology service
after undergoing exploratory laparotomy, total abdominal
hysterectomy, bilateral salpingo-oopherectomy, sigmoid resection
and reanastomosis, resection of umbilicus, and optimal tumor
debulking for stage 4 ovarian cancer. Please see the operative
report for full details.
Her post-operative course is detailed as follows. Immediately
postoperatively, her pain was controlled with an epidural and
dilaudid PCA. She had a nasogastric tube in place and a JP drain
in her left lower quadrant draining the pelvis.
On postoperative day #1, her nasogastric tube was removed. Her
epidural was removed and her pain was controlled with a dilaudid
PCA. Her diet was advanced slowly to clears. She received 2
doses of kefzol postoperatively.
On postoperative day #3, her urine output was adequate so her
Foley catheter was removed and she voided spontaneously.
On postoperative day #4, she experienced an episode of emesis
and was made NPO.
On postoperative day #6, her hematocrit had declined from 29.9
to a nadir of 25.8. She received 2 units of packed red blood
cells for blood loss anemia. Her hematocrit rose appropriately
to 32.0 and remained stable throughout the remainder of her
hospitalization. Her nausea had resolved and she was advanced to
a clear liquid diet. Nutrition was consulted given minimal oral
intake for nearly 7 days.
On posoperative day #7, her diet was advanced without difficulty
to a regular diet. She was then transitioned to oral percocet
and motrin for pain control.
On postoperative day #8, her JP drain output decreased and the
drain was removed.
She received lovenox for venous thromboembolism prevention
throughout the course of her hospitalization.
By post-operative day #8, she was tolerating a regular diet,
voiding spontaneously, ambulating independently, and pain was
controlled with oral medications. She was then discharged home
in stable condition with outpatient follow-up scheduled.
***. | PELVIC EVISCERATION RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY 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.
***
Mrs. ___ is a ___ female with a history of
cerebral palsy with spastic paresis who presented to the ___
with an episode of confusion, perseveration, rigidity, and
temperature of 100.3. She returned to baseline over the course
of about one hour following administration of 2 mg IV ativan.
She was recently admitted to ___ for a similar episode
which per the reports available indicate that they were
concerned about a seizure secondary to Gabitril. She was not on
other AED's on admission and her Gabitril is prescribed for her
muscle spasticity. An MRI and an EEG at ___ which do not
indicate acute pathology or epileptiform discharges.
.
ACTIVE ISSUES:
# Altered mental status/? Seizure: The two most likely causes of
her event are a seizure and anticholinergic toxicity. Given the
response the ativan, a seizure is mostly likely, but the
anxiolytic effects of ativan may also relieve the delerium
associated with anticholinergic toxicity. The etiology for a
seizure could also be secondary to anticholinergic toxicity
(rare) given that she is very dry, was tachycardic, had an
elevated temperature, and was altered. However, she was not
mydriatic or experiencing mumbling speech or picking behavior
compatible with pure anticholinergic toxicity. Her reflex exam
on admission was inconsistent with Seritonin syndrome and NMS as
she was not rigid. An infectious etiology is also possible and
subacute meningitis/ecephalitis, was on the differential
initially, but this is unlikely given improvement with ativan
and improved clinical status. Following the ativan she received
in the ED, she was loaded with 750 mg IV Keppra and started on a
dose of Keppra 500 mg BID. She was lucid on arrival to the floor
and never recalled any of the event. She was maintained on
seizure precations while an inpatient, but never had another
event. Her EKG was normal and her urine and serum tox screens
were both negative. Communication with her PCP was accomplished
upon discharge where a plan to discharge on keppra 500 BID and
continued gabitril was was discussed.
.
# Leukocytosis: She had a WBC count of 17.3 on admission.
Infection was initially on the differential. CXR and UA were
both negative. Likely represents demarginalization secondary to
her seizure. Following the night of admission her WBC count
returned to normal and she remained afebrile.
.
# Hypercalcemia: She had a calcium of 10.7 on admission. She was
asymptomatic throughout her admission and a repeat the morning
after admission was normal.
.
# Overactive bladder: Due to the possibility of anticholinergic
toxicity, her detrol was held the night of admission. This was
resumed on discharge, with instructions to the patient to be
sure not to take more than prescribed.
.
INACTIVE ISSUES:
# Hyperlipidemia: Her home simvastatin was continued.
.
TRANSITIONAL ISSUES:
The course of her presentation and admission was discussed
briefly with the NP at her primary care clinic (PCP ___
___, ___, and at length with her outpatient
neurologist at ___ ___, ___.
.
# Medication reconciliation: There were some conflicts between
the medications that she was prescribed and what she had been
taking. While she was an inpatient, the team went through all of
her home medication bottles with her and compiled a list of the
medications and dosages she is currently taking. The medications
listed under "medications on admission" on this discharge
summary represent those medications that the patient says she
currently takes.
.
# Follow-up:
- She was scheduled for a follow-up with her PCP and her
outpatient neurologist at ___ as listed above, she plans to call
to confirm those appointments and will reschedule if she has a
time conflict
- She was encouraged to discuss her two recent hospitalizations
with both of the above physicians
***. | SEIZURES WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a tibial shaft and fibula fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for tibial IM nail fixation, which the
patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after 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 perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization.
The patient experienced hyperglycemia while hospitalized, ___
was consulted and their recommendations were followed. His blood
glucose remained difficult to control and on discharge his
glucose was 248. On POD#2 the patient became tachycardiac with a
sustained HR in the 120's-130's. An EKG showed sinus
tachycardia, and he remained asymptomatic throughout and was
monitored on telemetry until discharge. On POD#3 he was still
tachycardiac which prompted a CTPA to r/o PE. The official read
come back negative for PE, although they could not visualize the
sub-segmental vessels. On POD #2 he also developed a transient
fever of 102.3, which resolved spontaneously. Again, he
remained asypmtomatic. A workup for the fever yielded a negative
CXR and UA. Blood cultures were drawn and will be followed up.
On the morning of POD#4 the tachycardia resolved spontaneously.
The patient worked with ___ who determined that discharge to home
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is WBAT in the RLE extremity, and
will be discharged on lovenox for DVT prophylaxis. The patient
will follow up in two weeks per routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course, and all questions were answered prior to
discharge.
***. | LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP FOOT AND FEMUR WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ was admitted to the Neurology medicine service s/p
traumatic subdural hemorrhage for 24-hour stabilization in the
context of continuing occipital headache. Her home dose of
aspirin was held given concern for bleed. She was initially seen
by the neurosurgery team, with no further intervention
recommended due to reassuring exam. Given the unclear etiology
of the initial fall, the patient was evaluated for syncope and
placed on cardiac telemetry which revealed no abnormalities. An
EEG showed breech rhythm secondary to traumatic SDH but no
seizures. The patient's phenobarbital levels for long-standing
seizure disorder was found to be therapeutic.
While on the floor the patient continued to be alert and
oriented, language intact, no focal neurological deficits.
However her blood pressure elevated to 190s/80s overnight, with
decrease in SBP to 150s s/p hydralazine 10 mg IV. She also was
hydrated given a Cr of 1.6 and no prior comparison of baseline
Cr. At discharge she appeared back to her baseline, with stable
BPs, continued reassuring MSE, and full mobility per physical
therapy evaluation. She was scheduled for ___ as well as
outpatient follow-up with the ___ Neurology clinic.
***. | TRAUMATIC STUPOR AND COMA COMA >1 HOUR 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 hospital and brought to the
operating room on ___ and underwent right thoracotomy, redo
tricuspid valve replacement with 33mm ___ Mosaic
bioprosthetic valve and right femoral cut down. She did undergo
a bronchoscopy in the OR for copious secretions. She tolerated
the procedure well and post-operatively was transferred to the
CVICU in stable condition for recovery and invasive monitoring.
Initially she was bradycardic and was started on Dopamine for
heart rate support. She was on Neo, which was switched to
Levophed, and this was weaned off POD#3. She remained
hemodynamically stable. She was started on a Lasix drip for
aggressive diuresis, and on POD # 3 she was bronched again for
copious secretions and temperature to 102. She was started on
Cefepime, Ciprofloxacin and gram stain revealed 2+ Gram negative
rods. Which resulted in Serratia by the time of discharge.She
was extubated on POD# 3 without incidence and continued to
require aggressive pulmonary toilet. Oxygen was weaned off. Her
WBC normalized and she remained afebrile throughout the
remainder of her hospital course. She will complete a 8 day
course of antibiotics. Preoperatively it was noted that the pt
has a remote history of HIT. Heme consult was called. Per Heme:
she has never had a documented positive SRA and given all the
caveats regarding ___ testing, particularly in cardiac
bypass patients, this patient has been erroneously labelled as
having had HIT. In view of this, her "heparin allergy" should be
erased from her allergy list, and she should proceed with
standard heparin anticoagulation perioperatively.
POstoperatively her PLTs dropped to 66. A repeat HIT was
checked, which was positive. SRA was pending at discharge. As
per ___, hematology, there is no action to be taken.
Her PLTS have been recovering and by the time of discharge were
134. Beta blocker was initiated and she was switched to bolus
Lasix dosing and diuresed toward her preoperative weight. She
remained hemodynamically stable and was transferred to the
telemetry floor for further recovery. Chest tubes were
discontinued without complication (no pacing wires were placed.)
She was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD#6 she was ambulating freely, the thoracotomy incision was
healing, and pain was controlled with oral analgesics. She was
discharged home with ___ services in good condition with
appropriate follow up instructions advised.
***. | CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION 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 gentleman with a past medical
history of morbid obesity, hypertension, and lymphedema, who
presents with symptomatic new onset atrial fibrillation. On
___, Mr. ___ was discharged from ___
___ in good condition, with stable vital
signs, and with appropriate outpatient follow-up care arranged.
Mr. ___ hospital course was notable for:
.
# atrial fibrillation- The patient was seen and evaluated for
new-onset atrial fibrillation. He was admitted to the hospital
and monitored on telemetry. The precipitant of this episode was
not clear. He was started on Metoprolol XL 200 mg daily and
discharged on this medication. During his hospitalization Mr.
___ remained intermittently in this rhythm. During episodes
when he was in this rhythm he was asymptomatic, denying chest
pain, chest discomfort, palpitations, and shortness of breath.
Cardioversion was discussed but was deferred since the patient
was never symptomatic.
.
#Anticoagulation- Due to new onset atrial fibrillation, upon
admission Mr. ___ was started on a Heparin drip, and oral
coumadin. He was discharged with a prescription for Coumadin and
with follow-up arranged at the ___
___ clinic. The patient also received 81 mg aspirin
daily while in the hospital.
.
#Abdominal pain- While hospitalized, on a few occasions Mr.
___ complained of abdominal pain, focused around the area of
his ventral hernia repair. A thorough evaluation, including
consultation with gastrointestinal surgery, revealed that the
patient had a seroma, which was stable and unlikely to be
infected. He was briefly started on Ciprofloxacin and Flagyl
for concern of possible infection, but these medications were
discontinued shortly thereafter. His fever curve was trended
carefully, as was his white blood cell count. The patient
remained afebrile and his leukocytosis upon admission resolved
spontaneously.
.
# Hyperkalemia: On admission the patient was noted to have a
serum potassium of 5.6. He was given Kayexelate in the Emergency
Department, and his hyperkalemia resolved. His serum potassium
was checked daily during his hospitalization, and he was placed
on telemetry, and the patient was normokalemic thereafter.
.
On ___, the patient's symptoms had resolved and he was
discharged to his facility of residence, in good condition, with
stable vital signs, and with appropriate outpatient follow-up
care arranged. The following medication changes were made:
START Metoprolol XL 200 mg daily
STOP Atenolol
START Warfarin (Coumadin) 5 mg daily
***. | CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is a ___ year old man with a history of CAD s/p ___
(___), rheumatic heart disease s/p mechanical MVR with
tricuspid valve repair (___) on Coumadin, HFpEF (LVEF 50%
___, SSS s/p pacemaker, HTN, and prior GIB (___) in the
setting of triple therapy, who presented to the ED with dyspnea
and chest pressure concerning for unstable angina. He received
cardiac cath, which showed patent prior LAD stent and "No
significant obstructive CAD - moderate mid RCA lesion with
negative FFR." He did not require any new stent placement. He
was heparin bridged back to home warfarin. His INR on day of
discharge was 2.3 and he was approved for discharge by attending
Dr. ___, with plan to resume his usual home warfarin regimen
and to have his INR rechecked at his PCP follow up on ___.
ACUTE ISSUES:
# Unstable angina
Patient presented with SOB and chest pressure for 3 days, which
felt similar to his anginal symptoms prior to previous stent
placement. This was concerning for unstable angina. He has a
significant history of CAD with ___ in ___, and he also
reports having had a cath at ___ in ___ during which a stent
was placed, though there were no records of this. This
admission, he was briefly on a nitro gtt with improvement in
chest pain, but it was stopped due to dizziness. He received
cardiac catheterization on ___, which showed patent LAD
stent and "No significant obstructive CAD - moderate mid RCA
lesion with negative FFR." He did not require intervention. He
was continued on home ASA, carvedilol, amlodipine, ezetimibe.
Home Lisinopril was held ___ cath and restarted on day of
discharge.
# Mitral stenosis s/p mechanical MVR
He is anticoagulated on outpatient warfarin 30mg daily except
for 40mg on ___. Home warfarin was held and he was heparin
bridged prior to cath in case of intervention, but he was
restarted on warfarin afterward (50mg on ___, 50mg on ___,
40mg on ___. Discharge INR: 2.3. He was discharged with plan
for him to resume his usual home warfarin regimen, with INR
recheck at his PCP follow up on ___. His INR is followed by
___ clinic.
# Chronic HFpEF
He has a history of HFpEF, with regimen per outpatient
cardiology notes to take torsemide 20mg PO daily as needed for
goal weight less than 242 pounds. His admission weight was 235
lbs, which is below his reported dry weight. He appeared
euvolemic this admission.
# RLE edema
He had asymmetric RLE edema on presentation. ___ negative for
DVT. Per ___ records from ED in early ___, plain films of
right femur knee and hip were negative. His edema resolved this
admission without further intervention.
CHRONIC ISSUES:
# HTN
Continued home Carvedilol and amlodipine. Lisinopril was held
___ cath and restarted on day of discharge.
# HLD
He was continued on home ezetimibe. He is followed by outpatient
___ clinic and has a history of adverse reaction to statins.
# Anxiety
Continued home LORazepam 0.5 mg PO QHS:PRN.
# BPH
Continued home Terazosin 10 mg PO QHS
# OSA
Continued home BIPAP
# COPD
# Tobacco use
Continued home Tiotropium Bromide 1 CAP IH DAILY. Continued
nicotine patch.
TRANSITIONAL ISSUES:
NEW MEDS: none
CHANGED MEDS: none
STOPPED MEDS: none
[] Recheck INR at PCP visit on ___. Discharge INR 2.3; OK to
discharge at INR 2.3 per attending Dr. ___. He was
instructed to resume home warfarin regimen on discharge (40mg on
___, and 30mg on the rest of the days).
[] Recheck BMP for renal function at primary care visit.
[] Patient reports that he has a history of gout and was meant
to start allopurinol but never did so. Please address this in
outpatient follow up.
[] Patient requesting pulmonology referral for COPD. Please
address at ___ ___.
# CODE STATUS: FULL presumed
# CONTACT: Dr. ___
___: Sister
Phone number: ___
***. | CIRCULATORY DISORDERS EXCEPT AMI WITH CARDIAC CATETERIZATION WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Upon admission, Ms. ___ had an MRI that showed as per
report:
Subacute infarcts in a watershed distribution between the MCA,
PCA, and ACA
territories, most prominent in the right occipital region
(MCA/PCA watershed).
Initially, because the lesion was enhancing, a work up for a
possible oncologic porcess was done with a CT torso which
revealed a R ovarian mass. Ultrasound of the mass showed that
it was solid. Neuro-oncology was consulted and originally had
recommended an LP for cytology although when the final report
was available felt it was no longer necessary. Gyn-oncology was
consulted who recommended CEA which was slightly elevated,
___ which was pending and CA 125 which was elevated. They
plan to follow her in the clinic.
Included in her work up for the etiology of her stroke, it was
discovered on CTA imaging of her head and neck:
1. CT head: No intracranial hemorrhage. Known right occipital
infarct is
redemonstrated.
2. CTA of the head: High-grade stenosis at the level of the
carotid
bifurcation and both proximal internal carotid arteries. Mild
atherosclerotic
disease of both posterior cerebral arteries and the left
vertebral artery. No
flow-limiting stenosis, occlusion or aneurysms identified in the
intracranial
circulation.
Stroke team was consulted while the patient remained on the
epilepsy service. Most likely the etiology of her stroke is
related to severe stenosis of her carotid. She also has many
contributing risk factors including hyperlipidemia, hypertension
and now a recently discovered ovarian mass which may represent
malignancy and increased associated hypercoagulability.
Dr. ___ recommended to consult vascular surgery, continue
Aspirin 325mg and increase her current dose of statin. Dr.
___ felt that CEA would be preferred over carotid
stenting.
She had other stroke risk labs that were sent including 1) TSH
which was elevated although Free T4 was normal- Synthroid was
not changed due to recently starting 2)increase her statin in
response to elevated LDL. 3)Lipoprotein A was pending 3)
Fibrinogen was elevated.
Vascular surgery was consulted who felt that she would need a
medical clearance. Medicine felt that although her EKG showed
Qwaves, her cardiac risk factor was low and cleared her for
surgery. Vascular surgery felt that further investigation was
necessary and went on to a order a cardiac stress testing which
showed reversible inferior and inferolateral wall perfusion
defect with transient ischemic dilation. In response to this,
our inpatient cardiology was consulted who felt
"She ___ has asymptomatic coronary artery disease. She is on
a statin and should be on aspirin. The presence of CAD does
increase her risk of a peripoerative cardiovascular event, but
in the absence of acute symptoms there is no indication for any
coronary intervention or further testing at this time.
Recommendations:
As the patient has two cardiovascular risk factors (ischaemic
heart disease and cerebrovascular disease), she is at moderate
cardiovascular risk.
As her ECG suggests prior inferior infarct and her stress test
showed reversible ischaemic changes, we recommend that beta
blocker therapy be initiated prior to surgery. She should also
be
on an ace inhibitor rather than HCTZ. "
"In summary we recommend the following:
1. Start metoprolol succinate 25mg daily
2. If BP >130/80 on this start lisinopril 5mg daily
3. No additional cardiac testing needed
4. No cardiac contraindication to proceeding with surgery
acknoweldging increased risk of perioperative event given
underlying CAD"
Dr. ___ vascular surgery felt that with the cardiac
stress testing, it would be best if she underwent carotid
stenting. Based on this, the neurology team felt she should
undergo a second opinion for stenting versus CEA.
During this admission, ___ was placed on LTM which did not show
any seizures. However, she had reported that she may have
experienced an increase in her seizure frequency since
discontinuing the Lamictal on her own. It was felt that she
should be on a duel therapy and since she has in the past failed
many medications, Vimpat was thought to be the best agent.
Prior authorization was obtained and patient consented
initially, however, when the Vimpat was found out to have a
copay of 155 dollars/month, she declined. She also preferred
not to restart Lamictal because of the way she felt on it.
Instead, her Zonegran was increased from 300mg/300mg to
300mg/400mg which she tolerated well.
During the admission, she had systolic blood pressures ranging
120s to 140s. She was found to have a mild hyponatremia and
hyocholeremia with normal urine electrolytes. It is possible
that this effect was due to the Hydrochlorothiazide that she was
started recently prior to admission. This was discontinued as
it would be best to have increased flow across her stenosis to
prevent stroke and because of her electrolyte disturbances. The
electrolyte abnormalities resolved.
Ms. ___ was also seen by ___ who felt that she may benefit
from support from a walker or cane, however, she refused. They
also felt that she may benefit from Home ___ but she refused that
as well.
***. | 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.
***
This is a ___ man with a history of HTN, migraine and a
fib on coumadin who presented with several days of progressive
and severe headache and found to have a right homonymous
hemianopsia (blurred) and L occipital hemorrhage. Of note,
patient did initially go to the ___ over the weekend where he was
given dilaudid for headache which caused him to have severe
vomiting at home. Angiogram ___ shows no AVM, MRI with no
visible mass. Etiology of bleed remains unclear- may still be
small AVM, mass or reversible cerebral vasoconstriction
syndrome.
NEURO:Pt was admitted to the Neurosurgery service, ICU status
for close neurological observation. His coumadin was held. He
was taken for a diagnostic angiogram to rule out vascular
malformation and this was negative. He was monitored in the ICU
post angio and remained neurologically and hemodynamically
stable. Neurology was consulted for assitance with further work
up of cause of hemorrhage. The patient had an MRI which showed
no underlying mass. The patient was transfered to the stroke
service for further workup. The leading theory for the cause of
the bleed is a reversible cerebral vasoconstriction at this
time. The patient will need a follow up MRI in 1 month. At that
time discussion of possible restarting coumadin can occur. His
___ score is low ( 1) but he would need anticoagulation prior
to cardioversion. The patient had a persistent headache which
was initially treated with oxycodone but then was well
controlled on tylentol and IVF.
CARDS: Patient went into RVR while in the ICU and was started on
Diltiazem both for afib and presumed vasoconstriction syndrome.
He will follow up with his outpatient cardiologist to arrange
cardioversion at a later date.
GI: The patient had severe constipation in the context of
narcotics. Narcotics were stopped and the patient was given an
aggressive bowel regimen. This resolved.
***. | INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION 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 history of CAD p/w painless jaundice to ___
___. There a CT Abdomen showed mulitple liver lesions and
possible ascending colon mass and so was transferred to ___
for ERCP. The OSH CT scan was concerning for HCC vs
cholangiocarcinoma. He initially underwent a colonoscopy here
which did not reveal any colon mass. He then underwent ERCP
which showed a biliary stricture which was biopsied but only
revealed atypical cells. He had biopsy of liver mass on ___ to
get definitive diagnosis. The pathology is pending at the time
of discharge. For obstructive jaundice, He was prophylactically
placed on levo/flagyl. He had low grade temps but not true
fever. They were able to place Left intrahepatic biliary stent
but failed to place one on the right. His bilirubin levels
continue to remain elevated. This persistent bilirubinemia may
be ___ to intrahepatic cholestasis from liver masses or from
persistent obstruction. He then underwent PTC to relieve his
jaundice. He was scheduled to have internalization of the
external biliary drain on ___ as an out patient. His
bilirubin level will be checked on ___ before the upcomming
procedure (___). He finished levo/flagyl.
He will go to ___ for final treatment if any. He does not want
to stay in the ___ for treatment of his hepatobiliary malignancy.
He does not have a PCP. However, He will have ___
___ and Dr. ___ follow up his liver biopsy
results. He was given numbers to make outpatient appointments
with GI Oncology and Primary care physician.
.
# Hx CAD - No chest pain here. ASA held ___ procedures. Cont
ISMN, Atenolol. Lisinopril held ___ fluctuating renal function,
resume when stable.
.
# HTN - cont ISMN, atenolol, restart lisionpril when renal fxn
stable.
.
# BPH - terazosin held as hepatically cleared, no evidency of
urinary retention so far.
.
The plan discussed with daughter. Total discharge time: 78
minutes.
.
.
.
***. | MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ y/o male with a h/o multiple myeloma s/p auto transplant at
___ ___ (currently receiving zometa) who presented to urgent
care with gross hematuria. He had LFTs done concerning for
transaminitis and hyperbilirubinemia to 8.9 and so was sent to
___.
#Transaminitis/Cholestatic hepatitis: The etiology of his
abnormal liver blood tests and jaundice was felt to be due to
drug induced liver injury potentially due to
voriconazole/fluconazole (last ___ for thrush. Patient's
increased alcohol intake in recent weeks while travelling to
___ may have been contributing as well.
He had a RUQ U/S that was negative for portal vein thrombosis or
obstruction, and had an MRCP that showed normal biliary tree as
well. Autoimmune hepatitis labs were negative, including ___ and
anti-smooth muscle Ab. He had immunoglobulins done with SPEP;
this showed elevated IgA consistent with etOH use. He had
negative CMV, EBV, HIV, and HCV VL. His liver blood tests were
downtrending by the time of discharge without needing
intervention. Of note, his MRCP was concerning for early
cirrhosis, and he warrants a fibroscan in the outpatient
setting.
