problem
stringlengths 431
32.6k
| solution
stringclasses 738
values |
|---|---|
What is the most likely Medicare Severity Diagnosis Related Group (MS-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 evaluated in the ED. He underwent a an abdominal
CT which revealed small bowel obstruction. He was admitted to
the General Surgery Service for management with NGT
decompression, IV hydration, and bowel rest. He was transferred
to ___.
.
ABD:His serial abdominal exams improved over the course of a few
days with decreased tenderness with palpation. His abdomen is
currently large, soft, NT/ND with active bowel sounds.
.
AFIB:He was triggered per Nursing staff on ___ for HR >130s
per telemetry. Patient remained asymptomatic. EKG revealed AFIB
which is chronic condition for the patient. He converted to
sinus with IV Lopressor 5mgx1. He had another episode of
asymptomatic AFIB, HR to 140's on ___, and responsed to
Lopressor 5mg x 1. His other vital signs remained stable. He
continues with oral Lopressor. Email contact was made with his
PCP, ___ for outpatient management.
.
NUT:He was NPO with NGT decompression for a few days. The NGT
was removed once his bowel function resumed, and gastric output
decreased. His diet was advanced gradually. He has been
tolerating a regular diet without complaints of nausea and/or
vomiting. His insulin regimen has been verified per his wife,
updated in ___.
.
ELIM/UTI:He had a foley catheter inserted intra-op. The catheter
was removed, and he was able to urinate without difficulty.
Reported some burning & frequency. A sample was sent for
analysis. He was diagnosed with a UTI, and treated with
Ciprofloxacin. He reports passing flatus, but had a bowel
movement on ___.
.
PAIN/Right shoulder:His abdominal pain was managed with an IV
Morphine which was discontinued once abdominal pain resolved. He
reported RUE shoulder pain/stiffness and back pain a few days
after admission. He denied h/o gout. Rheumatolody was consulted.
He underwent I&D of acronium joint with minimal aspirate that
revealed possible crystals indicating pseudogout. Attempt to
obtain MRI was unsuccessful due to patient's size. He has been
managed with Flexeril. He reports his pain ___ which is
well tolerated. He will follow-up with Rheumatology on an
outpatient basis.
.
Coumadin: His coumadin dose was held during first few days of
admission due to possible need for surgery. Th s/s related to
small bowel obstruction resolved with non-surgical management,
surgery was not indicated, and coumadin dose was resumed.
***. | G.I. OBSTRUCTION WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___: Admitted to ___ from ED; continued cipro/flagyl; sent
type and cross. R radial a-line placed. OR with ACS. Found to
have perforated diverticulitis. ___ and colostomy done.
Became hypotensive, started on neo, levophed, vasopressin. Was
also in afib with RVR. Dilt gtt increased to 15/hr. Got
cipro/flagyl in OR. Lost 1L blood and given 6L crystalloid in
OR. intraop ECHO showing poor EF (estimated ___ and poor
biventricular function. Remained hypotensive upon return to the
ICU and developed worsening renal function, increasing lactate
which peaked at 7.0. Likely septic shock complicated by
cardiogenic failure. Antibiotic coverage expanded to vanc and
imipenem-cilastin. Given albumin. Adrenal insufficiency
considered due to possible recent steroid use. Cortisol was
elevated. INR continued to increase, no obvious source of
bleeding. Given Vitamin K and FFP. Given cisatracurium.
Respiratory rate increased due to elevated CO2 on ABG.
Respiratory status improved. Initially anuric, now having some
UOP. Neo and vasopressin weaned off overnight.
___: Code status changed to DNR per family (patient reported to
have clearly expressed his wishes multiple times in the past).
500cc 5% Albumin given in AM for hypotension. Attempted to
increase PEEP and wean FiO2 with resultant drop in BP to
systolic in the 60’s. Vasopressin started in addition to
already-administered Levophed for persistent hypotension.
Oligouric. Imipenem dose decreased from 500mg q6hr to 500mg
q8hrs for impaired renal function. Nephrology consult: rec d/c
IVF but no indication for HD/CVVH for now. 1U FFP given in AM
for INR 4.9 -> 3.9. LFTs persistently elevated but stable. INR
trend: 3.9 -> 6.9: 2 more units FFP given. 10mg IV vitamin K
given. Hct 27.8->23.9: 1U PRBCs given. 50cc of 25% Albumin given
in ___ for persistent hypotension and inability to wean pressors.