#Pyuria: Patient was noted to have pyuria at urgent care prior
to admission. He was initially continued on ceftriaxone and
transitioned to po ciprofloxacin. He will complete a ___nding ___.
# Multiple myeloma s/p autoBMT ___. Currently on zoledronic
acid. His home acyclovir and Bactrim were held during admission
due to concern for hepatotoxicity and were restarted on
discharge as transaminitis resolved. Per outpatient heme/onc
records, he should remain on ppx for ___ after autoSCT (end
___. UPEP and SPEP were not concerning for myeloma
progression.
#GERD: continued on home omeprazole.
TRANSITIONAL ISSUES
- Hepatitis labs were consistent with non-immune HepB status;
please consider hepatitis B vaccine.
- Patient started on ciprofloxacin for pyuria seen in urgent
care. Please follow up Atrius records for urine culture data,
which was pending at time of discharge. He will complete a ___nding ___.
- Patient was restarted on prophylaxis with Bactrim and
acyclovir, which should continue post-SCT until ___ per
heme/onc notes. If LFTs continue to rise, these may need to be
discontinued.
- MRCP with concern for early cirrhosis on this admission as
above. Patient will follow in ___ clinic for fibroscan
and further management.
***. | 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.
***
Primary Reason for Hospitalization:
===================================
___ with ALS, HIV on HAART with undetectable VL (per pt),
hepatitis C (written in records, antibody positive, reported by
primary care physician as not having hepatitis), recent
diagnosis of esophageal adenocarcinoma admitted to ___
___ and transferred to ___ following presumed episode of
ventricular tachycardia.
.
ACTIVE ISSUES:
===============
# WIDE COMPLEX TACHYCARDIA - Patient presented without a known
history of coronary artery disease with largely preserved EF on
most recent available echocardiogram from his outside hospital.
He was presumed to have sustained wide complex tachycardia with
an episode of unresponsiveness at the outside hospital. He did
not receive shocks or resuscitation at that time. It is
difficult to determine the sequence of events leading to the
patient's event. It was possible that it was a primary ischemic
cardiac event. It is also possible that it was a non-cardiac
event such as respiratory arrest due to obstructed airway, from
a food bolus. Regardless, the patient had anterior EKG changes
and an elevated Troponin indicating myocardial infarction likely
in the LAD territory versus myocarditis. His cardiac cath
(___) showed no evidence of significant coronary disease,
however. He also had a 2D-Echo on ___ which showed moderate to
severe regional left ventricular systolic dysfunction with
inferior/inferolateral akinesis with an LVEF of 30%. We trended
his cardiac biomarkers to improvement (peak Troponin of 0.16,
CK-MB peak at 16). We empirically heparinized him given concern
for coronary ischemic prior to his cardiac catheterization, but
this was discontinued. We maintained him on Aspirin 325 mg PO
daily. We also restarted his ACEI (Lisinopril) and titrated this
to a dose of 40 mg PO daily for better blood pressure control.
We also uptitrated his beta-blocker to 75 mg by mouth three
times daily with good effect, given some tachycardia and
hypertension. We also considered placement of an ICD given his
inferior or inferolateral hypokinesis and presumed V.tach event,
but this must be weighed against life expectancy given his
esophageal adenocarcinoma and progressive ALS diagnosis. He was
not started on any anti-arrhythmics and had no further issues
with dysrrhythmia. His electrolytes were optimized and he was
monitored via telemetry.
.
# ASPIRATION - The patient presented with a mild oxygen
requirement and decreased breath sounds at bases with CXR
showing bibasilar haziness concerning for aspiration
pneumonitis. Held antibiotics on admission. He remained afebrile
and without leukocytosis. We did start utilizing his PEG tube
this admission and speech and swallow evaluation noted the need
for thin liquids and soft-moist consistency diet given his risk
of aspiration.
.
# Acute Encephalopathy He began to develop agitation in the
evenings with some delirium noted on HOD#2. Although he
intermittently remained alert and oriented to time, place and
location, his wife noted that this is not atypical for him
during prior hospitalizations. She notes that in the past he has
needed benzodiazepines and other sedating medications. We
provided aggressive reorientation, avoided deliriogenic
medication. An infectious work-up showed a reassuring urinalysis
and his urine and blood cultures were reassuring; a CXR was
reassuring. We also dosed low dose Seroquel in the evenings for
agitation with some benefit. His mental status improved on the
regular medical floor after transfer from the ICU to his prior
baseline.
.
# FALL - He had a likely mechanical fall in the setting of his
ALS and trying to use the bathroom by himself on the evening of
___. Head CT was negative for fracture or intracranial
bleeding. No other injuries were sustained.
.
# HYPERTENSION - Evidence of elevated systolic pressures even
when not agitated. Titrated up Metoprolol and Lisinopril to
improved pressures.
.
CHRONIC ISSUES:
===============
# HIV - apparently stable disease: We sent repeat CD4 count
which was 515 and HIV-1 viral load which was undetectable. This
will be followed as an outpatient. We continued his HAART
medications: Truvada, Efavirenz, Raltegravir.
.
# ALS - stable disease without current issues; we continued
Rilutek.
.
# ESOPHAGEAL ADENOCARCINOMA - seen by ___, MD ___
___ in ___ who said he was non-operative and could
benefit from radiation; Dr. ___ Heme-Onc saw him as
well - patient not likely chemoradiation therapy candidate given
other co-morbidities and patient disinterest in aggressive
therapy; will need repeat endoscopy and EUS in ___ months for
re-evaluation of disease progression.
.
# CHRONIC SYSTOLIC HEART FAILURE (EF 30%): Nonischemic
cardiomyopathy given clean coronaries. Unclear etiology. Patient
clinically euvolemic.
- Metoprolol increased to 75 TID
- Lisinopril increased to 40mg daily
- Outpatient cardiology follow-up
.
# GERD - We continued his Omeprazole without issue.
.
# VITAMIN D DEFICIENCY - We continued Ergocalciferol dosing.
.
TRANSITION OF CARE ISSUES:
===========================
1. Blood culture final reports pending at discharge.
2. Followup with PCP, ___, and Cardiology scheduled.
***. | 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.
***
___ y/o M with PMHx of HTN, hyperlipidemia, obesity, GERD, who
presented cough and chest congestion x10days. EKG in the ED
showed worsening ST depression in V3-V5, with sinus tachycardia.
# Tachycardia: Tachycardia developed overnight in the ED.
Baseline in the clinic HR ___. Tachycardia likely
multifactorial ___ volume depletion (dry MM and orthostatic
hypotension), multiple albuterol and ipratropium nebs given in
the ED, and methylprednisone x125mg. Patient with negative
d-dimer on ___, no prolonged immobilization, malignancy, or
clinical signs, symptoms suggestive of DVT. Other possibility
to consider include myocarditis ___ viral illness, but patient
without signs or symptoms of CHF and chest pain only with cough.
Anxiety may also contribute to his presentation (patient
endorses anxiety at the onset of symptoms prior to presentation
to the ED). TSH wnl. Tachycardia resolved to baseline HR ___
after additional 1LNS on the floor. Anxiety treated with 0.5mg
Ativan.
# EKG changes: Patient with old partial RBBB and baseline TWI in
V1-V3 and downsloping ST depression <1mm in V2-V3 at baseline.
Transiently with increased downsloping STD in V3-V5 in the ED
concerning for ACS. However, patient without anginal chest pain
and trop neg x3. ST changes resolved by the time he reached the
floor. Initially changes could have been non-specific in the
setting of tachycardia
# Throat discomfort: Likely ___ irritation from bronchitis in
addition to dehydration. History not concerning for allergic
reaction- patient without wheezing or rhonchi in the ED, no
rash, symptoms onset 2 hours after azithromycin, and resolved
with albuterol neb. Patient also with chronic GERD which may
contribute to laryngeal irritation. Symptoms impoved with mist
face tent, flonase. H2 blocker increased to BID. Plan to DC
home on albuterol nebulizers, advised patient to drink adequate
amount of fluids.
# HTN: Continued lisinopril.
# GERD: Increased H2 blocker from daily to BID.
# Transitional issues:
- code status: full
- follow up: Dr. ___ on ___
- medication changes:
- STARTED nebulized albuterol
- STARTED Flonase
- STARTED Ativan
- INCREASED Nizatidine from 150mg daily to twice a day
***. | BRONCHITIS AND ASTHMA 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. ___ was admitted to Dr. ___ service on ___
with non-healing ulcer over the left first metatarsal head. He
was started on broad spectrum antibiotics. He was taken to the
angiography suite the following day for left SFA stent and PTA.
Please see operative note for details. He tolerated the
procedure well and did well post-operatively. Given the anatomic
findings he was taken to the operating room for a redo below
knee popliteal to ___ bypass with right saphenous vein graft as
well as left first hallux amputation. Post-operatively he did
well and remained on pathway. He was aggressively diuresed and
maintained a graft signal detectable with doppler. ___
recommended rehab and he was discharged on ___. At time of
discharge, patient was doing well with stable vital signs, pain
was well controlled, tolerating regular diet, and voiding
without assistance.
***. | OTHER VASCULAR PROCEDURES WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is a ___ year-old right-handed ___ speaking man
with a history of dementia, multiple ischemic strokes, possible
single seizure ___ years ago, left eye blindness, CKD, CAD, HTN,
and HLD who presented from home after 3 witnessed GTCs.
# Seizures:
He has many risk factors for seizure including dementia
(possible Alzheimers given medial temporal atrophy seen on MRI)
and prior strokes. His seizures leading to this admission were
likely precipitated by a UTI in conjunction with his AED being
recently discontinued. The Keppra was stopped by the PCP because
the patient had not had a seizure in years, so it was possible
that the medication was unnecessary. Given the patient's
significant brain atrophy and multiple strokes, it was
subsequently felt that he has a low seizure threshold and the
keppra was restarted. He had an LP in the ED and CSF was not
concerning for infection. He had a routine EEG during admission
which showed a slow and poorly organized background, but no
focal or epileptiform abnormalities. No further seizures
occurred in the hospital, and he returned to baseline mental
status. He was discharged on Keppra 500mg BID.
# Intubation:
The patient was intubated in the ED for airway protection,
although DNR/I because the family felt that in the acute
setting, intubation would be consistent with his wishes. He was
extubated the following day, with the understanding based on the
family's decision that the patient should not be re-intubated if
he failed extubation because this would not be consistent with
his goals of care.
# CAD/HTN/HLD:
His EKG had lateral T wave flattening. Troponins were slightly
elevated but did not rise and his CK-MB was within normal
limits, so there was no concern for MI. His troponin leak was
likely from an acute kidney injury. He continued ASA 81, Plavix
75, Pravastatin 20mg daily, Metoprolol tartrate 25 mg BID, and
Imdur ER 30 mg daily.
# UTI:
The patient had a UA on admission highly concerning for UTI, and
was started on ceftriaxone 1g daily for a 7 day course. His
urine culture showed contamination. He was transitioned to oral
Bactrim on discharge (last day = ___.
# History of stroke: Continued ASA 81, Plavix 75, Pravastatin
20
# Alzheimer Disease: Continued Exelon patch
TRANSITIONAL ISSUES:
- Code status: DNR/DNI
- patient discharged on Bactrim for UTI (last day = ___
***. | SEIZURES WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with history of perforated appendicitis ___ ___
requiring drainage of an appendiceal abscess. The drain was
subsequently removed. She returned on ___ for interval lap
appy. The case was complex with significant inflammation,
requiring extensive lysis of adhesions. She had a long recovery
period complicated by ileus, urinary retention, and slow ability
to tolerate PO. She was discharged on ___ and was
tolerating a diet and feeling well for the first day at home.
She represented to the ___ ED on ___ complaining of one day
of multiple episodes of bilious emesis, diarrhea, and abdominal
bloating and discomfort, with subjective difficulty breathing.
An NGT and foley were placed and she was made NPO and given IVF.
She was found to have a WBC of 13.4 with 85.6% neutrophils and
CT findings of multiple intraabdominal abscesses. IV cipro and
flagyl were started.
On ___ she had CT-guided ___ aspiration and drainage of two
of the left sided abscesses, specifically a large one ___ the LUQ
and one ___ the left hemipelvis. On the morning of ___, her
foley was discontinued and she was able to void. Her NGT was
removed and we advanced her diet. Fluconazole was started for
budding yeast seen on gram stain from the LUQ abscess. On ___,
the urine culture sent on admission grew >100,000 e.coli,
resistant to cipro. The pelvic abscess culture also grew
resistant e.coli. ID recommended switching antibiotics to
ceftriaxone, flagyl, and fluconazole. She was able to tolerate a
regular diet without nausea or vomiting and ambulated multiple
times a day. She continued to have loose bowel movements. C-diff
negative x 2.
On ___, she had some increasing distension and tenderness
with a Tmax of 100.7, tolerating less PO. We repeated a CT scan
on ___ which showed an enlarged, organized, right sided
collection which was successfully drained. The cultures were
negative, and the fluid output was serous. Her diet was advanced
again and she was able to tolerate POs, doing well with multiple
small meals a day.
The left sided anterior drain continued to drain 50-150cc of
succus a day, consistent with a low output fistula, likely from
the distal small bowel. The posterior drain had scant output
throughout, and the right sided drain had ___ of serous
output. Ms. ___ was out of bed and ambulating daily and
able to tolerate PO without nausea and vomiting. She continued
to have loose bowel movements which decreased ___ frequency, and
became more formed.
Repeat CT scan on ___, showed interval decrease ___ all
collections with no new drainable collections. She began to
prepare for discharge and was sent home on ___ with 3 more days
of cefpodixime and fluconazole, as well as ___ to assist with
drain care. She was discharged with all three drains still ___
place and instructed to record the apperance and outputs and
bring the record to her follow up appointment.
***. | POSTOPERATIVE AND POST-TRAUMATIC 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.
***
A/P: ___ year old woman with UC a/w UC flare.
.
#UC Flare: She was admitted and was evaluated by GI who
recommended continuing the current home regimen, in addition to
IVF. GI recs were followed. She underwent flex sig the next
day, and it showed diffuse erythema, congestion and friability
without bleeding in the rectum (to 10cm) c/w ulcerative colitis.
Distal descending colon was wnl. Based on this findings, GI
recommended po asacol, po steroid taper and cortifoam enema BID
and f/u with Dr. ___ GI) on ___ for biopsy f/u
and steroid taper and further management.
.
#Anemia: Hct at admission 31.5 (baseline 35). Her hct remained
stable at low ___.
.
FEN: Clears with IVF and then NPO for flex sig replete lytes PRN
PPX: ambulation
***. | INFLAMMATORY BOWEL DISEASE 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 plastic surgery service on
___ for observation and treatment of a zone 5 extensor
tendon laceration. He underwent irrigation and debridement of
right dorsal hand wound, arthrotomy and irrigation of third
metacarpophalangeal joint, and repair of zone 5 extensor tendon
laceration on ___. The patient tolerated the procedure well.
.
Neuro: Post-operatively, the patient received Morphine IV with
good 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;
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. Intake and output were closely
monitored.
.
ID: Post-operatively, the patient was started on IV Unasyn, then
switched to PO augmentin for discharge home. The patient's
temperature was closely watched for signs of infection.
.
At the time of discharge on HD #3 and 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. His right hand/forearm splint was in
place.
***. | HAND OR WRIST PROCEDURES EXCEPT MAJOR THUMB OR JOINT 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.
***
Hospital Course Summary
This is a ___ with history of hypertension with recent
admissions ___ for hypertensive urgency as well as subsequent
orthostatic hypotension, idiopathic PEA arrest complicated by
anoxic brain injury admitted with hypertensive encephalopathy in
setting of elevated blood pressures, started on a new
antihypertensive regimen.
Active Issues
# Hypertensive encephalopathy - patient w/prior admissions for
hypertensive urgency, as well as recent subsequent visit for
orthostatic hypotension secondary to a new regimen, subsequently
discharged on metoprolol monotherapy; patient presented with SBP
>200 and confusion. With input from PCP and cardiologist,
patient had home metoprolol uptitrated, was initiated on
diltiazem and restarted on torsemide (had been held on a prior
hospital stay). Remainder of workup for altered mental status
included negative infectious workup and non-contrast head CT
without acute process. Blood pressures continued to remain
elevated in the 160-190 systolic range, so renal was consulted.
Trial of spironolactone resulted in hyperkalemia. Multiple
medication adjustments were made, and he is being discharged on
torsemide, carvedilol, and amlodipine. He had no episodes of
dizziness or lightheadedness with walking. A broad work-up was
initiated including a 24hr urine collection for metanephrines
and serum renin and aldosterone, which are pending at the time
of discharge.
# Insulin-dependent diabetes mellitus with renal complications:
Pioglitazone was held during this admission and Lantus and SSI
were up-titrated. Given his predisposition to volume overload
in the setting of his CKD, his TZD was discontinued and ___
was consulted who provided a slight increase in his insulin
regimen on discharge.
# CAD/hyperlipidemia: Continued home aspirin and atorvastatin.
# OSA: Continued home CPAP.
# BPH: Continued home tamsulosin.
Transitional:
Pt will need to have blood pressures and blood glucoses
monitored as outpt
Pending labs include serum renin, ___, and urine metanephrines
***. | 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.
***
___ DLBCL on R-CHOP (___) admitted with temp of
100.6 at home. Throughout hospital stay she looked comfortable
and well
appearing with no focal symptoms.
not convinced this was an untreated UTI though did have more WBC
in urine than expected. Culture had NGTD. Given larger picture
chose to continue CTX and then
discharge on cefuroxime for 3 days to complete course. Will
follow cultures.
#Right shoulder/scapular pain: Likely MSK and not reflective of
malignancy or chemotherapy related complication. resolved by
discharge.
#DLBCL: s/p 2 cycles of R-CHOP. CT showing improvement in burden
of lymphadenopathy.
- follow-up already scheduled.
Dispo planning and coordination: 35 minutes
***. | 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.
***
The patient was admitted to the plastic surgery service on
___ and had a split thickness skin graft (right thigh donor
site) to right leg and left hip defects. The patient tolerated
the procedure well.
.
Neuro: Post-operatively, the patient received Dilaudid PCA with
good 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;
vital signs were routinely monitored. The patient was on a
regimen of fluconazole, ciprofloxacin and was also re-started on
methadone during this hospitalization. EKG was performed and
there was no QT prolongation.
.
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. The patient did complain of abdominal pain and
vomiting intermittently during this hospitalization and
requested IV dilaudid repeatedly. KUB showed no signs of acute
bowel obstruction and general surgery was consulted who felt
that his abdominal pain was most likely related to methadone
withdrawal. Chronic pain was consulted who recommended
restarting methadone with a long taper over a period of weeks.
The patient is being discharged on this regimen.
.
ID: The patient was maintained on the antibiotic regimen that he
had upon admission from his rehab including; daptomycin,
Bactrim, ciprofloxacin. Infectious Disease was consulted on
POD#2 to help with antibiotic recommendations and management.
Based on their recommendations the bactrim was discontinued and
he was started on ciprofloxacin. He is to continue on
daptomycin, fluconazole and ciprofloxacin on discharge and will
follow up with ID as an outpatient. The patient's temperature
was closely watched for signs of acute infection.
.
Prophylaxis: The patient received subcutaneous lovenox during
this stay, at a 'therapeutic' dose for treatment of recently
diagnosed right lower extremity DVT. He will continue with
lovenox on discharge.
.
At the time of discharge on POD#7, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet, and
pain was well controlled.
***. | O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES 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.
***
___ HTN, HLD, and prior polysubstance abuse who presents with
new L groin soft tissue swelling, improved on antibiotics.
# L GROIN CELLULITIS: CT pelvis showed soft tissue swelling in
the left inguinal region without reactive lymph nodes, evidence
of Fourniere's gangrene, or any evidence of intestinal hernia.
Patient was initially treated with IV Clindamycin and Keflex.
He was subsequently transitioned to Vanc + Keflex when blood
cultures (see below) grew out GPCs. After speciation of his
blood cultures, the patient was discharged on a 10 day course of
Bactrim and Keflex. UA was negative.
# Positive blood culture: Patient had only 1 bottle of blood
cultures which grew coag-negative Staph, most likely just a
contaminant. The patient was afebrile without any leukocytosis
so did not need continued IV antibiotics; discharged on Bactrim
and Keflex for total 10 day course per above.
# BLADDER MASS: New nodule seen on CT concerning for
transitional cell carcinoma. Patient will f/u with Urology as
an outpatient.
# EtOH use: Per patient, last drink was > 4 days prior to
admission and he waswithout any symptoms consistent with
withdrawal. Did not require CIWA scale.
# T2DM: Home metformin held. Placed on HISS while in-house.
***TRANSITIONAL ISSUES***
- Will f/u with Urology regarding incidental nodule seen on
pelvic CT concerning for potential transitional cell carcinoma
of the bladder.
***. | CELLULITIS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is a ___ male with history of alcoholic
cirrhosis status post liver and kidney transplant in ___ with
multiple complications from his biliary tract, status post
multiple ERCPs and stent placed, hepaticojejunostomy and
Roux-en-Y, also with a recent elevated bilirubin, PTC with no
strictures, liver biopsy done at OSH, presenting from clinic for
elevated T bili of 38.
ACUTE ISSUES:
# Eleveated T bili, concern for chronic late liver rejection -
Patient has hx of alcoholic cirrhosis s/p liver transplantation
(and renal tranasplant) in ___ with multiple complications from
his biliary tract, status post multiple ERCPs and stent placed,
hepaticojejunostomy and Roux-en-Y. Bili in ___ was 2.8,
underwent an empiric balloon dilatation, and ___ internal
external biliary stent was placed. Bili continued to rise, liver
biopsy on ___. Referred to ___ for possible new
transplant evaluation. Labs on ___ notable for INR 1.6, cr 1.4,
AST 432, ALT 440, AP 251, tbili 38.1, CEA 15, AFP 11.8, ___. Infectious w/u showed HIV negative, quantiferon gold
negative, HSV 1 pos, HSV 2 negative, hx of HBV infection (now
cleared), HAV positive, EBV positive for past exposure. On
admission, T bili 28.4. MELD 29. Patient was comfortable, AOx3,
ambulating. Denied any recent illnesses. Biopsy results were
obtained from ___, and brought to our pathologists for
re-reading. Per report from OSH, biopsy consistent with chornic
late rejection. However, pattern of transaminitis not consistent
with chornic late rejection. Our reread pending at time of
discharge. Blood tests for other viral illnesses negative
including CMV, HIV negative. ___ negative. Toxo pending.
Underwent MRI, with wet read showing fibrosis of liver but no
acute changes from previous. Given 3 days of 10mg PO Vitamin K
for elevatd INR. Case was discussed at transplant meeting, with
consideration to place patient back on transplant list pending
biopsy results. Patient discharged as there rest of workup will
be performed as an outpatient. T bili at discharge 24.
# ___ - Creatinine 1.4 on ___, baseline of 1.2-1.3 per wife.
Patient has history of renal transplant along with liver
transplant in ___ due to hepatorenal syndrome. He reports
elevated creatinine to 1.8 a week ago and subsequently passed
kidney stone. Cr remained stable throughout hospitalization.
Will need follow up as outpatient.
CHRONIC ISSUES:
# HTN: Continued metop tartrate 50mg TID and home nifedipine 60
ER
# Anxiety/Insomnia - continued BID trazodone 50mg
Transitional:
- Follow up of pending transplant work up
- Follow up labs in 1 week faxed to transplant surgery office.
- Follow up biopsy reread
- Pt should have Cr checked at next visit to monitor for
stabilization
- You will need your labs checked in 1 week on ___ with the
results to be faxed to the Liver Tranplant Center. There is a
script for this lab draw with the fax number.
- FULL CODE
- CONTACT: Wife and HCP ___: Cell ___ Son ___:
___
***. | 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.
***
___ y/o M with PHMx significant for multiple myeloma s/p multiple
pathologic fractures, who presented with bilateral hip pain and
left arm pain, found to have a left humerus pathologic fracture,
T12 compression fracture with moderate spinal cord compression
due to bone disease from multiple myeloma
# L Humerus Pathologic Fracture: ___ multiple myeloma. Ortho
evaluated in the ED and recommended NWB LUE with sling.
- LUE in sling
- f/u ortho recs
- outpt ortho follow-up
- pain control with home regimenen of oxycontin/oxycodone; IV
dilaudid only for severe breakthrough pain
# Bilateral Hip Pain and T12 compression fracture with moderate
spinal cord compression :
-high dose steroids followed by Dexamethasone taper, patient was
evaluated by RAD/ONC and started on urgent radiation therapy
- continue clamshell brace
- neuro checks q 8 hours
- ___ consult
-continue outpatient pain managment
# Multiple Myeloma: restared systemic treatment with bortezomib,
he recieved dose on ___ and ___, he will continue with his
primary oncologist Dr. ___
# Hyponatremia: Likely SIADH in the setting of acute pain vs.
hypovolemic hyponatremia ___ recent GI illness.
- repeat in the AM
# CKD, Stage III: Likely related to multiple myeloma. Cr at
baseline.
- renally dose meds
# FEN: Regular diet, replete lytes PRN
# COMM: with pt and wife
# PPX: ___
# CODE: full (confirmed)
# DISPO: home
***. | PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
This ___ yo male with extensive CAD history was admitted for
epistaxis and hypotension.
1. Epistaxis--the patient was evaluated in the ER by ENT and
had packings placed in the nare with good control of hemostasis.
Given his systolic BPs in the 100s he was observed overnight in
the FICU. He received vit K in the ER for reversal of his
coagulopathy. His coumadin was held during the admission but he
was continued on asa and plavix. He had no further significant
bleeding. The packing was left intact with ENT follow up the
week after discharge. In that interval the patient will
continue on the po keflex (empiric treatment) which was
initiated on admission. He was given afrin sprays PRN if the
bleeding were to reoccur with instructions to return to the ER.
2. Afib--the patient was rate controlled during the admission
with a beta-blocker. As above, his coumadin was placed on hold.
In a telephone discussion with his cardiologist it was decided
to hold his coumadin for now given his risk of rebleeding. He
will continue on asa and plavix. The patient was informed of
the risks and benefits of taking coumadin including stroke
prevention and he agreed with stopping the coumadin for now.
3. GERD--continued outpatient regimen.
***. | EPISTAXIS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year-old man with CAD, s/p CABG in ___, multiple PCI's, now
admitted following increase in angina s/p catheterization.
# HEART FAILURE: Given pt's EF 25% (doc ___, increasing
dyspnea, and, and elevated pressure in diag cath, he was
diuresed with IV lasix in preparation for a metabolic stress
test and possible interventional catheterization. Pt's
metabolic stress test resulted in an mVO2 of 14.2 and
interventional catheterization was deferred on this visit. Pt's
ICD generator was interrogated as routine and the generator was
reported to have ___ months battery life remaining. As such,
pt's ICD generator was replaced without complication. At
discharge, his PO lasix was switched to PO torsemide, which was
effective.
# CAD: Pt has an extensive CAD history with CABG, multiple caths
previously. Catheterization at admission showed disease
progression without areas for intervention. Pt was maintained
on his home medication regimen in house (atorvastatin,
clopidogrel, exetimibe, isosorbide dinitrate, aspirin) with no
anginal episodes during this admission. Pt underwent a
metabolic stress test which showed some progression of disease,
but nothing that warranted immediate action.
# Vascular disease: given pt's extensive vascular disease, there
was concern for peripheral vascular and carotid disease. Carotid
US and ABI both show no change in disease in vessels.
# constipation - Pt complained that he has not moved his bowels
since two days prior to admission. His bowel regimen was
increased and he was able to have a proper bowel movement the
day of discharge. As he had complained of mucous in his stool,
stool studies were sent but returned normal.
# Thrombocytpenia: At admission, pt's platelets were 94,
although RBC and WBC were wnl. No splenomegaly was noted on exam
at that time. Given his polypharmacy it is possible that
medication were causing a thrombocytopenia; during his stay,
pt's platelet count trended upward without any over
intervention. At discharge, they were 124.
Chronic Issues:
# HTN: Pressures well controlled on home lopressor.
# IDDM - HBA1c 9.4 by patient report, but ___ glucose stable
during admission.
# GERD - Was switched to famotidine during his hospitalization
without any adverse interactions. Was returned to ___ at
discharge.
# BPH: Stable with home flomax
# Neurology - stable on home gabapentin tid
# Hypothyroidism - stable on home levothyroxine
Transitional Issues:
- Post-ICD generator implantation check to be performed at ___
prior to return to ___
***. | AICD GENERATOR PROCEDURES |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Pt. is a ___ y/o with hypertension, hyperlipidemia, tobacco use,
who woke up this morning with R sided numnbess. On exam she has
diminished sensation to all modalities in the right hemibody
(face, arm, and leg) and some drift in her right arm that looks
like a sensory drift. She has evidence of cortical sensory loss
as well. Her strength is intact on that side except for some R
deltoid weakness which feels more like giveway (especially since
strength is intact in the rest of the arm). Her face is
symmetric. Her exam is most consistent with a lacunar infarct in
the thalamus on the left.
Her MRI/A showed evidence of an acute L thalamic infarct. The
likely cause of her infarct is longstanding hypertension. She
was switched from ASA to Aggrenox. She was started on a statin
for hypercholesterolemia, LFTS were nml.
Carotid US to eval for carotid atherosclerotic disease showed
mild plaque, both ICAs, less than 40% stenosis, both ICAs.
TTE with bubble to eval for cardiac source of emboli has been
done and shows mild LVH, nml EF, no PFO, no thrombus, no wall
motion abnls, no valvular abnls.
She was monitored on telemetry and did not show evidence of
Afib.
She was ___ and enzymes were negative.
Initially her Atenolol dose was halved and the HCTZ was held to
allow autoregulation
and maximize cerebral perfusion, with goal systolics 160-180.
Her HCTZ was then restarted.
CXR and UA to r/o infectious stressor causing re-expression of
deficits were unremarkable.
***. | INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION 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 h/o HTN, HLD and NIDDM who presented with
sudden-onset right arm numbness followed by progressive
right-sided weakness, slurred speech and ?aphasia.
# NEURO: Patient clinically worsened in the ED and he developed
vomiting and somnolence and required intubation for airway
protection. ___ revealed a large left basal ganglia hemorrhage
with intraventricular extension and accompanying subarachnoid
hemorrhage. CTA (suboptimal quality) did not reveal any
aneurysm. Neurosurgery evaluated patient in the ED and deferred
intervention. He was then admitted to the Neuro ICU for further
care. On initial exam after intubation he was unresponsive to
deep noxious stimuli in all extremities. Overnight on HD#1 his
exam improved: began purposefully moving his left arm and leg
and following simple commands on the left (squeeze hands, wiggle
toes etc). Repeat NCHCT showed some progression of ICH with
surrounding edema but no hydrocephalus. The patient was started
on 3% saline due to anticipated swelling. This was stopped ___.
He had an angiogram on ___ which showed a very small dissection
and pseudoaneurysm in the middle of the hemorrhage. This was too
small to intervene on. Repeat angiogram was done ___ which
redemonstrated the aneurysm which was too small on which to
intervene.
# CARDS: The patient has a history of hypertension. He required
a nicardipine drip at times to maintain his blood pressure less
than 140 (after angio) and the 150 subsequently. He was started
on all of his home medications by ___ and labetolol was also
added and titrated up.
# ENDO: The patient was placed on an insulin sliding scale and
oral hypoglycemics were held. ___ were consulted for better
control of glucose for which standing insulin and SSI titrations
were made.
# INFECTIOUS: The patient was seen to spike fevers over the
course of the week of ___ which extensive workup with
repeat Blood Cx, UA/UCx, Chest XRays were are neegative for any
pathology. These fevers were likely central in origin, and only
fluconazole was given for oropharyngeal thrush.
# F/E/N: The patient had dobhoff place and tube feeds started.
He had a video swallow on ___ which showed he could tolerate
modified consistency and thin liquids which was initiated. On
___ and ___, the patient was seen with calorie counts to be
100% of diet; NGT was pulled.
# TRANSITIONS OF CARE:
- Left Thalamic/Basal Ganglia Intraparenchymal Hemorrhage with
Intraventricular extension c/b Right Hemiplegia, Hemisensory
loss
- Pravastatin continued
- SSI used to maintain normoglycemia with recommendations
provided by ___
- Vanc/Zosyn used for repeat low grade fevers and concern for
bilateral lower lobe consolidation which were d/c'ed upon repeat
negative cultures and chest x-rays, making the fever likely
central in origin
- 7-day course of Fluconazole for Thrush. Nystatin swish and
spit may be used for isolated cases s/p.
***. | INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is an ___ year old woman with a history of vascular
dementia, osteoarthritis, recurrent UTIs, and hypertension who
presents to the ED s/p fall found to have evidence of UTI,
patchy pulmonary opacification, and degenerative C-T-L spine
changes.
# S/P fall:
Per collateral history from her son and staff at the ___
___, she has history of increasingly frequent falls over the
past year due to gait instability. She walks with a walker. She
notes weakness and fatigue over the week preceding her fall, and
with leukocytosis and evidence of possible pneumonia and/or
urinary tract infection, her underlying predisposition to falls
was likely worsened. No evidence of MI on EKG. History not
suggestive of neurogenic etiology. Appeared euvolemic to
hypervolemic on exam, with elevated blood pressure, suggesting
against orthostatic hypotension. Fall may also represent
progression of her underlying dementia. Telemetry demonstrated
frequent premature ventricular beats followed by pauses, which
may contribute to overall bradycardia. Atenolol initially held,
but was restarted due to increased heart rate and hypertensive
urgency. She continued to have right hip pain, evaluated by
orthopedic surgery and felt to be due to exacerbation of chronic
osteoarthritis after falling. This limited her ability to
ambulate but she showed modest improvement over her hospital
course. Although below her functional baseline ambulatory status
at discharge, she will likely benefit from physical therapy
while at rehab.
# UTI:
Patient has reported history of recurrent UTI's, however
microbiological data or additional information was not available
in ___ records. UA on admission with large leukocytes, blood
negative, nitrite positive, WBC 92, bacteria few, epi 0. She
notes urinary frequency and urgency, but denies dysuria. She had
leukocytosis but no fevers or signs of systemic infection.
Received doses of ceftriaxone and azithromycin and was
transitioned to levofloxacin 750mg Q48H and completed a 7 day
course. Urine culture grew E. coli sensitive to ciprofloxacin.
# Pneumonia:
Patient presented with hypoxemia of unknown cause. Pulmonary
exam notable for basilar crackles. CXR, CT scan (of spine, but
with images of lung) were concerning for bronchopneumonia.
Started on azithromycin on admission, changed to levofloxacin on
___ given better cardiac side effect profile. She had no
fevers, and initial leukocytosis of 13 decreased to 10 on day of
discharge
#Osteoarthritis:
She complained of pain in her right shoulder. She had right
shoulder effusion on exam and evidence of chronic degenerative
changes on x-ray. Pain control regimen included acetaminophen as
necessary, and lidocaine patch to right shoulder affected by
osteoarthritis, as well as low dose oxycodone as needed. Right
hip was evaluated with CT scan which demonstrated osteoarthritis
of the right hip as well as widening of the anterior right SI
joint and chronic changes in the pubic symphysis. She was
evaluated by orthopedic surgery, who felt that her pain was
likely due to her fall exacerbating her chronic osteoarthritis.
She can bear weight as tolerated on her right leg.
#Hypertension:
Continued home doses of furosemide, diltiazem, atenolol and
losartan. Atenolol was held due to concern that it may have
contributed to her fall, and she was transitioned initially to
metoprolol. Losartan dose also reduced by half. However, she
developed hypertensive urgency with acute pulmonary edema and
tachycardia with frequent ectopy, and so her pre-admission doses
of atenolol and losartan were resumed and metoprolol was
discontinued. BP remained approximately 140-160 systolic for the
duration of her hospitalization.
#Hypertensive urgency and respiratory distress:
On hospital day 4 for she was noted to be in moderate
respiratory distress on AM rounds. At the time she had
difficulty explaining symptoms, but when asked if she was
feeling short of breath she answered "I guess so."
She had worsening hypoxemia to 88% on 2L NC with tachypnea,
diaphoresis, wheezing, with markedly elevated BP at 197/91. SPO2
briefly improved to 93% on 3L NC after ipratropium nebulizer,
with decreased wheezing but then signs of pulmonary rales.
Telemetry demonstrated tachycardia with frequent ectopic beats
(PACs and PVCs). 12-lead EKG demonstrated sinus tachycardia with
frequent PVCs but no ST/TW changes (and patient denied chest
pain). Repeat CXR with worsening moderate pulmonary edema and
small pleural effusions. Was treated with furosemide IV in
addition to scheduled losartan and metoprolol, and BP decreased
to normal range and SPO2 stabilized in mid-90s on 3L NC, with
decrease in patient's respiratory distress. Given improvement
with control of BP and diuresis, suspect that modification of
losartan and beta-blocker regimen produced hypertensive urgency
leading to pulmonary edema, and sinus tachycardia with PVCs
likely a result of hypoxemia as well as contributor to edema.
She required additional doses of IV furosemide on subsequent
days, and follow-up chest XR demonstrated resolution of
pulmonary edema. However she continued to require intermittent
supplemental oxygen for the remainder of her hospitalization
felt to be due to atelectasis as this improved with frequent
incentive spirometry. She will continue to be weaned off of
supplemental oxygen at rehab.
TRANSITIONAL ISSUES:
==========================
-Patient with right hip pain when walking. Will benefit from
moderately aggressive physical therapy
-Oxygen requirement: patient with intermittent ___ nasal
cannula during this admission. Was adequately diuresed with
improvement but continued to require intermittent supplemental
oxygen due to atelectasis. Should be encouraged to be upright
for most of the day, and use incentive spirometry frequently.
While at rehab continue supplemental O2 and diuresis as needed.
-Rib fracture (question of lung nodule): patient has posterior
right 5th rib fracture that should not be confused for lung
nodule
-Bowel movements: Increased frequency of bowel movements on day
of discharge. Suspect secondary to aggressive bowel regimen
after constipation. Please titrate bowel medications from
1BM/day. If diarrhea, consider sending c. difficile, though low
suspician at this time.
-New medications this admission: Lidocaine patch, docusate,
vitamin D
-Code status: DNI/DNR confirmed via MOLST form
-Contact: son/HCP ___ ___, son ___
___ ___
***. | SIMPLE PNEUMONIA AND PLEURISY WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year old woman with history of pulmonary fibrosis, DVT, and
CKD presenting with fever and cough.
.
# Fever: Has underlying IPF and CXR without significant chage
from prior. U/a unremarkable. High fevers and lack of other
symptoms likely due to influenza. However, given her multiple
risk factors and recent stay at ICU, there was initial concern
for noscomial PNA. She was initially placed on vanc/zosyn for
24 hours. She defervasced quickly and chest CT was done which
showed improvement in her previous infiltrate, so she was
switched to Levofloxacin (plan for 7 day course or d/c sooner if
flu DFA returns positive). She continued to have cough and was
given tesslon perrls and robitussin for symptomatic relief. Flu
DFA returned positive for Influenza B. Urine legionella, blood
cultures and urine cultures remained negative. Antibiotics were
discontinued and patient was afebrile for the duration of her
admission.
.
# Acute on Chronic renal failure: Initially with elevated
creatinine on admission. Was likely from dehydration leading to
pre-renal azotemia. She was given 1L IVF with improvement in
her creatinine. No further issues.
.
# Recent DVT: Continued on coumadin, INR was supratherapeutic on
day 3, so coumadin held on ___ and ___. Restarted at a lower
dose 5mg on ___, and she was discharged on this regimen with
close follow up.
.
# Code Status: DNR/DNI - confirmed with daughter.
***. | OTITIS MEDIA AND URI 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 LEFT AMA ON ___ ***
BRIEF SUMMARY:
====================
Ms. ___ is a ___ year old F w/ hx of Crohn's disease on
Humira, anxiety, COPD, and type B aortic dissection s/p graft
presenting with severe microcytic anemia likely due to iron
deficiency without obvious source of bleeding or symptoms of a
Crohn's flare. She received 3U pRBCs with appropriate rise in
hematocrit. She was admitted for continued workup of the source
of her profound anemia. On ___ she had a EGD/Colonoscopy
showing new actively bleeding and ulcerating stricture in the
T/A colon, with concern for malignancy in the setting of her
long-standing Crohn's disease. Patient left AMA before further
CT imaging for malignancy, evaluation of her iron deficiency
anemia and the severity of her current Crohn's status. A
discussion of the risks of leaving including but not limited to
bleeding, lack of characterization of her potential malignancy,
and ultimately death if her bleeding causes hemodynamic
instability. Despite comprehending this risks, patient elected
to still leave AMA.
TRANSITIONAL ISSUES:
========================
*Severe microcytic anemia with iron deficiency
[] Please arrange for outpatient IV iron infusion
[] Please recheck CBC to ensure stable hematocrit
*IBD, concern for new malignancy
[] Please ensure patient received MRe or other imaging to
further evaluate for colonic masses
*IBD maintenance:
Please ensure pt has the following completed while on Humira
[] Seasonal flu shot (not the live version)
[] Pneumovax
[] Prevnar 13 (needs both pneumonia vaccines if on
immunosuppression)
[] Tdap vaccine/booster
[] Hepatitis B vaccine if not immune
[] Hepatitis A vaccine if not immune
[] Yearly Tb testing if on biologic therapy
[] Yearly dermatologic assessments
[] Shingrix
[] DEXA scan (patient is overdue)
[] Yearly pap (patient reports compliance with this)
ACUTE ISSUES:
=============
# Severe microcytic hypochromic anemia
# Severe iron deficiency
Hgb 4.3 on admission s/p 3U pRBC. Last Hgh on record from ___ year
ago in the ___. Severe anemia with new microcytosis compared to
last year and given inappropriately low reticulocyte count, very
suspicious for occult bleeding leading to severe iron
deficiency.
Tsat <2% with essentially no ferritin stores. Stool guiac was
negative in the ED, but this is only about 30% sensitive for GI
bleeding, so clinical suspicion in the setting of Crohn's
disease
is still very high. Iron deficiency may also be sequalae of poor
absorption, Celiac IgG and TTG antibody negative. She does have
low-normal folate levels, normal B12 and was started on a folate
supplement. Also likely contributor is anemia of chronic
disease in the setting of her IBD. Other causes of microcytic
anemia such as thalassemia with low clinical suspicion as she
has
had prior normal MCVs and low MCHC. She is post-menopausal, so
vaginal bleeding is not the source. Labs are not consistent with
hemolysis given, negative hemolysis labs including haptoglobin,
LDH. Will treat with IV iron while inpatient as long-term iron
supplementation is favored via IV rather than PO given poor
absorption. EGD/Colonoscopy ___ showed stricture with
active bleeding and ulcerations in transverse vs ascending colon
concerning for malignancy as the cause of a slow, chronic bleed.
She went for CT A/P ___ to further characterize any colonic
masses.
# Crohn's disease
Longstanding history of Crohn's disease first diagnosed at age
___. Last colonoscopy in ___ with severe ulcerations @ cecum and
ileocecum showing active oozing. Variably controlled on
adalimumab and mesalamine. Currently without symptoms of typical
flares which for her include abdominal pain and more frequent
bowel movements. CRP is also 1.6, not consistent with
inflammatory response in flares. Unlikely to be diarrhea from
infectious colitis however, studies were sent to rule out
causes. Patient is overdue for colonoscopy monitoring given her
disease severity and also for screening for possible malignancy
in the setting of her recent unintentional
weight loss. She had a CT A/P, results of which are pending at
discharge. She will need close GI follow-up as her Crohn's
disease is currently poorly controlled. Her home humira was
held, and she was continued on home mesalamine.
CHRONIC ISSUES:
===============
# Type B aortic dissection
Continued home aspirin.
# Anxiety
Continued home alprazolam, escitalopram, lamotrigine.
# Insomnia
Continued home trazodone.
# GERD
Continued home omeprazole
# COPD
Continued home albuterol prn, substituted tiotropium for home
umeclidinium while inpatient.
# Tobacco use disorder
Offered Nicotine patch.
===============================
#CODE: Full, presumed
#CONTACT: Name of health care proxy: ___
Relationship: daughter
Cell phone: ___
Proxy form in chart: No
Comments: Other contact: son, ___ ___
***. | INFLAMMATORY BOWEL 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.
***
FEVER / PROSTATITIS: The patient reportedly has one blood
culture bottle positive for GNRs. This is unlikely to be a
contaminant. His urine culture grew Serratia marcescens, so
this is the most likely source and organism. His prostate was
tender on exam in the ED, and he has had prostatis before, and
he has had similar symptoms but they have not been this severe
with the rigoring. A blood culture from At___ was communicated
to me by the patient's PCP, and it grew out Serratia marcescens
with the same sensitivities as the organism in the urine
culture, suggesting that the prostatitis was the underlying
cause of bacteremia. He received IV ceftriaxone for this in the
hospital and felt much better. After consultation with the
infectious disease service, they recommended prostate ultrasound
which showed no abscess. The patient was discharged on 3 weeks
of ciprofloxacin.
HEAD CT: There was a hypodense area on the noncontrast head CT
that was further evaluated with MR, on which no abnormalities
were seen.
DYSPNEA: The patient does not appear to have pneumonia. He has
a history of asthma, and his chest film is concerning for
underlying obstructive disease, according to radiology. He has
a remote smoking history, making COPD less likely. He is
oxygenating well at rest on room air, but the exertional
component also raises the possibility of a cardiac process. He
has no murmur, and GNRs would be unusual for endocarditis. He
has no chest pain or discomfort to suggest ischemic disease.
His dyspnea improved overnight with albuterol. Ambulatory
saturation was 96-98% on room air.
TRANSAMINITIS: No RUQ pain or clear reason for these symptoms.
AST and ALT were mildly elevated but stable throughout his
hospital course. A RUQ ultrasound was normal. Hepatitis
serologies were negative.
***. | SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
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.
Otherwise, pain was initially controlled with a PCA followed by
a transition to oral pain medications on POD#1. The patient
received lovenox for DVT prophylaxis starting on the morning of
POD#1. The foley was removed on POD#2 and the patient was
voiding independently thereafter. The surgical dressing was
changed on POD#2 and 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. Gabapentin was added since pain
was not controlled on dilaudid alone. 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.
Ms. ___ 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.
***
Mr. ___ is a ___ year old gentleman with PMH significant for
CAD s/p PCI in ___, Hodgkin's lymphoma s/p radiotherapy
to neck/chest as child, iodine-resistant papillary thyroid
carcinoma/PDTC metastatic to lungs, pleura, and hilar LN on
Lenvima, DM, HLD, depression, and PUD who is admitted with
worsening cough, fatigue, and bilateral UE aching after
completing a course of Augmentin for pneumonia concerning for
treatment failure of pneumonia.
ACUTE ISSUES
============
# Pneumonia
Patient recently diagnosed with pneumonia in ED on ___ and
completed course of Augmentin. Symptoms initially improved, but
then recurred with worsening cough & leukocytosis. CXR w/ stable
bilateral consolidation. Blood cultures obtained with no growth.
Started on vancomycin, cefepime, and azithromycin in the ED then
narrowed to cefpodoxime and azithromycin prior to discharge.
Symptoms improved. Discharged home to complete a 7 course of
cefpodoxime (through ___ and 5 day course of azithromycin
(through ___.