Short runs of V-tach. Fluconazole started for continued increase
in WBC and worsening septic picture: WBC 24.2->31.6->37.5.
Lactate increasing: 4.8->8.4->8.8->8.4. ___ Vanco level 23.4: not
re-dosed overnight
___: On ___, the patient became further hypotensive and the
decision was made to make the patient CMO. He expired shortly
thereafter.
***. | MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ was evaluated by interventional radiology on
___ and taken to the radiology suite for ultrasound-guided
placement of ___ pigtail catheter into the gallbladder.
78cc bilious fluid aspirated. Samples was sent for microbiology
evaluation. Given his co-morbidities, recent surgery, overall
functional nutritional status; and concern for sepsis with
tachycardia, leukocytosis and recent instrumentation; he was
subsequently transferred to the ICU for careful fluid
resuscitation, IV antibiotics, and observation. He was cared for
in the ICU for approximately one day and then transferred to the
ward on post-procedure day two.
Neuro: The patient was alert and oriented to person and place
throughout his hospitalization; He demonstrated confusion at
times, though overall his mental status improved with each day
of his admission. His pain was initially managed with IV and PO
pain medications though transitioned to PO pain regimen only by
post-procedure day 2.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable on 3L NC during his
admission; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. He was noted to have some
dyspnea with bibasilar crackles on HD#3, for which a CXR was
obtained which was negative for pneumonia or acute pathology,
though noted some unusual atelectasis. More frequent incentive
spirometry was encouraged, and formal repeat CXR demonstrated
low lung volumes with atelectasis. Radiology recommended a
formal PA/Lat CXR series in ___ for re-evaluation.
GI/GU/FEN: Since his recent prior hospitalization, Mr. ___
was d/c to SNF with NPO status and NGT. he had been receiving
SLP services for swallowing tx at rehab. He was maintained NPO
and restarted on tube feeds on post-procedure day 1. ON HD#3,
per the recommendation of the Inpatient Nutrition service at
___, the patient was placed on a continuous tube feed regimen
of Jevity 1.2 at 80mL/hr. He was re-evaluated by ___ on
HD#3 with suspected oropharyngeal dysphagia most
notable for reduced hyolaryngeal elevation/excursion, occasional
soft s/s of aspiration with nectar thick liquids, and overt s/s
of aspiration with thin liquids. Given presentation at the
bedside, improvement in mental status, and prolonged NPO status,
___ recommended another videoswallow evaluation to further
work-up his oropharyngeal swallowing abilities objectively. A
videoswallow study was obtained on ___ and the
patient was cleared for thin liquids and soft solids in small
quantities while upright. Given increasing po intake, his tube
feedings were discontinued prior to discharge.
ID: The patient's fever curves were closely watched for signs
of worsening infection, of which there were none. Cultures of
the blood urine, and bile fluid collected from ___ procedure were
collected. At the time of Mr. ___ discharge, all cultures
remained no growth to date.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a soft
solid and thin liquid 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.
***. | DISORDERS OF THE BILIARY TRACT 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 from ___ Rehab on ___ for his
elective right craniotomy. Consent was obtained from his wife
for the procedure. His VP shunt setting was changed from 1.5 to
2.5 preoperatively. His VP shunt sutures were removed. He was
taken to the OR for a right cranioplasty which was completed
without complication. See operative note for more details.
Postoperatively he was taken to the Neuro ICU for q1h neuro
checks, which were stable. His post-operative CT scan showed
expected postoperative changes. He was continued on PO
vancomycin for his diagnosis of C-diff.
On ___ he was stable and was transferred to the step-down
unit. He was restarted on the tube feed regimen he was on during
his prior admission (replete with fiber with goal rate of 90
cc/hr) and Nutrition and Speech and Swallow were consulted to
reassess his dietary plan.