# Anemia
# GERD
Admission Hb 9.6 from 11.1 one week prior. CBC trended and
stable while admitted at 9.5. Iron studies pending at discharge.
Will defer further anemia workup to primary care provider. Will
follow up with PCP ___ 1 week for repeat CBC as an outpatient.
# CAD s/p DES to LAD
Admitted in ___ for NSTEMI, now s/p DES to proximal LAD. Trops
flat on admission and EKG stable. Continued on home DAPT,
Atorvastatin, Metoprolol.
# Transaminitis
Alk phos and ALT elevated on admission. Bili and AST within
normal limits. No abdominal pain, nausea, vomiting. Will repeat
LFTs in one week at PCP ___ if still elevated, would
recommend further work up with hepatitis viral serologies and
RUQ ultrasound.
# Papillary thyroid carcinoma
Patient is followed by Dr. ___ as outpatient and is
treated with Lenvima. This medication was held during prior
hospitalization after discussions with outpatient oncologist.
Patient has a follow up appointment with hematology/oncology in
1 month to discuss restarting Lenvima.
CHRONIC ISSUES
==============
# Diabetes
Held home metformin and started ISS. Will restart home Metformin
at discharge.
# Hypothyroidism s/p thyroidectomy
Continued home levothyroxine.
# Depression
Continued home sertraline.
TRANSITIONAL ISSUES
===================
[ ] Admission Hb 9.6 from 11.1 one week prior. CBC trended and
stable at 9.5 while admitted. Iron studies pending at discharge.
Will defer further anemia workup to primary care provider,
including repeat CBC in 1 week, stool guaiac, etc. No clinical
evidence of bleeding.
[ ] Please follow up iron studies (ferritin, TIBC, iron), and
start iron supplementation with bowel regimen if appropriate at
PCP follow up
[ ] Please ensure leukocytosis resolves with treatment of
pneumonia.
[ ] Will need repeat LFTs in one week at ___ ___ if
still elevated, would recommend further work up with viral
serologies and RUQUS.
[ ] Ensure follow up with hematology/oncology ___) in
one month
[ ] Ensure follow up with cardiology as scheduled on ___
# Contact: ___ (wife) ___
***. | SIMPLE PNEUMONIA AND PLEURISY WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is a ___ PMHx PMR, OA, and recent diagnosis of L
frontal meningioma who presents from her assisted living
facility for weakness, difficulty ambulating and AMS, found to
have PNA.
# Altered mental status, acute metabolic encephalopathy. Likely
metabolic encephalopathy in the setting of acute infection.
Patient's confusion seems resolved at this time and she is back
at her baseline mental status according to her home health-aide
and niece. CT head showed no evidence of acute pathology or
change in appearance of known L frontal meningioma.
# PNA. Pt with mild respiratory symptoms with CXR showing
possible right lower lobe infiltrate. Given overall clinical
stability and because patient is very well-appearing, she was
treated for CAP with levofloxacin. Speech and swallow were
consulted and on bed-side evaluation she had no signs or
symptoms of aspiration, they recommended continuing with a
regular diet with thin liquids.
- Continue PO Levofloxacin q48h, last dose on ___
# Deconditioning and gait instability. Patient reports having
no increased trouble with her gait immediately preceding this
presentation despite recent falls over the past couple of
months. Patient was recently evaluated by Neuro-Onc on ___ who
felt that her symptoms did not correlate with her imaging
findings. Discussed with her niece who feels that she has had a
further decline since her gabapentin was discontinued and her
prednisone was decreased to 1 mg. Restarted home gabapentin and
increased prednisone dose back to 2 mg daily. ___ was consulted
and recommended discharge to STR.
- discharge to STR
- Continue gabapentin 100 mg qHS and prednisone 2 mg daily
# Meningioma. Stable appearance on head CT. Pt followed by
Neuro-Onc (Dr. ___.
- Continue 2 mg prednisone daily
# Enterococcus in urine:
Urinalysis with only 7 WBC, small ___ negative nitrite. Culture
growing >100K enterococcus species. She denies any urinary
symptoms. Most likely colonization.
-Continue to monitor, if febrile or worsening mental status
consider treatment
CORE MEASURES:
=======================
# FEN: regular diet
# PPX: Subcutaneous heparin, Senna/Colace, analgesics prn
# ACCESS: PIVs
# CODE: full (presumed)
# CONTACT: patient, HCP ___ (___) ___
# DISPO: to short term rehab
Greater than 30 minutes were spent on discharge related
activities on day of discharge.
***. | SIMPLE PNEUMONIA AND PLEURISY WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
#. CAD: No history of CAD. No signs or syptoms concerning for
ischemia. Aspirin was continued.
.
#. Endocarditis: Patient with a history of mitral valve
prolapse, moderate MR and previous endocarditis in ___ and
___. He presented to his PCP with fevers, chills and night
sweats for ~1.5 wks. Blood cultures were drawn and found to be
positive. He was told to come to the hospital for further
evaluation of possible endocarditis. On admission he was started
on vanc and gent. He had a TTE done which revealed myxomatous
mitral valve leaflets, focal thickening of the posterior leaflet
with a mobile acoustic density on the atrial surface that
probably represented a vegetation, mild mitral valve prolapse
(posterior leaflet) and an eccentric, anteriorly directed jet of
moderate (2+) mitral regurgitation. The ID team was consulted.
They recommended continuing vanc/gent until sensitivities came
back, a CT abd/pel to rule out septic embolization and a spine
MRI to rule out epidural abscess given patient's back pain. His
CT abd/pel revealed no abnormalities and spinal MRI showed no
evidence of infection or abscess (see below for full details).
His OSH BCx->Strep viridans that was pan-sensitive. Blood
cultures taken on admission subsequently grew possible Gemella
sp and were sent to the ___ Clinic for speciation. A TEE was
done which revealed 1.3 cm x 0.6 cm vegetation on the P2 scallop
of the posterior mitral valve leaflet and moderate to severe,
eccentric mitral regurgitation. Despite multiple attempts, on
multiple different culture mediums the micro lab was unable to
grow the bacteria to perform sensitivity testing. The ID team
along with Dr. ___ then decided that penicillin G and
gentamycin would be a better option for the patient until final
sensitivities could be obtained from ___ ___. A
___ line was placed and patient discharged with instructions to
complete a 6 week course of pen/gent and close ID follow up.
.
#. Rhythm: No history of arrythmias. Daily EKG's revealed no
conduction abnormalities.
.
#. Gout: Patient presented with with L toe inflammation and pain
that he attributed to a gout flare despite not carrying a
diagnosis of this. A foot X-ray was done to evaluate for
fracture or possible infection and was normal. He was started on
treatment with colchicine and indomethacin with improvement of
the inflammation and pain.
.
#. Back pain: Patient with a history of lower back pain but no
neurological deficits on neuro exam. The ID team recommended a
spinal MRI to rule out abscess. It showed no evidence of
discitis, osteomyelitis, epidural collection, or paravertebral
collection, but did reveal mild-to-moderate spinal canal
stenosis at L3-4, with displacement and possible compression of
the traversing right L4 nerve root in the subarticular recess.
The exiting L3 nerve roots are contacted within the moderately
narrowed neural foramina at L3-4. These findings were thought to
be the cause of his lower back pain. He was treated with
percocet with improvement of his pain. This should be followed
as an oupatient.
***. | ACUTE AND SUBACUTE ENDOCARDITIS WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
BRIEF HOSPITAL COURSE:
___ yo F with h/o developmental delay, h/o aspiration pneumonia,
and other medical issues presents with ___
because of cough and O2 Sat 88%.
.
ACTIVE ISSUES:
# Aspiration Pneumonia: Based on limited history, most likely
an aspiration event, with differential including aspiration
pneumonitis vs. pneumonia. She was afebrile without leukoctyosis
on admission. CXR demonstrated left lower lobe pna. Noted to
have significant secretions and requiring ___ NC. Levofloxacin
was started for empiric coverage of aspiration pneumonia. On HD2
she spiked a fever and flagyl was added for better anaerobic
coverage. On HD3, she desaturated to the low ___ on 5L NC after
receiving chest physical therapy. She received a nebulyzer
treatment. A repeat chest xray demonstrated worsening of left
lower lobe infiltrate and new RLL opacity. Concern for
persistent aspiration events despite NPO status, mucus plugging
versus/and volume overload in setting of volume rescussitation
the day prior. She was given 20mg IV lasix. An ABG demonstrated
hypoxic respiratory failure (7.36/66/52) on 5L NC. She was
transferred to the MICU for further management. In the MICU, the
patient was found to have multilobar pneumonia with bilateral
pleural effusions. She was treated with broad-spectrum abx,
cefepime and vancomycin, started ___ and planned for 8 day
course. She completed her course of antibiotics and remained
afebrile. She underwent a speech and swallow evaluation which
showed her to have a increased risk of aspiration during eating.
These results were discussed with her family and the decision
was made to allow her to continue to eat. Her family has decided
to go ahead with PEG tube placement in the future if she is
having difficulty eating. This decision was made by the family
even with an extensive discussion where they were informed that
it most likely not affect her mortality outcome.
.
# Tachycardia: Sinus tachycardia. She was given IV metoprolol
5mg x 2 on HD2 with improvement after triggering for
tachycardia. She was volume rescussitated with 500cc bolus NS
and given 1L NS as maintenance on HD with concern for
hypovolemia. Heart rates persistently in 110s on HD3. Her HR was
intermittently elevated during her stay in the MICU, likely due
to over-diuresis and in the setting of infection. Once her
infection resolved and she was adequately volume resuscitated
her tachycardia resolved.
.
# Left Upper Lobe Lung Collapse- On a portable cxr it was noted
that her LUL had collapsed most likely due to prior secretion
aspiration event. She was given chest ___ and deep suction which
improved her lung areation on PE. Breath sounds returned B/L.
Pulmonary evaluated her and determined no other intervention was
warranted. She was sating in the mid ___ on RA.
.
#Elevated Bicarb- Pt's bicarb was elevated to a max of 42 during
this admission. Most likely related to decreased free water
intake consider pt was not able to drink with her ___ cup like
she uses at home while in the hosptial. This corrected with IV
free water replacement. A nursing aide was asigned to helping
her drink more frequently during the day.
.
# T2DM: continued on a insulin sliding scale. Metformin was
held.
.
# Schizophrenia/anxiety: She was continued on home risperidone
and valproic acid. Sertraline was continued as well.
.
# HLD: She was continued on simvastatin.
.
# Code status: Confirmed as Full code by nursing facility. She
has a HCP who is out of state. In the hospital course, Health
Care Proxy changed her to code status to DNR/ok to intubate.
.
#Transitional:
Pt should be fed using strict aspiration precautions including
soft dysphagia diet, seated at 90 degrees, with 1:1 supervision
with eating. She has a follow up appointment with her PCP.
***. | RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ y/o male with history of alcohol abuse, HBV, HCV, cirrhosis,
likely HCC, admitted s/p TACE procedure of segments V, VI, VII.
The new meds started upon discharge include ranitidine and
oxycodone PRN. He had an elevation in his T bili to 2.1 on ___
following his procedure and thus will need repeat LFTs next week
when he sees Dr. ___. He had a low grade fever to 100.3 on
the day following his procedure, but he did not have abdominal
pain on ___ and was tolerating regular meals. His arterial
access site appeared good without bruit, hematoma, or pulsatile
mass. Given low fever and no abdominal pain, he was felt to be
ready for discharge on ___ with repeat LFTs next week.
.
He continued tenofovir, nadolol (history of varices). There was
no evidence of encephalopathy on exam.
.
We held glipizde while inpatient. On ___ qid with humalog SS and
diabetic diet with plans to resume glipizide upon discharge
.
He has been sober since ___. Continued folic acid and
thiamine.
***. | 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.
*** hx alcohol use disorder who presented as a transfer from
outside hospital for evaluation of traumatic injuries (L frontal
IPH, R shoulder dislocation s/p reduction), persistent
abnormalities in his neurologic exam, and persistent
encephalopathy. He initially presented to another hospital after
a neighbor heard loud sounds in his apartment and called ___. He
was obtunded, noted to be seizing at the other hospital, was
treated with AEDs, and intubated. He suffered a brief cardiac
arrest (2 mins). He was transferred to the ___,
where he was admitted to the ICU there for further care.
In the ___ ICU, he was loaded with phenobarbital
for ? alcohol induced seizures. He underwent cvEEG which was
reportedly abnormal suggesting profound nonspecific cerebral
dysfunction, but the report is unavailable. Orthopedics reduced
a R shoulder dislocation. TTE showed evidence of mycardial
stunning with EF of ___. At the family's request, he was
transferred to ___ for further care.
Initially admitted to the trauma SICU ___ given his injuries.
Neurosurgery was consulted for his L IPH. He was given Keppra
for seizure prophylaxis. Neurology was consulted. cvEEG was
initiated. Orthopedics was consulted for his R shoulder
dislocation (relocated on admission). However, his neurologic
exam revealed new abnormalities on ___ (vertical nystagmus,
episodes of rigidity and extensor posturing), and he was
persistently altered. This prompted new neuroimaging and
initiation of broad antibiotics for possible
meningoencephalitis. He underwent MRI which showed bilateral
occipital and parietal lobe hypoxic-ischemic injury. Based on
his relatively modest traumatic injuries and predominantly
neurologic presentation, he was transferred to the neuro ICU on
___. EEG showed no seizures and cvEEG was discontinued on ___.
A lumbar puncture was performed on ___ which showed elevated
WBC and RBCs. He was continued on empiric meningitis treatment
with vancomycin, ceftriaxone, and acyclovir. When HSV PCR came
back negative, acyclovir was discontinued on ___ but resumed on
___ per ID pending possible repeat LP.
He was noted to have bitten his tongue strongly and OMFS was
consulted. A bite block was placed. At around 920 am on ___,
patient was noted to have large cuff leak, noted that pilot
balloon was cut off, likely due to bite block. Anesthesia came
to bedside as well as ICU attending. Bronch cart and advanced
airway cart to bedside. ETT replaced over bougie with one
attempt. He then desatted and a bronch was done at the bedside.
His saturations improved.
Since his mental status did not improve, paraneoplastic workup
was done. He received a CT torso which showed no evidence of
malignancy and an ultrasound of the scrotum was unremarkable.
Additional history revealed long-term inhaled solvent abuse
(huffing), and his mother reports that he had definitely done
this in at least the last 5 days prior to presentation. This
could also potentially explain his overall brain atrophy, well
out of proportion to his age.
#Disorder of consciousness - likely multifactorial from anoxic
brain injury prior to being found by EMS and short cardiac
arrest in hospital; chronic toxic injury from inhalant abuse and
alcohol abuse; and intraparenchymal and subarachnoid hemorrhage
likely secondary to trauma. Diffuse axonal injury is likely;
these changes may not be evident on MRI.
- Autoimmune process likely ruled out. Preliminary results
discussed with ___ on ___ indicated negative antibodies for
NMDA-R, LGI1, CASPR2, and VGKC. Further results are pending but
considered highly unlikely in the setting of the above
negatives. Additionally, his seizures occurred early in his
presentation and were then most difficult to control, though
eventually subsided and readily controlled on a single agent --
whereas the course of autoimmune encephalitides is marked by
progressively worsening seizure activity.
- Repeat MRI with and without contrast was with subtle
progression of anoxic brain injury. Decision made not to repeat
LP given low suspicion for infectious process and suspicion that
pleocytosis may be related to TBI.
Repeat MRI showed evolving L frontal hematoma. Repeat CTH showed
enlarged hygroma in place of R SDH. LP was repeated for ENC1
autoimmune encephalitis panel, MS ___, CNS ___, VDRL, VZV,
HSV which were negative. CNS ___ not performed due to clotted
specimen. Repeat CT on ___ was stable.
# Autonomic storming with agitation, tachycardia, diaphoresis
He was continued on clonidine, propranolol, bromocriptine
titrated. Propofol and fentanyl drips were weaned off. He was
continued on oxycodone, ativan, diazepam, haldol. Addition of
diazepam seemed to improve sinus tachycardia (persistent up to
160s) and agitation. These agents may be gradually weaned at the
discretion of his rehab/long-term care.
#Seizures - reported seizures at outside hospital
No seizures seen on cvEEG; repeated on ___ showed no seizures or
epileptiform activity. He was continued on Keppra 1000 mg BID.
TRANSITIONAL ISSUES
--------------------
[]continue Keppra 1000 mg BID
[]oxycodone, ativan, diazepam may be gradually weaned at the
discretion of his rehab/long-term care
[]trach tube was capped while at ___ and can be discontinued
as tolerated while at rehab
[]follow up with neurology outpatient in ___. If you
would like to arrange follow-up at ___ in
___, please call ___.
***. | 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.
***
___ yo M with h/o poorly controlled IDDM (A1C 10.9%), HTN and HLD
presenting with hyperkalemia found incidentally during PCP
___.
.
# Hyperkalemia: Pt found to be hyperkalemic to 7.6 in ___ ED.
There are several etiologies that likely caused hyperkalemia in
this patient. First are his medications, notably Lisinopril and
Losartan which both cause low renin states (unusual for a
patient to be on both an ACE inhibitor and ___ at once). Pt
is also on a beta blocker (atenolol), which can also cause
hyperkalemia by preventing potassium entry into cells. He also
has history of poorly controlled IDDM, and a low insulin state
also causes hyperkalemia by preventing potassium entry into
cells. Acute renal failure can cause hyperkalemia, although
patient's elevated creatinine appears chronic(has ranged from
1.6 -1.9 in ___ per our records). Dehydration and diarrhea can
cause an impairment of potassium excretion, though this
patient's diarrhea seemed relatively mild and of short duration,
and he did not appear clinically hypovolemic or have a non-anion
gap acidosis or concentrated urine on UA. Patient's hyperkalemia
ultimately resolved to 4.2 after 2 doses of kayexolate, PO
Lasix, holding his ACE inhibitor and ___ and ___ diet.
He was discharged off both the ACE inhibitor and ___, and his
beta blocker was uptitrated to control BP (see problem #2).
Tight glucose control as an outpatient will also help prevent
future hyperkalemic episodes. Patient's PCP was emailed to
inform of med changes.
.
# HTN: Patient hypertensive on admission. His Lisinopril and
Losartan were held during hospitalization and on discharge
secondary to his hyperkalemia. His home atenolol was also
discontinued, as it is a renally-excreted beta blocker and
should be avoided in a patient with stage III CKD. He was
instead started on Labetalol 200mg BID, to which he responded
well. In the future, may need to restart either ACE ___ for
their renal protection properties in diabetes. Could also
consider starting diuretic such as chlorthalidone, which would
not cause hyperkalemia; however should be cautious given
underlying renal dysfunction.
.
# IDDM: Patient has poorly-controlled diabetes, with an A1C of
10.9% on this admission. Patient was hyperglycemic during
hospitalization. His metformin was discontinued because it can
worsen renal damage in chronic kidney disease. He is on BID
Lantus at home, so his AM Lantus dose was uptitrated from 55 to
60 units with decent effect. He also received diabetic teaching
with nursing staff. He will follow up on this at post-discharge
PCP ___.
.
# Stage III CKD: stable during hospitalization. Discontinued
potentially nephrotoxic meds (atenolol, metoprolol).
.
# Diarrhea: resolved on admission with no intervention.
.
# HL: Lipid panel on admission showed chol 199, ___ 270, HDL 36,
LDL calc 109. TGs likely elevated because bloodwork was
nonfasting. LDL is above goal of <100 in a diabetic patient.
Simvastatin 40mg PO qHS was continued during hospitalization.
PCP was emailed with this information, with the suggestion that
simvastatin potentially be uptitrated on an outpatient basis.
.
# Elevated TSH: TSH found to be 6.8 on admission, with free T4
and T3 both within normal limits. Patient had no signs/symptoms
of hypothyroidism on history or exam. This was thus diagnosed as
subclinical hypothyroidism, and should be monitored on an
outpatient basis.
.
# Depression: stable on home fluoxetine.
.
# GERD: stable on home omeprazole 20mg PO daily.
***. | RENAL FAILURE WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is a ___ woman with ___ kidney stone with stent
placement at ___ recently who presented to OSH with right sided
chest pain, with witnessed PEA arrest at 16:45, transferred for
further management.
History as above. On arrival to the MICU, she was tachycardic to
130s-140s, BPs ___. She was started on dopamine,
epinephrine, levophed, vasopressin, and phenylephrine and was
maxed on all 5 medications. Her BPs continued to persist at
___ with peak ___. She was given 2 amps of bicarb and
started on a bicarb gtt. Repeat CXR showed re-expanding of lung
and chest tube in place. Patient had respiratory acidosis based
on VBG results, so RR was increased on the vent and tidal volume
was increased to 400 with improvement in the respiratory
acidosis. MASCOT was activated and discussion was had with
decision that she was too unstable for further imaging or
invasive interventions. The plan was to start on IV heparin but
on reassessment of patient, she was found to have fixed and
dilated pupils more than an hour after vecuronium was supposedly
given. This was concerning for intracranial hemorrhage in the
setting of tPA so no heparin was given. The family was present
and we discussed the poor neurologic prognosis and her
hemodynamic instability on 5 pressor. The decision was made to
pursue CMO and after terminal extubation and discontinuation of
pressor she died at 12:07 am on ___.
***. | RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ Brief Hospital Course:
The patient was admitted to the ___ Surgical Service for
evaluation and treatment for partial small bowel obstructive
symptoms as well as chronic marginal uclers with malnutrition.
On ___, the patient underwent 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, on IV fluids and perioperative
antibiotics, with a foley catheter, and epidural for pain
control. The patient was hemodynamically stable.
Neuro: The patient received an epidural as placed by the Acute
Pain service with good effect and adequate pain control. When
tolerating oral intake, the patient was transitioned to oral
pain medications (liquid percocet) with IV dilaudid for
breakthrough pain.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. She has a
history of hyperlipidemia, and her simvastatin was resumed
without issue.
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.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Due to chronic marginal ulcers and subsequent
intolerance to PO with reliance on TPN, the patient's TPN was
continued, with appropriate repletions of electrolytes. She
underwent an UGI with G tube study on POD#5 which demonstrated a
patent G tube with no active extravasation at her previous
anastamosis, but noted moderate mid-esophageal reflux. The
patient was eventually advanced to a bariatric stage IV diet,
which she tolerated well without nausea or emesis; her TPN was
discontinued at this point and her tube feeds started, which
were increased to goal at 55ml/hr for 24 hours. She tolerated
this regimen for more than 24 hours when she developed nausea
with non-bilious emesis; her tube feeds were then temporarily
held, and concentrated to 40cc/hr. Her G-tube was capped and she
continued to have nausea, so the G-tube was put to gravity.
Overnight the nausea improved and the G-tube was recapped.
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, of which she had none.
She was noted to have a raised, erythematous, and pruritic rash
on her lower extremities on POD#3, which appeared fungal in
nature exacerbated by contact dermatitis secondary to her
compression boots. This improved with applications of miconazole
powder.
Endocrine: The patient has known type I diabetes, on long-acting
insulin at home. She was provided insulin through her TPN in
addition to a sliding scale. Her initial finger stick blood
glucose levels were elevated within the 130-170 range, with
adjustment of sliding scale and insulin in her TPN. Once her
tube feeds were started on POD#5, however, she was noted to have
elevated FSBG to 430; ___ was consulted at this time, with
recommendations to provide longer-acting insulin. She was placed
on 24 units of glargine in the morning with more aggressive
insulin sliding scale. Her blood sugar decreased appropriately.
Her blood sugars were in the ___ and she was started on IV
fluids with dextrose while she was not eating. This was stopped
prior to discharge and her blood sugars were 100-200s.
Hematology: The patient's complete blood count was examined
routinely; her post-operative hematocrit was noted to be 25.5
for which she received two units of blood with appropriate
response. However, she was noted to be mildly tachycardic to the
low 100s with symptoms of dizziness, and was transfused again
for a hematocrit of 27, which was stable, with an appropriate
response to 32.6. Her hematocrit was stable at 32.8 upon
discharge, with no evidence of bleeding. Her platelet count was
stable at 148.
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. Her nausea had improved. The patient
was tolerating po intake, ambulating, voiding without
assistance, and pain was well controlled. The patient received
discharge teaching regarding tube feeds and PICC line care and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. She will be seen by ___
tomorrow for further management of her tube feeds and PICC line.
She will follow-up with Dr. ___ in clinic.
***. | STOMACH ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Brief Hospital Course:
___ is a ___ yo M with a past medical history of
HepC, IVDU , currently incarcerated who presented with R arm
weakness since ___. He was brought to the ER where acute
imaging was obtained. A Non contrast head ct was obtained and
showed a hypodensity in L corona radiata some of the L
precentral gyrus, CTA showed concern for transverse sinus
thrombosis. CTA also shows 8 mm L ICA aneurysm. His exam on
admission was notable for R arm weakness, decreased sensation to
pinprick. He was admitted to the stroke team for further
management and work up:
#Acute R arm weakness secondary to venous sinus thrombosis:
-The patient was admitted to the stroke service where MRI was
completed. MRI showed:
a subacute L frontoparietal infarction likely due to
compression from cortical vein thrombosis. CTA and MRI showed L
transverse venous thrombosis and sagittal venous sinus
thrombosis. No clear explanation for a venous sinus thrombosis.
-The patient had an extensive hypercoaguable work up and was
initiated on a heparin drip (gtt, no bolus, stroke protocol goal
PTT 50-70).
-Hematology/oncology was also consulted
-The patient was treated with heparin gtt. Bridging to Coumadin.
His INR on discharge was 1.9
#Fever:
- Patient febrile to ___ F on ___.
- Blood cultures and urine culture negative. TEE was complete
and negative for any source of vegetation.
-CT abdomen showed possible evidence of acute cholecystitis
- Treated empirically with ceftriaxone, flagyl, vancomycin for 7
day course to complete after last doses on ___.
- no further fevers or symptoms
#Pulmonary embolism - bilateral PEs seen on CTA. No R heart
strain on TTE.
- treated with heparin gtt bridged to Coumadin, will need
Coumadin indefinitely and to be discussed with hematology
oncology
#Hypercoagulable state - still uncertain etiology
- CT Torso did not show obvious mass concerning for malignancy
- Beta-2 glycoprotein negative. Anti-cardiolipin pending.
#Acute cholecystitis seen on CT abdomen :
-CT obtained when patient was febrile. Acute cholecystitis on CT
abd and abd US - patient afebrile and
not symptomatic. General surgery was consulted, however given
that the patient was asymptomatic, they did not think the
cholecsytitis was acute nor did it need intervention. Patient
tolerating PO diet well without symptoms
Chronic issues:
#Multi-substance abuse
- patient with history of active IVDU with heroin. Also uses
cocaine, fentanyl, marijuana, Xanax illegally
- No withdrawal symptoms seen except for frequent night sweats.
-was written for Ativan prn 0.5mg Q8hours for anxiety.
Transitional Issues:
[] check INR daily to adjust Coumadin dose, please overlap
heparin and Coumadin for 48 hours once Coumadin is therapeutic.
Will need Coumadin indefinitely. INR goal 2.0-3.0.
[] complete IV antibiotics; last day ___
[] Follow up with hematology, appointment to be scheduled by
calling ___.
[] Follow up anti-cardiolipin ab (still pending)
[] Follow up with neurology (scheduled ___ at 8 AM)
[] ___ need resources for substance abuse vs possible rehab
referral
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. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - (x) No. If not, why not? Therapeutic
anticoagulated.(I.e. bleeding risk, hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 122) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL
>70, reason not given: Stroke caused by compression from venous
thrombosis
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? (x) Yes - () No [reason
() 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?
() Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? () Yes - (x) No [if LDL >70,
reason not given: Stroke caused by compression from venous
thrombosis
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A
***. | INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION 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.
***
All conversations with the patient were done with the aid of a
___ translator. Social work and case management were
involved in this patient's care given his undocumented status.
Patient was arranged to have medical follow up through
Healthcare Net.
Mr. ___ is a ___ year-old male with no ___ medical history
who presented after arrest for disorderly contact. Found to have
tachycardia of unclear etiology in the emergency department (ED)
and admitted to medicine.
.
#. Tachycardia-The patient was initially brought to the hospital
after a "shaking episode" in jail which is described below. In
the ED, he was noted to have a blood alcohol level of 267 and
was agitated. He was given 1mg of lorazepam and given time to
reach sobriety. Upon reaching his baseline mental status, the
patient was noted to be tachycardic. ECG showed sinus rhythym.
Tox screen only (+) for alcohol. Received IV fluids without
change in his heart rate which was ~110 at baseline but would
spike to ~140 intermittently. The changes in heart rate occured
even while the patient was asleep or resting comfortably. He
was admitted to medicine. On the floor, the patient was
connected to telemetry and a repet ECG was performed again
showing sinus rhythym. TSH was normal. Overnight, the patient
continued to have HR intermittently into the 140s although was
asympotatic. Seen by electrophysiology the following day who
agreed that this was sinus tachycardia and recommended further
work-up, including echocardiogram and holter monitoring, as an
outpatient. The patient remained without complaint and was
discharged on HOD #1. has an appointment with Dr. ___
(___) for ___.
.
#. Intoxication/disorderly behavior-The patient denies a history
of alcohol abuse and reports that this episode was only the
second time he has consumed alcohol. On this occasion, he drank
alcohol purchased by a friend from work and became intoxicated.
Reports only drinking 3 beers. After this alcohol consumption
he was disorderly and swung his belt at a police officer. In the
ED here his blood alcohol level was 267. He became sober in the
ED. Was tachycardic over the next day but no other signs of
alcohol withdrawal. Social worker called regarding substance
abuse and counseled the patient. Patient was discharged from
police custody on HOD #1 but will need to appear in court.
.
#. "Shaking" episode-The patient had an episode of "shaking" at
the police dept. Unclear if this was a seizure episode (had
seizures as a child) vs. effects of EtOH vs withdrawal. Blood
sugar was normal here. No further episodes while in-patient and
can be evaluated further with his PCP.
.
#. Undocumented ___: The patient is an undocumented
immigrant without insurance. Given minor status may be able to
obtain mass health coverage per social work. Social work has
been in-touch with the patient since discharge and will attempt
to enroll the patient in a suitable plan. If unable, patient
has information to follow-p at the ___ (___
___).
***. | ALCOHOL DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
*** M ___ DM, ___, nephrotic/nephritic syndrome, h/o liver
abscess ___ cholecystitis s/p open cholecystectomy (___),
presenting from an OSH with sepsis and vague RUQ abdominal pain
found to have strep viridans bacteremia - concerning for
infected RUQ fluid collection vs viral illness.
#Sepsis: prior to admission, pt reported x1 day high grade
fever, nausea, vomiting, and vague RUQ abdominal pain. He
presented to an OSH, had CT torso showing pneumobilia, small
fluid collection around porta hepatis, and pulmonary edema, and
received IVF and antibiotics prior to transfer to ___. On
transfer, his lab work was concerning for transaminitis and ___.
Given concern for cholangitis he was evaluated by Transplant
Surgery who felt his presentation was not consistent with acute
surgical pathology. He was started on unasyn. Blood cultures
grew x1 bottle strep viridans. ID was consulted for further
management and evaluation for source control - he was continued
on unasyn x1 week with significant improvement and transitioned
to augmentin on discharge.
#Transaminitis: at OSH pt had normal LFTs, however on admission
had AST/ALT in 400s with normal tbili. Exam with RUQ TTP. DDx
included acute viral hepatitis vs ischemic hepatopathy vs
obstructive process vs sepsis vs medication induced vs
congestive hepatopathy. RUQ U/S without evidence of obstruction
or mass. Tylenol, tox screen, hepatitis serologies, monospot,
flu negative. Likely ___ hypotension from sepsis. His LFTs were
monitored and downtrended.
___: baseline Cr 1.8, elevated to 2.8 on admission. Concern for
pre-renal etiology in setting of sepsis. His lasix/lisinopril
were held. He received gentle IVF hydration. His Cr was
monitored and downtrended. He was restarted on lasix/lisinopril
prior to discharge.
# HFpEF:
Acute on Chronic diastolic CHF exacerbation, LVEF >55%. Patient
with evidence of worsening volume overload, including CXR from
OSH with pulmonary edema. In the setting of bacteremia an ECHO
was obtained which showed preserved EF, signs of diastolic heart
failure and elevated PCWP without evidence of vegetations.
TRANSITIONAL ISSUES:
[] Antibiotic course: augmentin 875mg BID x14d (last day ___
[] Discharge weight: 138.7kg
[] Lasix 40mg daily on discharge
[] Small lesion in pancreatic head measures 5mm; should have
MRCP in x6mo to further evaluate
[] Right apical lung nodule measures 1.1cm - RECOMMENDATION(S):
Repeat CT chest in ___. If it is stable, no additional
follow-up needed.
[] please re-check CBC on PCP follow up visit. Hg 7.1 on
discharge.
[] Concern for pulmonary artery hypertension on TTE -> will need
Pulm follow up as outpatient
# CODE STATUS: Presumed Full
# CONTACT:
Name of health care proxy: ___
___: wife
Phone number: ___
Cell phone: ___
***. | 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.
***
PATIENT SUMMARY
============================
Mr. ___ is a ___ yo man with a history of
HBV cirrhosis (negative delta agent) s/p TIPs ___ who
presented
with 3 days of confusion and chest pain, found to have
transaminitis with T bili of 3.9 thought to be associated with
TIPS procedure.
ACUTE ISSUES
============================
#Hyperbilirubinemia
#Transaminitis:
#Hepatitis B Infection
Mr. ___ was noted on admission to have hyperbilirubinemia to
3.9 and transaminitis to AST 93 ALT 48. Given hx of Hepatitis B
cirrhosis, acute onset of encephalopathy
with transaminitis, hyperbilirubinemia, and INR 1.5 considered
likely due to hepatic
injury ___ TIPS placement vs hepatitis B flare. There was loow
suspicion for
acute cholangitis given absence of fever, leukocytosis, RUQ
tenderness, ductal dilation on US, or direct hyperbilirubinemia.
Doppler US on admission revealed no evidence of PVT. There was
low suspicion for hepatic
congestion ___ HF post-TIPS given absence of dyspnea or
orthopnea
and euvolemia on exam, and TTE on ___ showed normal EF,
ventricular function, and valvular function. Given transaminitis
w/indirect hyperbilirubinemia on
fractionation, appears ___ to hepatic injury rather than
cholestasis, likely multifactorial from recent TIPS and known
Hepatitis B not on antiviral therapy. During recent
hospitalization at ___ (___), hep B DNA
>1,000,000 and positive core antibody and surface antigen c/w
chronic active Hep B. Hep C negative at that time. Given
decompensated cirrhosis with known Hep B viral load ___ in
recent
hospitalization and not on treatment, initiated antiviral
therapy
with tenofovir disoproxil fumarate 300mg PO on ___. HBV VL
while here 3.5 prior to initiation.
#Confusion/HE: The patient with confusion consistent with
hepatic encephalopathy, given known
cirrhosis s/p TIPS and asterixis on admission. Head CT on
admission was negative,
with no focal deficits noted on exam. HE improved with lactulose
and
rifaximin, with resolution of asterixis and patient subsequently
alert and oriented to person, place, and location.
#Chest Pressure: The patient presented with non-exertional
non-radiating central chest
pressure for three days. He was assessed to be intermediate-risk
for CV disease (male, smoker, HTN, age ___, no known CAD, DM,
HLD,
CKD, obesity, or family hx), with low suspicion for ACS given
non-exertional CP persisting for three days, cardiac enzymes
negative x2. EKG with ST-depressions, bradycardia (baseline HR
unclear). Symptoms were more likely secondary to GERD or
musculoskeletal pain, and resolved spontaneously. Please arrange
for outpatient stress test as able.
#HBV Cirrhosis: The patient has a history of chronic Hepatitis B
cirrhosis (MELD-Na 17,
___ C) decompensated by portal hypertension s/p TIPS,
ascites, hepatic hydrothorax, hepatic encephalopathy, grade 2
esophageal varices (last EGD ___ at ___), and anemia,
not
on antiviral therapy, and presented this admission with acute
decompensation in the
setting of likely Hepatitis B flare. He has no known history of
SBP or
HRS. Patient recently hospitalized from ___ to ___ at ___
with melena and pancytopenia, with EGD revealing large
esophageal
varices, started on nadolol. TIPS successfully placed and
patient
referred to liver clinic. Diagnostic paracentesis negative for
SBP, completed 5 days of empiric ceftriaxone. Patient presented
this admission with
encephalopathy, no evidence of ascites or GI bleeding. As the
patient
was s/p TIPS and w/o evidence of ascites or volume overload,
home nadolol and diuretics were discontinued.
#Hepatic Nodules: Abdominal US on admission revealed multiple
hepatic hypodensities, although poor quality study, c/f hepatic
nodules. He underwent a triphasic CT that did not show any
lesions concerning for HCC. His AFP was normal.
#Pancytopenia: Initially diagnosed during hospitalization at
___ from ___ to ___, likely secondary to splenic
sequestration
and chronic cirrhosis. Stable on admission.
TRANSITIONAL ISSUES
===================
- Held nadolol, diuretics as s/p TIPS, no evidence of volume
overload on exam.
- Discharged on lactulose/rifaximin. ___ require PA of
rifaximin.
- Started on Hep B treatment with Tenofovir. HBV VL 3.5 prior to
initiation.
- Please consider arranging for outpatient stress test as needed
if ongoing chest pain/pressure.
- Pending autoimmune, Hep D serologies on discharge.
***. | 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.
***
Mr. ___ is a ___ with left hip replacement ___, and MM
s/p matched related donor allogeneic SCT (D0 ___ c/b
PTLD, persistent disease on Revlimid who presents from ___
___ for SOB found to have deep left extremity
DVT and possible PE.
# DVT/PE:
He had DVT seen on ___, and was transferred on heparin gtt.
Repeat ___ showed interval improvement with decrease in size of
previously seen DVT. VQ scan indeterminate. He was continued on
heparin drip for DVT and presumptive PE, and transitioned to
Lovenox prior to discharge. He has several risk factors for
thrombosis including multiple myeloma on lenalidomide and recent
hip surgery. He will likely need anticoagulation as long as
malignancy active and when it is not, will need to discuss the
benefits and risks of anticoagulation thereafter.
# PNA:
He was also noted on previous CXR to have LLL infiltrate
concerning for pneumonia. CT chest was also concerning for
retrocardiac consolidation. He was continued on levofloxacin
with plan for extended course to be determined at outpatient
followup.
# Multiple myeloma:
With regard to his multiple myeloma, he is S/P matched related
donor alloSCT (D0 ___, c/b PTLD treated with Velcade and
Rituxan with treatment stopped after four cycles due to
neuropathy. DLI on ___. In ___ noted rising free
light chain, started on Revlimid maintenance. We resumed
lenalidomide during this admission (had been briefly held in
setting of acute PE).
CHRONIC ISSUES:
# Zoster, post herpetic neuralgia:
Continued pain regimen.
# Infection prophylaxis:
Continued Valtrex, fluconazole prophylaxis
# Low IgG:
Regular IVIG, Neupogen and blood products at baseline.
#GVHD:
Chronic w/ mucosal and skin involvement. Continued prednisone.
Continued dexamethasone oral rinse.
#CKD III, Anion gap metabolic acidosis:
Creatinine 1.8 near or slightly above baseline. History of
cidofovir RTA. Continued sodium bicarb tabs.
#HTN:
Continued amlodopine and metoprolol.
TRANSITION ISSUES:
- He will continue levofloxacin with length of course to be
determined at outpatient follow-up for treatment of
healthcare-associated pneumonia.
- He had fungal markers (beta-glucan, galactomannan) which were
pending at time of discharge and will require follow-up
***. | PERIPHERAL VASCULAR 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 surgical service on
___ and taken to the OR for irrigation and debridement of right
hip, with revision of cement spacer. Please see separately
dictated operative note by Dr. ___ details of this
procedure. Postoperatively, pt was extubated and transferred to
the PACU, and remained afebrile.
N: Pain appropriately controlled, initially with IV and then
transition to PO pain medications.
CV: Vital signs were routinely monitored; the patient remained
hemodynamically stable.
P: There were no pulmonary issues.
GI: The patient tolerated a regular diet postoperatively
GU: Foley catheter was removed POD2, and the patient voided
without issues postoperatively.
ID: The patient was continued on ceftriaxone and vancomycin;
vancomycin dose decreased from vanc trough of 23 on POD1. She
was further decreased to 750 mg BID for a trough of 24.4 on
POD4. OR cultures showed negative gram stain and no growth to
date. Her drains were removed on POD3. Her dressings remained
dry post-drain removal.
Heme: The patient's lovenox was initially held postoperatively
given initial wound drainage upon presentation. She was
transitioned to Aspirin 325 mg. Patient received 2u PRBC upon
admission (in the ED), 2u PRBC intraoperatively, and 2u PRBC
postoperatively.
Endo: home metformin; SSI.
MSk: The patient was continued with toe touch weight-bearing on
the operative extremity with posterior precautions and with
crutches or walker. The overlying surgical dressing was changed
on POD#2; wound remaiend clean and dry without erythema or
abnormal drainage.The patient worked with Physical Therapy daily
postoperatively.
The patient was monitored for several days postoperatively for
signs of infection or surgical bleeding. However, wound remained
clean and dry and thigh remained soft, with stable hematocrit.
At the time of discharge, the patient was afebrile with stable
vital signs and good pain control; the operative extremity was
neurovascularly intact. The patient will follow-up in
___ clinic.
***. | HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with hx of hypercholesterolemia who presents with chest
pain, found to have an NSTEMI. Underwent successful PCI with a
drug-eluting stent placed in the first obtuse marginal.
ACUTE ISSUES
============
#NSTEMI
#CAD
Patient presented with multiple episodes of substernal chest
pain, back pain, jaw aching, and diaphoresis. Found to have an N
STEMI with troponin peaking at 1.76. Patient was started on a
heparin drip, aspirin, Plavix, and metoprolol tartrate 12.5 mg
every 6 hours. She was previously on atorvastatin which she self
discontinued due to joint pains. This was restarted at 40 mg
daily. Underwent cardiac cath on ___, which showed 90%
stenosis of the proximal segment of the first OM. A drug-eluting
stent was placed with 0% residual stenosis. There was also 30%
proximal LAD stenosis. Heparin drip was discontinued after
catheterization. Echocardiogram was obtained post-cath, and
revealed preserved ejection fraction and no regional systolic
wall motion abnormalities.
CHRONIC ISSUES
==============
# Hyperlipidemia
Restarted atorvastatin at 40 mg daily, as above
TRANSITIONAL ISSUES
===================
-CARDIAC MEDICATIONS: Aspirin 81 mg, Plavix 75 mg, atorvastatin
40 mg, metoprolol succinate 25 mg daily
[ ] Patient previously described joint pains while taking
atorvastatin. She was restarted on atorvastatin at 40 mg daily
during this admission with no symptoms. Consider increasing
atorvastatin to 80 mg daily if LDL is not less than 70.
[ ] Please ensure the patient continues to take her aspirin and
Plavix every day to prevent in-stent thrombosis.
[ ] Patient should follow-up with her new cardiologist, Dr.
___.
***. | PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
This is a ___ year old female with a past medical history of
active intravenous drug use and new diagnosis of hepatitis C who
was transferred with TV endocarditis (MRSA) for concern for
spinal abscess.
#MRSA TV endocarditis
#MV endocarditis:
She had MRSA tricuspid valve endocarditis ___ the setting of
IVDU. A transthoracic echocardiogram at her previous hospital
showed a vegetation (6x3 mm on TV) and blood cultures were
significant for MRSA. She was last culture positive on ___.
She had her PICC replaced because it was placed prior to a
positive blood culture. Given evidence of left-sided septic
emboli (see below) a TEE was completed on ___ which showed a
moderate-sized (0.6 x 0.2cm) mobile echodensity of the mitral
valve most consistent with a vegetation/endocarditis without
evidence of mitral valve abscess is seen, ___ addition to mild to
moderate (___) mitral regurgitation. ___ also demonstrated a
1.1 x 0.2cm mobile echodensity of the tricuspid valve most
consistent with vegetation/endocarditis, without evidence of
abscess, as well as moderate [2+] tricuspid regurgitation.
Cardiac surgery was consulted and did not recommend operative
management. She was continued on vancomycin on admission and she
will receive this through her PICC to complete a minimum of a 6
week course on ___.
#Epidural abscess
#L3-L4 facet joint infection:
MRI L-Spine on ___ showed an ill-defined 2.3 x 1.0 cm
posterior epidural collection at L3-L4, concerning epidural
abscess. Patient underwent successful drainage of L3/L4 facet
joints on ___ growing 4+ leukocytes and 4+ gram positive
cocci ___ pairs and clusters and singly. Given persistent back
pain during patient's hospitalization, repeat MRI on ___
revealed infection of the L3-4 facet joints, similar ___
appearance to prior imaging. Orthopedic spine recommended no
operative management at this time and to follow up ___ clinic ___
6 weeks on an outpatient basis. For pain, she was continued on
methadone (see below) and PO dilaudid. She was transitioned to
standing Tylenol and oxycodone 5 mg PO Q6H prn on day prior to
discharge for pain control, which she tolerated well.
#CVA with likely cerebritis from likely embolic source:
Initially noted to left-sided weakness ___. Neurological
assessment revealed ___ left-sided UE and ___ weakness with
sensation to pinprick diminished on left lateral forearm. Due to
these new findings, a brain MRI was obtained on ___ (Required
sedation for MRI given anxiety) showing possible cerebritis and
early abscess formation after septic embolus and infarction.
Subsequent CTA of head/neck on ___ revealed no evidence of
abscess formation or mycotic aneurysm, ___ addition to multiple
predominantly peripheral pulmonary nodules some with central
cavitation, concerning for septic emboli. Workup revealed
triglycerides: 241, HDL: 27, CHOL/HD: 5.3, LDL calc: 68. Hg A1C:
4.6%. Patient should avoid therapeutic anticoagulation given
infarction.
#Septic pulmonary emboli:
Given findings on CTA head/neck on ___ (see above), CT Chest
on ___ revealed numerous pulmonary nodules, many of which
were cavitary, compatible with cavitary septic infarcts versus
abscesses. Per radiology, these pulmonary emboli were not
amenable to drainage and patient was continued on antibiotics as
above.
#Acute on chronic kidney disease:
She presented to her previous hospital with an creatinine to 2.6
with unknown baseline. Her creatinine was 1.4 on transfer. She
had a renal US (___) without evidence of abscess or emboli and
a FeNa (___) was 0.88%, initially consistent with pre-renal
etiology due to poor PO. However, Cr remained elevated to
1.6-1.7 during hospitalization and repeat FeNa on ___ was
2.5%, suggesting intrinsic renal pathology cause. Vancomycin
troughs were monitored regularly during hospitalization and ___
coordination with pharmacy, was recommended to continue dose at
500 mg IV Q24H.
#Heroin abuse
Patient had ongoing IVDU up until admission which worsened ___
the setting of her mother's death. The atient was receiving
methadone prior to transfer. She was restarted on methadone 20
mg qd while here, which was down-titrated to 15 mg daily prior
to discharge.
#Hepatitis C virus:
She had positive serologies prior to transfer here. Her LFTs
were normal and she had an undetectable viral load.
#Chronic obstructive pulmonary disease:
The patient carries this diagnosis, but she is not on any
medications. She says she takes advair and Spiriva from ___
___, but she has not had any medications filled for quite
some time. She was treated with albuterol q4h PRN or wheezing.
TRANSITIONAL ISSUES:
==================
-Please schedule a follow up appointment with primary care
provider within ___ week after discharge from hospital:
Name: ___.
Location: ___
___
Address: ___, ___
Phone: ___
Fax: ___
-Patient will follow up with ___ clinic at ___ as outpatient;
please ensure CBC with differential, BUN, Cr, AST, ALT, CRP, and
vancomycin trough levels are drawn weekly and faxed to
___
-patient will require follow up with Orthopedic Surgery with
repeat MRI L-Spine ___ ___ weeks to ensure resolution of L3-L4
facet joint infection.
-New medications: Methadone 15 mg qd, vancomycin 500 mg IV Q24H,
and naloxone. Please consider up-titration of methadone as
needed to achieve pain control.
-Antibiotic course: She will take vancomycin for through
___.
-Cr level at discharge: 1.6
-CODE: Full code
-CONTACT: ___ (brother) ___
***. | BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
SUMMARY:
======================================================
___ hx light chain MM, CKD stage IV, recent urosepsis
presenting with hypotension and recent urine cx with VRE, c/f
complicated UTI vs urosepsis. He was treated with IV daptomycin
with resolution of the UTI. He was also found to have RCA
distribution hypokinesis which was managed medically.
ACUTE ISSUES:
======================================================
#Hypotension
#VRE UTI
On ___ a surveillance urine culture was obtained outpatient
which subsequently grew VRE(E. faecium) sensitive to linezolid
and tetracyclines. Although the patient did not have urinary
symptoms or fever, he was treated with IV daptomycin given his
risk factors including immunosuppression from his MM as well as
obstructive uropathy requiring straight cath multiple times
daily. Additionally, he was noted in clinic to have hypotension
to the ___ which was concerning for sepsis given his
positive urine culture. He subsequently remained normotensive in
the ED and throughout his hospital stay with the exception of
orthostatic vital sign testing. A culture was drawn in the ED a
few hours after receiving his first dose of daptomycin on ___
which showed no growth. Daptomycin was thus discontinued on
___ (he only received 1 dose as an inpatient). He remained
afebrile without urinary symptoms after discontinuation of
antibiotics.
#Light chain multiple myeloma
He is status post 4 cycles of ixazomib/dex and 1 cycle of
pomalidomide/dex. The patient is currently in cycle 1 of
daratumumab/pomalidomide/dex. His ___ chemotherapy was hold
given his VRE UTI. Light chains on admission showed improved
kappa/lambda ratio compared to 1 week prior. He was continued on
his prophylactic regimen of acyclovir and atovaquone as well as
Lovenox for DVT prophylaxis. He will follow up with Dr. ___
___ on ___ for continuation of his chemotherapy regimen.
#Chronic exertional dyspnea
#RCA distribution hypokinesis
The patient describes ___ year of worsening exertional dyspnea and
generalized fatigue without orthopnea, PND, or chest pain. He
walks with a walker at baseline. Although his CXR showed no
acute intrathoracic process, a TTE was performed and showed new
inferior posterior hypokinesis with reduced EF (45%) compared to
a prior echo in ___. Cardiology was consulted and
recommended nuclear stress testing which the patient underwent.
This showed reversible, medium sized, moderate severity
perfusion defect involving the RCA territory as well as mild
systolic dysfunction with normal LV cavity size. Based on the
patient's comorbidities and patient preference, the decision was
made to continue with medical management, namely ASA 81mg, high
dose atorvastatin 80mg, and the patient's home metoprolol.
Ultimately he likely has a component of both cardiac amyloidosis
and ischemia contributing to his cardiac dysfunction. He was
discharged with plan to follow up with his cardiologist, Dr.
___. Of note, he is on a regimen including pomalidomide which
is associated with an increased risk of cardiovascular events.
CHRONIC ISSUES:
======================================================
#Chronic kidney injury stage IV ___ obstruction (BPH)
On admission the patient's creatinine was 2.6 which is his
approximate baseline. He was continued on his home medications
of sevelamer carbonate, sodium bicarbonate, and sodium chloride.
He continued to straight cath as needed.
#Orthostatic hypotension
He was continued on his home fludrocortisone and midodrine.
Orthostatic vital signs were performed and were positive x2. The
patient denied dizziness and had no falls during
hospitalization.
#Atrial fibrillation
He was continued on his home metoprolol and warfarin. He was
subtherapeutic with INR 1.3, and his warfarin was increased
accordingly. He was discharged on 4mg daily.
#Chronic anemia
His hemoglobin was 8.5 on admission, which appears to be his
baseline. He remained stable.
#Depression
His home paroxetine was continued.
TRANSITIONAL ISSUES:
======================================================
[]New medications: ASA 81mg daily, atorvastatin 80mg daily
[]Needs Neurology follow-up for possible ___
syndrome/dysarthria
[]Will follow up with Dr. ___ new RCA territory
hypokinesis on stress testing
[]Will need ongoing conversations between Cardiology/Oncology in
terms of optimization of his chemo regimen given risk of CV
events with pomalidomide
***. | 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.
***
The patient with incarcerated ventral hernia was admitted to the
General Surgical Service for laparoscopic ventral hernia repair.
On
___, the patient underwent primary reduction and repair of
incarcerated ventral hernia with mesh, 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, on IV fluids and pain killer for pain control. The patient
was hemodynamically stable. The patient was abdominal binder in
place. The patient received subcutaneous heparin and venodyne
boots
were used during this stay. 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 stage 3 bariatric
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
***. | HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL 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 is a ___ year-old male with history of ETOH abuse who
presents with massive hematemesis and melena (thought to be
secondary to a bleeding gastric varix, banded at OSH) and
alcoholic hepatitis; his course was complicated by respiratory
failure, alcohol withdrawal, and encephalopathy.
.
# Upper GI bleed: Prior to transfer to ___, the patient had an
EGD at OSH, which revealed an actively bleeding Dieulafoy's
lesion versus gastric varix, which was clipped. Upon arrival to
___, EGD revealed non-bleeding gastric varices with no
esophageal varices. Patient presented with an HCT of 23.2, and
required a total of 10 units of PRBC while in the ICU to
maintain HCT. He was started on protonix and octreotide gtts.
Following EGD, his protonix was changed to 40 mg IV BID and
octreotide was continued for three days. Patient was
administered prophylactic dose of 1g ceftriaxone daily for five
days.
.
The day following the EGD, the patient underwent TIPS procedure
by interventional radiology. This proceeded without
complication, and follow-up ultrasound showing patent vessels.
His HCT remained stable following TIPS procedure ranging between
25 - 27. During his hospital course, he had no further episodes
of GI bleeding. He was discharged home with PO PPI.
.
# Alcoholic Hepatitis/Cirrhosis: The patient presented without a
previous diagnosis, however his elevated INR, bilirubin,
ascites, and spider angioma were consistent with cirrhosis
complicated by portal hypertension. Ultrasound confirmed
findings consistent with cirrhosis, splenomegaly, ascites, and
portal hypertension. The etiology of his liver disease was
believed to be EtOH given the clear history, however given the
patient's young age, he was ruled out for viral etiologies and
autoimmune hepatits. The patient's acute clinical picture and
laboratory findings was consistent with alcoholic hepatitis.
Discriminant Function was approximately 40. This was believed to
be the cause of his persistent leukocytosis and low-grade fevers
throughout hospital course. At the time of discharge, his
bilirubin was 9.1.
He underwent TIPS procedure sucessfully, pressures improved from
16 to 12. He was started on lasix and aldactone following his
ICU course. He was discharged with lasix 40 mg and
spironolactone 100 mg, to be further titrated with outpatient
follow-up. He was also prescribed rifaximin to be taken as an
outpatient.
.
# Altered mental status/encephalopathy: Believed to be
multifactorial; contributions included hepatic encephalopathy,
delirium (ICU) and EtOH withdrawal. Patient's hepatic
encephalopathy was treated with lactulose and rifaxamin. He was
frequently reoriented and had tethering minimized. For evidence
of alcohol withdrawal, he was administered ativan as necessary.
Patient remained ___ when discharged from ICU, though improved
to A+Ox3 over subsequent days with above interventions. As the
patient's acute encephalopathy improved, he was observed to
display underlying cognitive impairment, characterized by
extensive confabulation despite good attention and orientation.
There was suspicion of underlying Wernicke's
encephalopathy/Korsakoff's due to patient's long-term alcohol
intake. Psychiatry evalauted the patient, but did not find
evidence of Wernicke's/___ towards the end of his hospital
course. He was discharged with MVI/thiamine/folate
supplementation. He will follow-up with outpatient Neurology.
.
# Seizure: Believed to represent withdrawal seizure, as
patient's family provided history of prior seizures in setting
of alcohol use. Seizure occurred approximately ___ days
following last alcoholic drink. No clear medications or
electrolyte abnormalitites were implicated as cause. He was
placed in restraints temporarily, though these were removed the
following morning. He was continued on low-dose Ativan for
alcohol withdrawal with no further seizures. He will follow-up
with outpatient Neurology.
# Hypoxic Respiratory Failure: On hospital day 4 of admission,
patient became acutely hypoxic and a respiratory code was
called. There was concern for aspiration event in the setting
of benzodiazepine use. Patient was intubated. Patient
sucessfully extubated the next day when his condition improved.
He completed a seven day course of vancomycin/zosyn as below.
.
# Fever/Leukocytosis: Patient spiked fever to 100.4 on ___ with
cough and increased abdominal distension; aspiration PNA and SBP
were both on differential. Patient underwent paracentesis, which
was was grossly bloody and showed Hgb of 9 with elevated WBC and
polys. Patient was started on vancomycin and zosyn for HCAP and
SBP coverage (though he did not strictly meet criteria for SBP
when ascites sample corrected for HCT) and recived 75 g of
albumin on days one and three of treatment. After seven days of
treatment, antibiotics were discontinued. Subsequent fevers were
attributed to ongoing alcoholic hepatitis. All urine, blood, and
peritoneal cultures showed no growth.
.
# Disposition: Goal of disposition was inpatient alcohol
treatment facility. This was unable to be coordinated given
patient's insurance status. He was discharged home under his
parents' supervision, and will initiate an intensive outpatient
alcohol treatment program at the beginning of ___.
***. | 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.
***
MICU Course ___
===========
#DKA
Upon admission to the MICU she had a BG of 260's, HCO3 16,
+Ketones and Glucose in urine, K+ 5.0, and pH of 7.32. She was
started on DKA protocol with insulin gtt, ___ NS and K+
repletion. Her anion gap closed and she was transitioned to SQ
insulin with ___ following. Insulin drip was stopped at ___. SQ insulin regimen: Humalog 3 units @ Breakfast, Humalog 3
units @ Lunch, Humalog 3 units @ Dinner, Glargine 22 units @
Bedtime, with Humalog SSI with meals. Upon transfer her BG 152,
and K+3.6
# Seizures
Had two events concerning for GTC seizures. Unclear etiology but
potential triggers could be dehydration, DKA, and labile BG. She
was afebrile with no leukocytosis and no evidence of
meningismis. Urine tox was positive for opiates but negative for
other substances. Porphobilinogen urine scree was negative.
Neurology was consulted and recommended brain MRI w and w/o
contrast and possibly outpatient EEG. During MICU admission she
did not have any recurrence of seizure like activity. At time of
transfer heavy metal blood screen was pending.
# Abdominal pain/N/V: Had very extensive workup as outpatient
including abd US, CT, HIDA, MRCP, EGD, gastric emptying study,
and a cholecystectomy. She was diagnosed with H. pylori and
gastroparesis. She was started on reglan TID and Zofran which
helped nausea, but abdominal pain remained an issue throughout
MICU admission. Her abdominal exam remained reassuring with no
peritoneal signs. Pain was difficult to controlled with
hydromorphone and acetaminophen.
# Thrombocytopenia: Plt 120 upon admission which is a new since
prior ___ visits. Possibly due to dilution in setting of fluid
resuscitation. Upon transfer her plt were 144.
The patient is a ___ yo female with a PMHx of IDDM,
Gastroparesis, and H. Pylori with chronic abdominal pain,
nausea/vomiting who was transferred from an OSH to the ___ ICU
after an episode concerning for seizure vs. syncope and was
found to have DKA. Following the resolution of her DKA, the pt
developed worsening abdominal pain likely secondary to
gastroparesis flare in the setting of poor glycemic control.
During her hospitalization, the pt was seen by GI, who
recommended a combination of standing and PRN antiemetics and
bowel motility agents as follows: Metoclopramide, Ondansetron,
Compazine, and lorazepam, as well as a GI cocktail and bowel
rest. The pt's symptoms improved, and her diet was advanced to
clears on ___. She tolerated clears well, however decided to
leave against medical advice on ___. The risks of leaving
were explained thoroughly to the patient, and she expressed good
understanding of these risks. The problems assessed in the
hospitalization are outlined below:
#Gastroparesis:
#Nausea
#Worsening abdominal pain: Likely gastroparesis flare in setting
of DKA. No exam or lab findings concerning for acute
intra-abdominal process. Pain and nausea were resistant to
medical treatment, and patient was without enteral nutrition for
nearly a week. Pt was dependent on IV hydration during this
time. The patient repeatedly voiced a desire to leave AMA
despite acknowledging the risks of dehydration and recurrent
hyperglycemia. GI recs appreciated for pain control, with
intermittent improvement, though worse today, though agreed to
stay until the afternoon of ___. Per GI recs, patient was
started on a regimen of Zofran, reglan, Compazine, Ativan for
nausea, IV Tylenol and a GI cocktail for pain, and an aggressive
bowel regimen. After improvement on this regimen, diet was
advanced to clears on ___ which were tolerated well. Despite
clear understanding of risks, pt decided to leave AMA on ___.
# Concern for seizure - Seizure vs syncopal episode with
seizure-like activity in the setting of DKA and dehydration. MRI
head was obtained, but was incomplete and not conclusive, though
did not display abnormality. Seen by neurology, but deferred
seizure workup to be completed as an outpatient. Will recommend
neuro follow up as outpatient.
# DKA - Resolved after short ICU stay. ___ consulted for
diabetes management. Recommend close follow up with ___, or
current endocrinologist for insulin plan moving forward.
TRANSITIONAL ISSUES:
- Patient was known to be hypokalemic, and repleated with 60mEq
prior to leaving AMA: Please f/u K at first follow up
- Please check BMP at first follow up appointment
- Please discuss PO intake and glycemic control plan at first
follow up
- Please discuss plan for inability to tolerate PO. Patient
failed conservative measures and may ultimately require invasive
measures for enteral nutrition (NJ tube, percutaneous
jejunostomy, etc)
- Consider EEG as suggested by inpatient neurology team
- Full, presumed
***. | DIABETES 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.
***
UGIB/BLOOD LOSS ANEMIA:
He was resuscitated with crystalloid and 2 units of PRBC's. EGD
showed erosions with stigmata of recent bleeding. Biopsies were
obtained, and cultures sent for H.pylori, and a gastrin level
was sent. Based on the EGD findings and subsequent history, it
is believed that this is related to alcohol binging in the
setting of amoxacillin induced gastric irritation. He is
scheduled to return for repeat endoscopy and review of lab
results.
***. | 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.
***
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right ankle fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for right ankle ORIF, 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 home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non weight bearing in the right lower extremity, and will be
discharged on aspirin 325mg for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
***. | LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP FOOT AND FEMUR WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
# Acute hepatitis: LFTs still elevated (800+) but trending down.
No current evidence of encephalopathy. No HTN or hemolysis labs
to suggest HELLP. Tylenol level was negative here which is less
indicative of acetaminophen toxicity but given patient taking up
to 1g Q2H (total could be 12g/day) this is still possibility.
Liver team was consulted. Pt was treated empirically with NAC
for 3d. Many studies were pending prior to discharge but
patient (and her mother) ensured that they will f/u with Dr. ___
in hepatology. Her INR trended down to 1.1 prior to discharge.
Never encephalopathic.
.
# Pancytopenia: Evidence of trilineage cytopenia suggesting
overall suppression of marrow production. No evidence of
microangiopathic anemia on smear, no evidence of DIC on labs
___ normal, no elevated fibrinogen), no evidence of
hemolysis (haptoglobin normal). Retics low, confirming marrow
suppression
- numbers stabilized.
- thought ___ trileptal, HCV, or underlying liver disease.
- also entertained HIV as possible dx but pt refused HIV testing
a number of times.
.
# Psychiatric: Patient with significant anxiety. Also recent
diagnosis of bipolar and started on Trileptal in past few days.
Patient convinced symptoms of headache, fever and rash at home
are side effects of Trileptal. Also recent (___) inpatient
detox from heroin and cocaine. We asked psych to help with
meds. Held klonopin and used ativan for anxiety given liver
dysfunction. Changed back to klonopin once INR normalized. F/u
with psych outpt program. Pt denied SI or HI.
.
# F/u: with PCP and Dr. ___. Pt's contact info updated on OMR
***. | 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.
***
Ms. ___ was admitted to the hospital, made NPO, hydrated with
IV fluids and started on Unasyn. Her pain was controlled with
Dilaudid. She had an ERCP on ___ which showed a leak at the
duct of Luschka and had a sphincterotomy and a stent placed. She
subsequently underwent ultrasound guided drainage of the biloma
and her pain gradually improved. She had a HIDA scan which did
not show a bile leak.
Although she was improving her pain was still bothersome,
possibly secondary to the drainage catheter. She had an
abdominal CT on ___ which showed no new collections but still
some undrained areas. Her tube was repositioned on ___ and
she remained afebrile with some pain around the drainage tube.
Her antibiotics were switched to oral Augmentin and her diet was
advanced without difficulty. She was discharged to home with
the PTC drain in place and will have a total of 10 days of
antibiotics. She will follow up with Dr. ___ in 1 week and has
an ERCP on ___ for stent removal and if there is no visible
leak the drain will be removed at that time.
She will also have ___ services for drain care and teaching.
***. | OTHER DIGESTIVE SYSTEM 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.
***
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:
POD1: Ms. ___ was found to be mildly hyponatremica to 132 and
a 500cc fluid bolus given along with a 1500 fluid restricted.
POD2: Na improved to 135 with fluid restriction. Remained
asymptomatic. Worked well with ___.
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. The foley was
removed and the patient was voiding independently thereafter.
The surgical dressing was changed on POD#2 and 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.
Patient is discharged to home with services 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.
***
Ms. ___ is a ___ year-old woman with HFpEF (last EF 55-60% in
___, CKD III, CAD s/p CABG, and pHTN, who presents from home
at the request of her outpatient cardiologist/family for
management of her CHF, as well as weakness. She initially
presented to the hospital with volume overload and
___ syndrome. Repeat echocardiogram on ___ shows
progression of mitral and tricuspid regurgitation and further RV
dilation. Given her multiple recurrent admissions for heart
failure palliative care ___. Her age and frailty would make
surgical risk prohibitive. She was diuresed with IV lasix x2
days with good effect initially and her kidney function
improved. She was then transitioned to PO diuretics but became
more overloaded so received one day of IV diuresis with lasix.
The following day, the patient became more weak and lethargic.
She developed ___ with Cr going from 1.0 to 2.5. Diuresis was
held, however her kidney function continued to decline. The
patient continued to have poor PO intake and minimal urine out
put. Palliative care was involved and there was a family meeting
planned for ___. Overnight on ___ the night MD was called
to the bedside as the patient was noted to be unresponsive and
not breathing following transfer from the commode to the bed.
Time of death was 20:40 on ___.
***. | HEART FAILURE AND SHOCK WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is a ___ F with history significant for Crohn's,
lupus, HTN, alcohol use disorder who presents with fall vs
syncopal episode while intoxicated, found to have bilateral
orbital fractures.
ACUTE/ACTIVE ISSUES:
====================
# Syncopal episode: Likely combination of intoxication and
orthostasis given alcohol use and episode that occurred shortly
after standing. Less likely vasovagal given no prodromal or
precipitating factors. Cardiogenic causes also less likely given
no history of significant heart disease, benign exam and normal
EKG, normal echo, and no events on tele.
# Facial trauma:
# Orbital fracture: Evaluated by opthomology and PRS in the ___.
No concern for globe injury, optic nerve injury or entrapment.
No evidence of CSF leak. Plastics reocmmned 7 days abx, so
recieved 3 days kephlex, then switched to augmentin. Sinus
precautions put in place. The patient's pain was controlled with
PO Tylenol, ibuprofen and oxycodone PRN. At time of discharge,
the patient was tolerating a soft diet and her pain was
well-controlled.
# Nondisplaced C5 spinous process fracture: Fracture without
compromise of supporting ligaments suggestive of whiplash
injury. Ortho spine service consulted and recommended a ___ J
collar and close follow-up.
# Incidental ascending aortic aneurysm
# Incidental sinus of Valsalva aneurysm: The patient was
incidentally found to have an ascending aortic aneurysm and
sinus of Valsalva aneurysm. The patient will follow-up with
cardiac and/or thoracic surgery as an outpatient. Goal SBP
105-120.
#HTN: Patient has h/o HTN, likely exacerbated by facial pain
here. Patient's losartan was increased to 100mg and she was
uptitrated to 25BID carvedilol with improvement in her blood
pressures. Given her aortic aneurysm above, will follow-up with
outpatient providers for SBP goal of 105-120.
#Fever
The patient had a one time fever 100.3 F accompanied by sinus
pressure. The patient was started on augmentin for empiric
sinusitis coverage to complete a ___izziness/weakness: Likely residual effects of head injury
from
fall. The patient was evaluated by physical therapy.
# Alcohol use disorder: She received a 300mg phenobarb load at
OSH where she was hypertensive but not tachycardic or agitated.
She was given thiamine, folate, and an MVI. SW was consulted.
Transitional Issues
===================
[] SBP goal 105-120 given her aortic aneurysm. She was initiated
on max dose losartan and carvedilol in house with improvement
but not quite reaching goal. Will likely need additional agent
pending BP check. Patient instructed to monitor BPs at home and
bring to PCP follow up.
[] consider secondary hypertension work up given elevated BPs
despite maximal ___ and carvedilol therapy
[] Augmentin for ___ for orbital fracture
sinus ppx
[] f/u with ophtho in ___, sooner if worsening vision, new
floaters, flashing lights or worsening diplopia
[] ensure follow-up in orthopedic spine clinic in 4 to 6 weeks,
instructed not to remove c collar until then
[] ensure follow up with plastics w/in 1 week for possible
operative intervention
[] ensure follow up w/ cardiac surg for aortic anuerysm and
sinus of valsalva aneurysms, will likely need q6month monitoring
[] Can consider repeat holter monitor although no evidence of
cardiogenic etiology of fall/syncope
[] Lipid panel normal with LDL 75, HDL 81. Did not initiate
statin, but could consider in the future if needs it for primary
risk reduction
[] avoid fluoroquinolones due to risk of anuerysm rupture
[] recommend Thyroid ultrasound for 1 cm enhancing thyroid
nodule
Greater than 30 minutes was spent in care coordination and
counseling on the day of discharge.
***. | OTHER DISORDERS OF THE EYE WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mrs. ___ is a ___ year old female with ESRD s/p kidney
transplant ___ on immunosuppression, s/p multiple ureteral
stent placements, last one 3 days PTA, admitted with fever.
.
1. Fever: The patient's fever and fatigue were likely secondary
to infection. The urinary tract is the most likely source given
the recent instrumentation. She is likely chronically colonized
due to frequent ureteral stent placements (roughly every 2.5-3
months). Her admit UA had moderate leuk esterase, but nitrite
and bacteria were absent. She was seen by urology in the ED.
Her admission chest x-ray was negative for pneumonia and blood
cultures were also negative. No other source of infection was
observed. Given her history of allergic reactions to
antibiotics and that she was febrile despite 3 days of
levofloxacin and macrobid, there were few antibiotic choices
available. She was started empirically on ceftriaxone 1g Q24H.
Several hours after receiving the second dose she woke in the
middle of the night with shortness of breath and a sensation of
having her airway swell. Her previous allergic reactions have
all involved hives. She had no hives on this occassion. She
had some wheezing, but no stridor on exam. She received
benadryl and albuterol and returned to her baseline shortly
thereafter. She subsequently received levoquin 500 g the
following day, and then was switched to aztreonam as her urine
culture grew out skin flora and it was unclear what the organism
was that needed to be treated. Another urine sample (in/out
cath) was obtained prior to initiating aztreonam therapy,
however, that sample has not grown out any organisms, likely
because she was already partially treated. Her macrobid was
stopped as it was felt by ID that given her gfr, it was not
present at sufficient concentrations to suppress bacterial
growth.
.
2. Renal Transplant: On admission the patient had a renal U/S
that showed no evidence of pyelonephritis or interval worsening
in the transplanted kidney. She was continued on tacrolimus &
myfortic for immunosuppression and tacrolimus levels were
checked daily. Despite being on her home dose throughout her
stay, her tacrolimus level did decrease toward the end of her
admission, and this should be follow-up with her outpatient
nephrologist.
.
3. Chronic medical problems: include asthma, hypothyroid, HTN,
psych issues, and chronic pain. None of these were acute during
her admission. Her outpatient medication regimen for these
problems was continued.
.
4. FEN: Low Na, heart healthy diet. Electrolytes were repleted
prn. IV fluids given as necessary.
.
5. Prophylaxis: DVT prophylaxis with heparin sc tid.
.
6. CODE: Full code, though patient expressed wish not to be
intubated if major brain damage present.
***. | OTHER KIDNEY AND URINARY TRACT 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.
*** yo ___ with AML in first remission presenting for
consolidation HiDaC. She tolerated the chemotherapy without
issues.
#AML- HiDaC: Received cytarabine at all scheduled doses. WBC
nadir at 3.6 on day of discharge. Acyclovir prophylaxis was
continued. She was discharged with two days of prendisolone eye
drops to avoid cytarabine toxicity.
#transaminitis: AST, ALT, AlkP all slightly elevated at
discharge (51,41,167). We felt that this was likely a toxicity
from the chemotherapy. She should have this rechecked at her
appointment with her oncologist on ___.
#latent TB: moxifloxacin was continued.
#Pulmonary Nodules: continued Posaconazole at her admission
dose. Needs a followup CT in the next ___ months.
TRANSITIONAL ISSUES:
-LFTs recheck at appointment on ___.
-onc followup ___.
-eventual rescan of pulmonary nodules ___ months)
***. | CHEMOTHERPY WITH ACUTE LEUKEMIA AS SDX WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
This patient electively presented and underwent Transphenoidal
tumor resection on ___. Surgery was without complication.
She was extubated and transferred to the intensive care unit. At
approximately 9 pm the patient began ehibiting urine output >
250cc. The hourly output persistent overnight 450-900 cc/hr.
Endocrine followed closley overnight and increased replacement
fluids from 1:1cc/hr to 1.5 cc/1cc per hour. The serum sodium
was 144 osmoality was 295, specific gravity was 1.001.
On ___, the patient was neurologically stable. A Physical
Therapy consult was placed. The patient was mobilized out of
bed to the chair. The foley catheter remained in place as the
urine output was monitored hourly. The patient was on hydrocort
50 q 8. The urine output continued to be > 250cc/hr in the
morning and the patient was given a dose of DDAVP at 10 am for
continued high urine output approx 700cc/hr with 1cc:1cc
replacement. At 11 am the patient was positive 9,404cc for
length of stay and 5338cc since ___ midnight. The patients IVF
were discontinued with a goal for the patient to be fluid volume
even. Overnight, patient's urine out put was increased and she
was given 1 dose of 1 mcg of DDAVP. Her serum NA was 146 at this
time. Labs were resent and improving to 143. She remained stable
overnight.
On ___, urine output once again increased, endocrine then
recommended that she be on standing DDAVP at 1 mcg BID. She was
stable for discharge. Her foley was removed and should continue
0.1mg PO BID DDAVP until seen in follow up by endocrine. She had
no drainage from her nose and was told to only drink to thirst.
She was also told that she should take her medication as
prescribed with no skipped dosing of DDAVP. If she notices that
she has increase urine and thirst, she should take two pills of
DDAVP.
***. | ADRENAL AND PITUITARY PROCEDURES 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.
***
___ is a ___ P1 who underwent an uncomplicated total
laparoscopic hysterectomy and cystoscopy for placental site
trophoblastic tumor. Her surgery was uncomplicated. Please see
operative report for full details.
Her post operative course was only complicated by some gas
discomfort on post-operative day #1 which went from her right
lower abdomen to her right chest. Pain was aggravated by deep
inspiration. All vital signs were consistently normal, with
normal HR, BP, and O2 saturation. An EKG was obtained which
demonstrated normal sinus rhythm. The pain quickly dissipated
with one Percocet. Given the stable vital signs and the quick
response with oral pain medication, the pain was attributed to
her recent surgery/pneumoperitoneum. The pain never recurred
throughout the ___ hospital course.
The patient was discharged home on POD#1. At the time she was
voiding on her own, tolerating a regular diet, ambulating
unassisted, and her pain was well controlled with Percocet and
ibuprofen.
***. | UTERINE ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
=====================
BRIEF HOSPITAL COURSE
=====================
Ms. ___ was admitted with hyperesthesia/increased
sensitivity to cold and
pinprick over entire LLE with no sensory level. She also had
decreased vibratory sense up on LLE up to ankle. Several
apparently active lesions were found on MRI, the largest of
which in the right parietal centrum semiovale was thought to
have caused her symptoms. She responded well to 3 days of
1gm/day methylprednisolone IV. Her course was only complicated
by nausea and dizziness (pre-syncope, explicitly not
vertiginous) which appeared steroid-related and were
near-resolved by time of discharge. Her medication regimen was
not changed. She has follow-up with Dr. ___ new MS
neurologist, on the day of discharge.
***. | MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is a ___ year-old man with PVD who was admitted to
the ___ on ___. The patient
was taken to the endovascular suite and underwent a right upper
extremity diagnostic angiogram without further intervention. For
details of the procedure, please see the surgeon's operative
note. Pt tolerated the procedure well without complications and
was brought to the post-anesthesia care unit in stable
condition. After a brief stay, pt was transferred to the
vascular surgery floor where he remained through the rest of the
hospitalization.
Post-operatively, he did well without any right arm swelling. He
was able to tolerate a regular diet, get out of bed and ambulate
without assistance, void without issues, and pain was controlled
on oral medications alone. He was deemed ready for discharge,
and was given the appropriate discharge and follow-up
instructions.
***. | 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.
***
The patient was admitted to the General Surgical Service for
treatment of acute appendicitis. The patient underwent a
laparoscopic appendectomy without complications. After a brief,
uneventful stay in the PACU, the patient arrived on the floor on
regular diet as tolerated, on IV fluids and 2 doses of
antibiotics, and IV pain medications for pain control. The
patient was hemodynamically stable.
Neuro: The patient received IV pain medications with good effect
and adequate pain control. When tolerating oral intake, the
patient was transitioned to oral pain medications without
problems.
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: Post-operatively, diet was advanced as tolerated. The
patient's intake and output were closely monitored, and IV fluid
was adjusted when necessary. Electrolytes were routinely
followed, and repleted when necessary.
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.
***. | APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year old male with a history of CKD secondary to DM and past
silent inferior MI who presented with worsening uremic symptoms
and abdominal pain admitted for initiation of HD. Additionally,
he underwent cardiac catheterization with a DES placed to the
left circumflex, complicated by embolism in L MCA territory
without persistent neurologic sequelae.
#ESRD: Patient w/ ESRD s/p fistula placement presented with
progressing symptoms of uremia. His dialysis proceeded
successfully, with one session delayed for AM nausea which
responded well to metoclopramide. PPD was placed and negative,
he was started on nephrocaps, and he was transitioned to an
outpatient TTS schedule. HBV unexposed
-HBV immunization as outpatient
#Type II NSTEMI: Patient w/ elevated troponin to 0.16 -> 0.14 on
follow up. No evidence of acute ischemic change on ekg, BNP of
7251. History of past silent inferior MI. Most likely a
combination of demand ischemia in setting of HTN as well as
renal failure and impaired clearance. However, given his risk
factors and history of CAD he was started on a heparin drip and
was catheterized with a drug eluting stent placed to the left
circumflex, a procedure which had been planned before surgery
but delayed until HD initiation given contrast load. Home beta
blockade was continued, see afterload management below. He was
discharged on aspirin and plavix for minimum of 6 months. His
discharge metoprolol dose was Metoprolol Succinate 25mg daily
and atorvastatin 80mg He should not stop these medications until
talking to his cardiologist.
#Embolic Ischemic Stroke: Immediately post catheterization, he
experienced transient word finding difficulties which fully
resolved within minutes. The next morning headache and nausea
prompted a head ct which was negative for acute bleed, but
subtle findings prompted an MRI which was most consistent with
recent embolic activity in the Left insula and temporal lobe. He
had no focal findings beyond his baseline neuropathy and no
lateralizing signs.
-No further follow up necessary
#HTN: On 75mg irbesartan at home, was initially covered with
25mg losartan but remained hypertensive to the 180s and
hydralazine was added. He became symptomatically orthostatic,
likely secondary to his autonomic neuropathy, and when his
hydralazine was held he became hypertensive to the 200s after
catheterization and briefly required a nitroprusside drip. He
was discharged on 150mg irbesartan without any hydralazine.
-Antihypertensive titration
# DM: Used 60 u detemir + aspart sliding scale at home. Last A1c
7.7 in ___. Past complications include retinopathy,
neuropathy, autonomic neuropathy and nephropathy. He was
initially treated with 60 Lantus BID and sliding scale, with the
lantus downtitrated secondary to low glucose levels. He is
discharged on 40 u detemir BID plus the sliding scale, with
instructions to adjust with his outpatient providers if coverage
is insufficient.
-Follow up sugars and adjust detemir accordingly
#GERD: Patient reports worsening over past few months of
substernal chest pain. Brief episodes ~5 seconds of squeezing
pain associated with gasping hiccup. Increased cough over same
period. Denies dysphagia, possible but less likely to be DES.
-8 weeks of high dose ppi, to be followed up as outpatient
-transition to 40mg pantoprazole bid, given omeprazole
interaction with clopidogrel.
#Cardiac echo: normal EF with no wall motion abnormalities, as
well as mild symmetric left ventricular hypertrophy. Echo with
mildly dilated ascending aorta, seen in ___ as well.
-Recommend follow up echo in ___ year
# Anemia: Normocytic, and stable at hgb ___, adequate per
renal. Likely secondary to deficiency of renal epo production.
Recent baseline ___
-EPO or iron as per his outpatient renal team
#LLQ Pain: Presented with intermittent LLQ pain, with no
reliable pattern. CT negative for acute processes, stones, signs
of diverticulitis or other acute process. Resolved without
intervention.
Transitional Issues
========================
-Intermittently hypertensive and orthostatic, will discharge
with 150mg irbesartan qd, please follow up and adjust
medications
-DES of Lcx on ___, will need minimum 6 months dual
antiplatelet therapy.
-Trialing 8 week course of high dose ppi (40 mg bid
pantoprazole), followup to assess effect
-periods of hyperglycemia with in house conversion of detemir to
lantus. Will discharge with 40 U Detemir BID from 60 U BID,
follow up to assess sugars and possible need to change when on
home diet
-5s run of narrow complex tachycardia, continue on home beta
blocker
-If palpitations from tachycardia persist, increase metoprolol
to 50mg
-___ outpatient Dialysis schedule
-Echo with mildly dilated ascending aorta, seen in ___ as
well. Recommend follow up echo in ___ year
-Negative hepatitis B serology, will need outpatient vaccination
Code status: Full
Proxy: ___, Relationship: fiancee, Phone number:
___
Patient Contact Number: ___
***. | EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ was admitted to the hospital with swelling of the
face and arms along with cough. She was found to have a
mediastinal mass on CT scan compressing her SVC. She underwent
staging imaging with MRI head, MRI chest, and CT abdomen/pelvis
with oral contrast along with nuclear bone scan. No evidence of
metastatic disease was found. Tissue of mass was obtained via
bronchoscopy, which showed small cell lung cancer.
ACTIVE ISSUES
# Small cell carcinoma with SVC compression: On imaging, patient
was noted to have 7 x 4.5 x 9-cm right mediastinal mass
engulfing the SVC, 5 x 6 x 7-cm right peritracheal mass with
mass effect on the right subclavian artery with patent airways.
Interventional pulmonology acquired tissue through endobronchial
biopsy ___ evening. Patient was transferred to solid oncology
service, had
a femoral port-a-cath placed by interventional radiology. CT
chest non-contrast, CT abd/pelvis non-contrast, MRV chest
non-contrast, MR head non-contrast, and bone scan demonstrated
no gross metastasis. Patient was started on Carboplatin and
Etoposide (Carboplatin on ___ and Etoposide on ___,
___, and ___ at a dose of 335 and 170 mg respectively)
without issue or symptoms or lab findings of tumor lysis
syndrome. Radiation oncology were contacted in house, with plan
for patient to have likely coordinated chemoradiation as
outpatient in our thoracic ___ clinic.
# Tachycardia, PACS: After patient's femoral port was placed, is
was noted that patient was slightly tachycardic and had
intermittent PACS (HR 100-110's). Due to concern for ectopy ___
port placement, KUB and CXR were performed which showed port
catheter terminated in IVC. As such, port was considered
unlikely source of ectopy, and consideration was given if PACs
for patient were baseline given her preprocedure tachycardia.
Patient was started on low dose metoprolol (12.5 BID) and her
heart rate remained in sinus rhythm in the ___.
CHRONIC ISSUES
# CKD: Cr of 2.3, she has history of stage III CKD with baseline
Cr at 1.5 in ___. In hospital, with IVF resuscitation as
needed, patient had a Cr of 1.1 by day of discharge.
# DM: Patient was seen by our diabetes team in house, and had a
diabetes educator meet with her. Her home regimen was ultimately
changed to glargine 6 U at night, with an insulin sliding scale
during the day.
# HTN: The patient's HCTZ was discontinued for now, given start
of metoprolol 12.5 BID. ___ restart at ___'s discretion.
# HLD: she was continued on atorvastatin.
# Depression: She was continued on Citalopram.
Transitional Issues
- Patient to follow up with Dr. ___ Dr. ___ in Oncology
on ___
- HTN: Hold HCTZ for now, given start of metoprolol 12.5 BID.
___ restart at ___'s discretion.
- Heme/Onc and Rad/Onc for directed therapy against malignancy.
- Ensure adequate control of diabetes and optimize regimen
outpatient. Patient is being discharged with 6 U lantus at night
and sliding scale; and had diabetes educator see her in house.
-Patient to have CBC/diff drawn on ___ (C1D14) for
chemotherapy planning. Last day neupogen ___, WBC nadir ___
(WBC 2.1, 50 % neuts). Please fax to ___
***. | OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
This is a ___ YO woman with etoh abuse who drank while taking
antibuse.
# AMS: ___ acute intoxication with benzos and etOH given
history and positive tox screen. Patient also hypoglycemic on
arrival. ___ normalized with dextrose. She was observed and
deemed clinically sober on morning of DC. Patient confirmed that
she had been sober for 15 days prior to single episode of binge
drinking. CIWA was 0 for duration of stay. Not felt to be
withdrwl risk . Her Disulfram and acamprosate was restarted and
patient was discharged home with PCP follow up.
.
# Anemia: Appears to be long standing and stable since ___.
Microcytic and patient is on iron repletion so likley ___,
especially in view of gastric bypass. Patient was continued on
Iron supplementation and will need to have her CBC checked by
her PCP on follow up.
.
# Hypernatremia: Secondary to free water deficit. Resolved with
hydration.
.
# Positive U/A: Suprapubic tenderness on Exam and reports of
frequency suggest UTI. Culture was nevative.
# Hypoglycemia: Secondary to EtOH ingestion. No oral
hypoglycemic medications. ___ prior to leaving ED was 128 and she
is asymptomatic. Normal fingersticks for duration of her stay.
.
# Community acquired pneumonia: She will continue Levoquin for a
___nd will need follow up X ray in 6 weeks to confirm
resolution
.
# SVT: Continued Verapamil
=======
TRANSITIONAL ISSUES:
#) Recheck lytes and CBC at follow up
#) Continue Levofloxacin for 7 day course
#) Follow up CXR in 6 weeks
***. | SIMPLE PNEUMONIA AND PLEURISY WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is an ___ year-old ___ speaking woman with h/o CAD
and AS s/p AVR/CABGx2, DM, who presented after a fall at home.
Patient had three months of diarrhea prior to fall and
complained that she felt lightheaded when standing.
ACTIVE ISSUES:
1. Diarrhea/Abdominal pain: Patient reports diarrhea and
abdominal pain that started immediately following her AVR and
had beeing ongoing for approximately 4 months. She has not been
on antibiotics recently to suggest c diff, but did receive
Keflex near her surgery. Her lipase was mildly elevated at
admission, though history not c/w chronic pancreatitis. Stool
osmotic gap is high suggesting malabsorption/osmotic diarrhea.
Differential diagnosis included medication side effect
(omeprazole was started near operation), infection (including c.
diff), pancreatic insufficiency, or bile acid diarrhea (given
history of cholecystectomy).
.
GI was consulted during admission to provide guidance regarding
diarrhea during admission. Patient had normal TTG making celiac
disease unlikely. Infection is a possibility - ESR and CRP were
elevated - c. diff, campylobacter, vibrio, and 0157:H7 were all
negative. Other stool studies including yersinia, stool
elastase, and Cryptosporidium/Giardia were pending at discharge.
.
Omeprazole was stopped during admission and ranitidine was
started instead. Imodium was started when infectious work-up
returned negative. Patient was also started on lactose
restricted diet. Symptoms improved and frequency of diarrhea
improved significantly. Patient's lightheadedness improved and
she felt much more steady on her feet prior to discharge.
.
2. Fall: Pt reported feeling lightheaded in the setting of
diarrhea, likely orthostatic. She denies LOC, ECG w/o evidence
of high grade arrhythmia or ischemic changes and neuro exam is
non-focal. Has had a recent ECHO. Patient was not orthostatic
here (although patient had received IV hydration prior to
checking orthostatics.) Patient was monitored on telemetry
first day of hospitalization without abnormal arrhythmia to
explain syncope. Patient received gentle IVF and her symptoms
improved.
.
CT scan in ED notable for minimally displaced fx of the nasal
bone. Patient had bilateral ecchymosis of eyes and swelling of
her nose. Plastic surgery saw patient and recommended outpatient
follow-up with Dr. ___ in one week. Physical therapy worked with
patient during hospitalization. Initially, physical therapy
felt patient was not safe to return home, but as diarrhea
improved patient became more steady. Patient was re-evaluated
by physical therapy prior to discharge and it was felt she was
safe to go home.
.
3. Superficial thrombophlebitis: During hospitalization, patient
developed thrombosis of cephalic vein in RUQ related to IV site.
The IV was removed and the patient was treated with elevation
and hot packs. The erythema and swelling improved. The patient
remained afebrile.
.
INACTIVE ISSUES:
1. CAD/AS s/p CABG/AVR: Continued home dose of statin,
metoprolol, lisinopril and plavix. Patient is not on aspirin as
patient has aspirin allergy.
.
2. H/o afib: In post-op setting, but during admission patient
was in sinus rhythm. Patient is not on coumadin at this time.
.
3. CRI: Cr was 1.2 at admission, which is patient's baseline.
Monitored electrolytes and renally dosed medications.
.
4. HTN: Initially antihypertensive medications were held given
concern for dehydration and orthostasis leading to fall. After
patient was rehydrated, restarted home medications: metoprolol,
lisinopril, HCTZ. Patient remained normotensive throughout
hospitalization.
.
5. Diabetes Mellitus: Diet controlled without complications.
Continued diabetic diet.
.
6. Dementia: Continued aricept.
.
7. Osteopenia: Continued calcium and vitamin D.
.
8. Nutrition: Patient was started on lactose reduced diet.
.
9. Prophylaxis: Heparin SC.
.
10. Code: Full - confirmed with patient.
.
TRANSTITIONAL ISSUES:
1. Pending studies: Please follow-up pending studies including
yersinia, stool elastase, and Cryptosporidium/Giardia. Patient
will follow-up with gastroenterology for diarrhea.
.
2. Superficial thrombophlebitis: Please evaluate right arm for
pain and swelling. At discharge, patient's arm had very small
amount of erythema and swelling - please monitor for resolution.
***. | OTHER EAR NOSE MOUTH AND THROAT 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.
***
BRIEF SUMMARY OF ADMISSION
===========================
___ year old male with PMH of HTN, HLD, DM II, CAD (s/p STEMI,
attempted PCI complicated by CHB, resolved), HFrEF (EF 35%),
ESRD s/p DDRT (___), hepatitis C (treated), history of DVT/PE
on Eliquis, PAD s/p SFA stent (___), c/b SFA in-stent
stenosis s/p catheter-directed lysis and placement of an
AK-popliteal stent, who now presents with acute worsening pain
and odor of LLE wound, admitted for workup and possible further
debridement.
Patient left AMA while awaiting his angiogram. The risks of this
were discussed with him and he elected to leave anyway.
Plan was made to discharge with PO antibiotic script for
doxycycline and augmentin to try to provide some antibiotic
coverage.
Of note- tacrolimus level was noted to be elevated in house and
in discussion with transplant pharmacy his dose was changes to
3mg BID from 4mg BID. This should be followed up closely as
outpatient.
ACUTE/ACTIVE ISSUES
===================
# LLE Wound
Wound developed about 1 month ago, after a callus broke open.
Poor wound healing in setting of PVD, diabetes mellitus, and as
patient works for ___ and is required to stand/walk
for hours at a time. Wound became malodorous, which prompted
admission. Evaluated by podiatry in ED; exploratory debridement
performed, found not to probe to bone. CT without evidence
necrotizing fasciitis or osteomyelitis. Was initially treated
with vanc/cefepime/Flagyl.
Unfortunately, while awaiting angiogram patient became
frustrated and decided to leave AMA despite risks of worsening
infection and death.
He was discharged with paper prescription for doxy and augmentin
for coverage until he goes to another hospital, which he states
is his plan.
# PAD status post right SFA stent
Significant vascular history, including recent SFA stent and
catheter-directed lysis. Likely also with vascular disease in
left lower extremity, contributing to poor wound healing on left
lower extremity. Planned for LLE angiogram ___ but patient
left AMA.
While in house was continued on heparin gtt in place of
apixaban, with home clopidogrel and atorvastatin as below.
At discharge was instructed to restart his home apixaban.
CHRONIC/STABLE ISSUES
=====================
# ESRD ___ Type 2 DM s/p DDK transplant
# Immunosuppression
ESRD ___ Type 2 DM with background Hepatitis C s/p deceased
donor kidney transplant on ___. Baseline creatinine
1.0-1.2. Continued home sodium bicarbonate tabs TID. Home
tacrolimus 4mg BID -> 3mg BID (goal level ___, home
mycophenolate sodium 360mg BID, and prednisone 5mg daily
# History of STEMI
# CAD
Coronary angiogram ___ with 50% stenosis in the proximal Cx,
100% stenosis of the mid obtuse marginal, 100% stenosis of the
distal RCA. S/p attempted CTO PCI of the RCA complicated by
complete heart block which resolved spontaneously. Continued
home Atorvastatin 80mg QD, clopidogrel 75 mg daily, and
anticoagulation with heparin gtt pending proceduralization.
# HFrEF(EF 35%)
Secondary to ischemic heart disease in setting of prior STEMI
and known CAD. Currently without anginal symptoms. Euvolemic,
warm.
- PRELOAD: currently euvolemic, no diuresis required
- AFTERLOAD: not on afterload reduction as outpatient
- NHBK: continued home metoprolol
# Type II DM- Continued home insulin glargine 30 units QAM/QPM,
home Humalog insulin sliding scale
# Hypotension/dizziness, chronic- continued home midodrine 5mg
BID
# Glaucoma- Continued home eye gtts.
# Gout- continued allopurinol ___ daily
# History of DVT
Recently switched to Eliquis from Coumadin; was held in favor of
heparin drip for possible intervention on left foot wound.
CORE MEASURES:
==============
#CODE: full, presumed
#CONTACT: ___
Relationship: Son
Phone number: ___
>30 minutes spent on coordination of care for AMA 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.
***
SUMMARY: ___ year old man with dilated ischemic cardiomyopathy
with refractory VT resulting in HMII Implant ___, listed for
heart transplant at ___ Status 1B, who presents with low PI
readings and cough. His VAD was alarming for low PI. He was
evaluated and this was felt most consistent with hypovolemia in
the setting of URI. He was given supportive treatment with fluid
repletion of 2L IVF and duonebs. He subsequently improved and
was discharged home.
# Hypotension:
# URI: Likely a viral illness. No fevers or leukocytosis to
suggest a more severe infection. His driver line was examined
and did not show signs of infection. Will provide supportive
treatment. Provided supportive treatment with 2L IVF with
improvement in his PI trend. He was given duonebs and discharged
with an albuterol inhaler for wheezing.
# Chronic systolic heart failure with dilated ischemic
cardiomyopathy Stage D NYHA Class III now status post HMII VAD
___. The patient presented with elevation in his lactate which
is likely form his CO not meeting his body needs under infection
from a URI. He was given 2L NS with improvement in lactate and
improvement in PI.
CHRONIC ISSUES:
# h/o of stable VT
# AF with RVR: Continued on metoprolol, Mexiletine 150 mg PO
Q8H, Amiodarone 200 mg PO DAILY
# left chest wall pain: likely neurogenic from the effect of the
LVAD. Continued on home oxycodone 5mg PO q4h:prn, gabapentin
800mg TID, lidocaine patch
# DM: Kept on ISS while inhouse, discharged back on PO meds.
# History of depression and anxiety: Continued mirtazapine,
lorazepam
# history of PUD and UGIB: likely form AMV in the past. Hb
stable on admission. Continued home pantoprazole, rantidine,
simethicone.
TRANSITIONAL ISSUES:
- Needs re-check and close f/u with ___ clinic for INR. INR was
3.9 on ___ and a lower dose of warfarin was given; INR re-check
on ___ was 2.8 and patient was restarted on home regimen
- Patient's torsemide was held due to concern for volume
depletion upon admission. Please re-evaluate as outpatient
# Code: Full
# Contact: Proxy name: ___
Relationship: sister Phone: ___
***. | OTITIS MEDIA AND URI WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with h/o sCHF (EF20-25%), CAD s/p stents, COPD (Gold IV),
chronic chylothorax, NSCLC (stage IIIB s/p chemoXRT ___ hx
lung cancer, past pulmonary aspergillosis presents with
worsening DOE.
# COPD Exacerbation: Patient presented with 3 weeks of worsening
dyspnea on exertion, increased cough and wheezing (but not
significantly increased sputum production). She had been on 40mg
prednisone qday for 7 days prior to admission without
improvement. On admission she was on 2L nasal cannula (her
baseline home O2 requirement) and satting 95-97%. She was
diffusely wheezy on exam but without crackles, JVD or lower
extremity edema to suggest any component of decompensated CHF.
CXR was read as possible pneumonia but was not compelling and
patient had no fever or sputum production. Her presentation was
felt to be most consistent with a COPD exacerbation and she was
treated with standing nebulizers and IV methylprednisolone 125mg
initially. Due to failure to improve over the initial 48 hours
of her admission, a Pulmonary consult was requested and they
recommended a trial of diuresis since this had significantly
helped the patient during prior admissions. She was given 80mg
IV lasix on ___ with great improvement in her dyspnea and
wheezing. She was transitioned to a prednisone taper on HD#3.
Her home prophylactic azithromycin was continued throughout her
admission and at discharge. She will complete a prednisone taper
upon discharge and have close follow up with her primary care
provider and pulmonologist.
==== TRANSITIONAL ISSUES ====
# COPD Exacerbation
- Continue prednisone taper: 50mg on ___ x3 days, then tapering
dose by 10mg every 3 days
- Continue home prophylactic azithromycin
- PCP follow up on ___
- Pulmonary clinic follow up on ___
- Pulmonary consult service recomended considering evaluation
for tracheobronchomalacia at her outpatient pulmonology follow
up
# Systolic CHF (EF~25%)
- It is unclear why this patient is not on an ACEi or ___. The
only allergy listed is a cough to lisinopril.
- Strongly recommend initiating an ACE ___ in this patient
unless there is a clear contraindication.
# T2DM:
- Patient's insulin sliding scale was able to be significantly
reduced compared with her home scale with adequate control of
her blood sugar (despite being on high dose steroids during this
admission). Please consider revising her insulin regimen to
minimize risk of hypoglycemia.
- Recommend her PCP assist the patient in downtitrating insulin
regimen as she progressively tapers off prednisone over the next
___ days.
CODE STATUS: Full (confirmed with patient on ___
EMERGENCY CONTACT HCP: ___ (sister, ___
***. | CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
ASSESSMENT/PLAN: The patient is a ___ yo man with with ESRD on
HD, DM, HTN, depression, fibromyalgia, and likely gastroparesis
who presents with abd pain and nausea.
.
#. Abd pain: The patient presented with left sided abdominal
pain that wraps around to his back that similar is to his
previous abdominal and flank pain. He's had this pain since
___ with multiple admissions and extensive work-up and it is
thought possibly due to diabetic thoracic polyneuropathy. He
received oxycodone prn for pain and was discharged on this
medications. See below concerning gastroparesis.
.
# Gastroparesis: His recent episodes of abdominal
pain/nausea/vomiting are concerning for gastroparesis. A
gastric emptying done during this admission confirmed ___
diagnosis of gastroparesis and showed marked delay in gastric
emptying. He received anti-emetics prn and was continued on his
reglan qid.
.
#. Hypertension: He was hypertensive on admission (any delay in
receiving his BP meds can cause a SBP in the 200s). His BP was
better controlled on his home BP regimen of metoprolol,
valsartan, nifedipine, and lisinopril.
.
#. ESRD on HD: The patient has a history of ESRD for which he
receives HD on T, Th, ___. He was continued on calcium acetate
and sevelamer.
.
#. DM: He was continued on his 70/30 insulin.
.
#. Depression: It is unclear but the patient seemed to be taking
a reduced dose of citalopram at home (10mg instead of 30mg)
because it required taking multiple pills and his PCP was trying
to simplify his medication regimen. Also there was concern that
the citalopram could be causing abdominal upset. However, having
taken care of the patient over the last several weeks his
abdominal pain appears independent of his citalopram. He was
discharged on citalopram 20mg po daily. He was also continued
on Methylphenidate to increase his energy.
.
# Coping and previous medication non compliance: Improved since
last visit. SW is following. SOCIAL WORK SHOULD ALWAYS BE
CONTACTED WHEN THIS PATIENT IS ADMITTED so that he can have his
medications in hand at discharge. His current financial
situation and depression make it impossible for him to get his
medications and is contributing to multiple admission.
.
#. FEN: Diabetic diet.
.
#. Prophylaxis: Heparin SQ for DVT prophylaxis
***. | ESOPHAGITIS GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE 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.
***
___ (AKA ___ ___ hx oral SCC of the R tonsil
s/p resection, chemoradiation completed in ___ (followed by
Drs ___ and ___ of Oncology), presented
with hemorrhage from the mouth, intubated for airway protection.
# Oropharyngeal Bleeding: Patient transferred from OSH with
oropharyngeal bleeding, intubated. Etiology of bleeding
unclear. Patient evaluated by Otolaryngology on presentation
and in the Operating Room given history of oropharyngeal cancer,
with no clear source found. Patient also evaluated by
Gastroenterology with no source found. Patient was started on a
PPI and H pylori antigen was sent. Patient was monitored with
serial HCTs and transfused as needed.
#ID/MSSA Bacteremia: Patient was briefly started on levofloxacin
and clindamycin (___) given concern for possible
aspiration PNA vs pneumonitis in the setting of recent
intubation. After ___ BCx with coag+ staph came back,
vancomycin was started (___) and narrowed to cefazolin
after sensitivities confirmed MSSA. TTE negative for
vegetations. PICC line placed and patient discharged home to
complete 4 week course of IV cefazolin.
# Respiratory Failure: Intubated for airway protection, no
report of altered mental status, respiratory distress, labs
unremarkable. Patient was extubated without complicated after
procedures.
# Oropharyngeal Cancer: Patient's outpatient ENT surgeon was
involved in his care here.
# Hypertension: Hold home metoprolol, valsartan.
# Cardiac: Held home ASA, restarted after Hcts stable.
# Psych: Resumed after extubation.
TRANSITIONAL ISSUES
-Will complete 4 week course of IV Cefazolin (end date ___
will follow up with ___ OPAT
- please ensure patient has h pylori stool antigen sent once he
is off PPI for 2 weeks, as his negative result may be false in
setting of PPI.
- home diclofenac for arthritic pain was discontinued
- patient was started on pantoprazole and ranitidine was
discontinued as patient had findings of gastritis/duodenitis on
EGD
***. | OTHER EAR NOSE MOUTH AND THROAT O.R. PROCEDURES WITH CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ was admitted to the inpatient colorectal surgery
with recurrent perirectal abscess. ___ CT scan showed
abscess tracking to right gluteus and L ischioanal fossa. This
was drained in the operating room by Dr. ___.
Post-operatively he was stable. The nursing staff assisted the
patient in caring for the surgical sites. Chronic pain was
consulted for pain medication recommendations as Mr. ___
has taken high dose narcotics in the past. Please see their note
for recommendations. Mr. ___ then had high ileostomy
output. We restarted Imodium and wafers and the output remained
elevated and tincture of opium was added. He then became bloated
with increased abdominal pain. The ostomy output significantly
decreased. It took ___ days for the effects of these
antimotility agents to decrease and the ostomy again had high
output. We restarted the Imodium and wafers and output slowed to
an acceptable amount. He was tolerating a regular diet.
Unfortunately, on
___ he was noted to have some redness and induration on his
scrotum. This was believed to be a new abscess. He returned to
the operating room for drainage of this abscess and ___
placement. Please see Dr. ___ note for further
details. Following this procedure, he was stable and his pain
was treated. He tolerated a regular diet. On ___ he was
stable enough for discharge and the ostomy output and pain were
controlled. He will need to follow-up with his outpatient
gastroenterologist and Dr ___ continued treatment of his
fistulizing Crohns Disease.
***. | ANAL AND STOMAL 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.
*** with history of HCV cirrhosis, ESRD on HD, diastolic CHF,
and cryoglobulinemic vasculitis who presents with 1 week of
scrotal swelling, suprapubic ulceration, and non-blanching rash.
This was ultimately felt to be from severe volume overload and
cellulitis, which responded well to dialysis, ultrafiltration,
and antibiotics, which he will continue on discharge.
# SEVERE ANASARCA, SCROTAL EDEMA: Etiology of severe scrotal
edema and pain was most likely dietary indiscretion in the
setting of CHF, cirrhosis, and ESRD. Notably, his admission
weight was 118kg, which is 13kg above his dry weight of 105kg.
He received 3 rounds of dialysis on ___, and ___, in
addition to ultrafiltration sessions of ___ and ___. Over 20
liters of fluid were removed. Pain was controlled with his home
oxycontin with PRN tramadol and IV dilaudid. Scrotal edema and
pain greatly improved. He was counseled extensively regarding
the need to limit his sodium intake to less than 2 grams per day
to avoid recurrence of severe hypervolemia.
# GROIN CELLULITIS: Patient reported an increase in erythema and
tenderness in his groin, raising suspicion for an infectious
process. Vancomycin HD protocol and Ceftriaxone were
administered for 6 days in the hospital and he was discharged on
Vancomycin and Ceftazadime, which are to be administered during
dialysis on ___ & ___ at his regular ___ dialysis center.
He will then complete a 1 week course of Bactrim (PO after HD)
and cephalexin PO. Detailed instructions below.
# GROIN ULCERATION AND RASH: Dermatology consulted for rash and
ulceration at the suprapubic area and base of the penis. They
believed ulceration was secondary to skin maceration and
recommended mupirocin ointment and zinc oxide cream to reduce
irritation and enhance healing. They did not feel that a biopsy
was needed at this time. Herpes and Varicella cultures were
preliminarily negative. Clustered macular rash on the left knee
and right groin faded during the course of his hospital stay.
### CHRONIC ISSUES ###
# CIRRHOSIS: Child ___ Class B, due to Hepatitis C s/p failed
treatment with IFN. He has tried to start sofosbuvir and
simeprivir but denied by insurance numerous times. He is not
eligible for these medications with his CKD per his liver team.
No history of esophageal varices or SBP, however he has had
episodes of hepatic encephalopathy in the past and is on daily
lactulose. Home rifaxamin and lactulose were continued, and he
has close follow up in ___ clinic.
# DMII: Blood sugars were well controlled with home NPH,
glargine, and ISS.
# CRYOGLOBULINEMIA: Hx. of cryoglobulinemia in the past.
Laboratory results were in support of cryoglobulinemia with RF
325, C4 levels <2. Cryoglobulins were pending at the time of
discharge. Most likely due to Hepatitis C, and would benefit
from treatment if he were eligible. He had no other evidence of
other organ involvement related to cryoglobulinemia.
# CHF, DIASTOLIC, CHRONIC: Home torsemide was continued and
increased to 80mg BID on non-dialysis/Ultrafiltration days.
Metoprolol succinate was also continued.
# CAD. Continue aspirin and atorvastatin.
# ASTHMA. Continue Advair.
# SEIZURE DISORDER. Continue Keppra.
### TRANSITIONAL ISSUES ###
- Patient noted to have a stage 2 chronic ulcer on right
buttock, despite ambulating on days prior to discharge. ___ will
continue to monitor. Continue with Mepilex dressings to
coccyx/gluteal change q 3 days.
- Patient will receive both Vancomycin 1g IV and Ceftazadime 1g
IV during dialysis on ___ and again on ___. Discussed with
___ and they are aware of plan. He will then
transition to PO Keflex BID and Bactrim (taken after HD) for a 1
week course (___) or longer at his PCP's discretion.
- Patient to have a home ___ to assist with wound care and home
___
- Started sevelamer TID with meals for CKD/high phosphate
- Given 10-days of oxycontin TID #30 and oxycodone TID PRN pain
#30 as patient states he ran out
ANTIBIOTIC REGIMEN:
___ TUE - Intravenous vancomycin and ceftazidime at
dialysis
___ WED - No antibiotics
___ ___ - Intravenous vancomycin and ceftazidime at
dialysis
___ FRI - Oral cephalexin twice a day
___ SAT - Oral cephalexin twice a day. Oral Bactrim 2 tabs
after dialysis.
___ SUN - Oral cephalexin twice a day
___ MON - Oral cephalexin twice a day
___ TUE - Oral cephalexin twice a day. Oral Bactrim 2 tabs
after dialysis
___ WED - Oral cephalexin twice a day
___ ___ - Oral cephalexin twice a day. Oral Bactrim 2 tabs
after dialysis
END ANTIBIOTICS, unless Dr. ___ you to continue.
***. | 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.
***
Left buttock abscess/cellulitis - Patient received IV Vancomycin
for cellulitis. Based on team's clinical suspicion for MRSA and
rare GNRs on I&D from OSH levofloxacin was discontinued. On
___, the site of cellulitis was marked and there was a degree
of fluctuance noted on exam underneath the site of the prior
I+D. Surgery was consulted and performed a repeat I+D at the
site. There was no drainage expressible. The incision was
packed with gauze. On ___, the area of cellulitis had
increased beyond the margins from the prior day. Due to lack of
resolution of the cellulitis, the patient's immunosuppressed
state on cellcept for her SLE, and the patient's multiple
allergies including sulfa and penicillin, infectious disease was
consulted. Due to the close proximity of the abscess and
cellulitis to the anal region, and the few gram negative rods on
gram stain, infectious disease recommended broadening antibiotic
coverage with levofloxacin and flagyl. A pelvic CT was also
obtained on ___ and showed no bony or deeper soft tissue
involvement of the infection. Blood cultures from ___ showed
no growth. On ___, the area of cellulitis had significantly
improved and there was no drainage expressible from the repeat
I+D site. Patient was sent home on linezolid, ciprofloxacin, and
flagyl to complete a ___llergic reaction to clindamycin - Patient had taken two doses
of clindamycin (prescribed by outside hospital) prior to her
arrival to the ___ ED. Patient reported developing a facial
rash and total body pruritus. She denied any other systemic
involvement including no dificulty breathing or wheezing,
abdominal pain or vomiting and had stable vital signs on
presentation. Patient was noted to have an erythematous,
bilateral facial rash and erythematous papules on the upper
chest. Patient received benadryl in the emergency department
with resolution of pruritus. The facial and chest rash improved
during her hospital stay with benadryl. Clindamycin was added
to her allergy list. Her vital signs were monitored and were
stable throughout.
3. SLE - No active issues during hospital course. Patient was
maintained on her home medications.
4. Bipolar disorder - No active issues during hospital course.
Patient was maintained on her home medications.
Patient was FULL CODE during this hospitalization.
***. | 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.
***
# Oxaliplatin desensitization: Followed protocol per
hematology/oncology service with one to one monitoring,
continuous vital signs monitoring, and premedication protocol
including hydroxyzine, famotidine, montelukast, and
methylprednisolone. In addition, prn lorazepam was given for
anxiety as well as nausea. Electrolytes were aggressively
repleted prior to initiation of the protocol. During initiation,
patient was noted to have a fever to 101. Blood cultures and
urine cultures were sent, which were ultimately negative, as was
a CXR, which was negative for cardiopulmonary process. There was
low suspicion for infection, and was thought to be drug related.
The hem/onc fellow was notified. Overnight during escalation of
dosing challenge, patient became acutely tachycardic to the 150s
although remained normotensive. She received 50 mg IV
diphenhydramine and 1 mg ativan in addition to a 1 liter fluid
bolus, after which her heart rate improved. Thereafter, patient
was found to have a 20 beat run of wide complex ventricular
tachycardia while having a bowel movement, and was again
tachycardic to the 130s, for which she received another liter of
fluid bolus. Electrolytes were again aggressively repleted.
# GERD: We continued her home omeprazole.
# Chronic back pain: In order to better monitor vital signs,
patient's home vicodin was held in favor of oxycodone for pain
control.
# Leukocytosis: Patient presented with a leukocytosis as noted
on relevant laboratory studies. This was attributed to chronic
steroid use, as the patient denied constitutional symptoms.
Fever, discussed above, was thought to be due to drugs. However,
blood culture, urine culture, and CXR were performed.
# Mild transaminitis: Patient presented with mild transaminitis,
likely secondary to chemotherapy. RUQ U/S was performed which
suggested that transaminitis was most likely secondary to known
extensive metastatic disease and no acutely reversible cause of
obstruction, inflamation, or infection.
# Chronic diarrhea: Patient complained of chronic diarrhea. C
diff DNA was sent, which was negative.
***. | 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.
***
___ is an ___ year old man with a multiple myeloma (on
daratumumab/pomalyst currently on hold, last ___, Stage III
CKD and prior statin-induced rhabdo (___) with reintroduction
of statin in ___ who presented with asymptomatic CK elevation
(initial CK 11K) and mild ___ on CKD consistent with
rhabdomyolysis with
course complicated by dysphagia, abdominal pain found to have
esophageal mass at GE junction with biopsy showing new
adenocarcinoma.
#Dysphagia
#Abdominal pain
#Esophageal dysmotility
#Esophageal adenocarcinoma
Patient noted ___ weeks of abdominal symptoms including
dysphagia and abdominal pain with associated retching and
vomiting with eating and sensation of food getting stuck
associated with 20lb weight loss since ___. Given
significant intermittent symptoms inpatient limiting his ability
to maintain PO intake, he was started on PPI and w/u for
dysphagia initiated. Barium swallow showed severe esophageal
dysmotility. Unfortunately, EGD on ___ showed an esophageal
mass at GE junction with biopsies confirming moderate-poorly
differentiated adenocarcinoma. OSH CT from ___ reviewed
with radiology without evidence of any mass on CT (limited
without IV contrast). Given that he was able to tolerate soft
diet with ensures, decision was made for outpatient work-up of
new esophageal adenocarcinoma. Plan is for EUS with Dr. ___
___ week and the thoracic oncology team is working on getting
him set up in their ___ clinic for staging and
evaluation of treatment options.
#Rhabdomyolysis
___ on Stage III CKD (baseline Cr 1.6)
#Transaminitis
Patient presented with asymptomatic rhabdomyolysis with evidence
of renal compromise from myoglobin, likely drug induced
(rosuvastatin) given prior Hx of statin-induced rhabdo. Denies
any trauma, no thermal extremes/dysregulation, unlikely
metabolic myopathy given late presentation in life, no e/o
active viral/bacterial infection (afebrile, no leukocytosis),
inflammatory myopathies unlikely as only rarely have been
associated with rhabdo and no correlated sign/symptoms. CK slow
to improve initially but ultimately downtrended to below 5,000
with improving LFTs. His ___ resolved to baseline. He was
counseled that he CANNOT take statins moving forward and
rosuvastatin was added to his allergy list. He did develop mild
overload from fluids for rhabdo which improved with IV Lasix x1
and compression stockings.
# Multiple Myeloma
Chronic, stable with improvement following treatment which is
now on hold(Daratumumab/Pomalyst). Neither of these medications
have been associated with Rhabdo
# HLD
Discontinued statin permanently and added to allergy list. Will
discuss possible alternatives with cardiology (seeing Dr.
___ on ___.
# HTN
Intermittently hypertensive during admission, although he
reports good baseline BP control. Not started on any new BP
meds. Will follow-up closely with cardiology.
# History of CAD:
Continued ASA, Plavix, metoprolol. Statin stopped as above.
# BPH:
Continued home tamsulosin and finasteride
Transitional Issues:
====================
[ ]Rosuvastatin stopped. CANNOT be on statin moving forward
given recurrent rhabdo. Please consider alternative treatments
for CAD and HLD as outpatient
[ ]New diagnosis of esophageal adeno - will need outpatient
thoracic onc f/u for staging and treatment as well as EUS for
evaluation of mass
[ ]f/u final esophageal mass biopsy results
[ ]consider additional antihypertensive agents if BP remains
elevated
=========================
=========================
>30 minutes in patient care and coordination on day of
discharge.
***. | 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.
***
ASSESSMENT AND PLAN:
Mr. ___ is a ___ year old man with a history of metastatic
colon cancer to the lungs, hypertension who presents with BRBPR
and rectal pain for 5 days.
.
1. Rectal pain and BRBPR: Ethiology unclear. CT scan showed no
evidence of an abscess but did suggest posssible colitis. Pt
was started on flagyl and cipro for possible colitis and initial
bowel rest which advanced to regular diet. Pt was also started
on stool softners for symptomatic relief. The GI service was
consulted and performed a flex-sigmoidoscopy which was normal.
Symptoms of rectal pain at defecation have improved
significanltly throughout hospital stay although ethiology
remains unclear.If symptoms recur patinet should have a
MR-pelvis fo rfurther evaluation.
2. Hypertension: Pt reports not taking any of his medications
in 2 days prioir to admission. He states that he often misses 1
day per week because he forgets. Blood pressure was elevated on
admission but improved throughout hospital stay. Pt encouraged
to be compliant with meds as he is on avastin. He may need
adjustments as an outpt fo rbetther blood pressure control.
.
3.Neutropnia; On admision wbc count low and pt close to
neutropenic , because of possible infectious colitis an
danticipated flex-sigmoidoscopy he did receive neupogen x days
with good response and no side effects.
.
3. Metastatic Colon Cancer: On FOLFOX and Avastin, responding
to treatment per recent CT scan.Will continue care per primary
oncologist.
.
4. Hypercholesterolemia: Continue Simvastatin
.
# PPx:
- Bowel regimen: senna and colace
- DVT PPx: SC heparin
# Code: FULL, confirmed on admission
***. | G.I. HEMORRHAGE WITH CC |
Subsets and Splits