On ___ he underwent a CT max/face which showed an increase in
the subdural space with accompanied midline shift. His exam
remained stable. Speech and Swallow recommended continued g-tube
nutrition. Nutrition recommended that Mr. ___ continue his
current tube feed regimen with Replete w/ Fiber @ 90 ___s
take daily multivitamin with minerals via his tube feeds pending
the recommendations of speech and swallow. Mr ___ removed his
own trach tube. It was replaced without incident.
On ___ CT scan was stable. Exam was unchanged.
On ___ the patient threw multiple PVCs. He denies chest pain.
Electrolyes were obtained that were within normal limits. An EKG
was also gotten which did not show any significant changes.
Speech and swallow evaluated the patient ___ and ___ there was
no acute need for treatment while in-patient and he could
continue treatment at rehab.
On ___: At the time of discharge on ___, POD #5,
the patient was doing well, afebrile with stable vital signs,
tolerating a regular diet, ambulating, voiding without
assistance, stable neuro exam and pain was well controlled. The
patient was given written instructions concerning precautionary
instructions and the appropriate follow-up care. All questions
were answered prior to discharge and the patient expressed
readiness for discharge.
***. | OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
#Severe cervical stenosis s/p C4-C5 ACDF on ___:
The patient presented to pre-op on ___. Patient was
evaluated by anaesthesia in pre-op. The patient was taken to the
operating room for C4-C5 ACDF. There were no adverse events in
the operating room; please see the operative note for details.
Pt was extubated in the OR, taken to the PACU where she had an
uneventful stay, then transferred to the ward for close
neurologic monitoring.
The patient was alert and oriented at her baseline throughout
her hospitalization; pain was well managed with IV+PO and then
only PO pain regimen. Both AP and lateral C-spine XR were
obtained on ___ and showed no signs of hardware complication.
Physical Therapy evaluated Ms. ___ on the morning of POD1 and
recommended discharge to rehab. She was discharged on ___.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. 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.
#Difficulty swallowing:
On the morning of POD1 Ms. ___ complained of difficulty
swallowing with a sensation as though "something were stuck in
[her] throat. The inpatient Speech and Language Pathology
service evaluated the patient on POD1 through POD3, and
ultimately recommended a diet of pureed and thin liquids, that
her medications be delivered PO crushed in applesauce, as well
as standard aspiration precautions. She was deemed fit for
discharge to rehab/SNF with follow-up evaluation by SLP at that
facility with advancement of diet guided by videofluoroscopic
swallow study. These recommendations were shared with the
patient, nurse and medical team. See swallow guide. Copies of
reports were placed in her chart for d/c.
***. | 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.
***
SAFETY: The pt. was placed on 15 minute checks on admission and
remained here on that level of observation throughout. She was
unit-restricted. There were no acute safety issues during this
hospitalization.
LEGAL: ___
PSYCHIATRIC: The patient's cymbalta was changed to 120 mg PO
morning (instead of lower dose BID) because patient was feeling
difficulty sleeping at night. She was continued on abilify 20
mg PO daily, trazodone 100 mg PO qhs, wellbutrin SR 200 mg PO in
morning and at 2PM, and Ativan 0.5 mg PO TID. Her ECT was
delayed initially for medical reasons (high BP that was brought
down to 140s/90s and SOB on exertion that was stable). She was
found by medicine and cardiology to have likely decompensation
due to severe weight gain (60 lbs within past 3 months ___
severe anhedonia and immobility), and cleared for ECT as BP
improved. During her hospital stay we explored Ms. ___
extreme feelings of guilt regarding past life events, including
alcohol/cocaine use and previous stealing from family/friends
when she was intoxicated. We also explored complex relationship
with a friend who passed away last year, which may have caused a
spiraling of her anhedonia. She had been unmotivated to the
point where she could not get out of bed or out of her house for
weeks. During hospitalization, we set goals of increasing laps
around unit. Ativan was decreased to 0.5 mg PO BID to allow for
more effective ECT treatments. Hydroxyzine was started ___ mg
PO qhs PRN anxiety/insomnia, and increased to QID PRN
anxiety/insomnia. She was planned to have ECT #6 on ___,
but this was held because of concern on ___ for new-onset left
arm swelling by PICC line site (inserted due to difficulty with
access), left arm U/S limited by body habitus showed no DVT and
cellulitis was found more likely, PICC line was removed and
cellulitis treated with PO keflex. She continued with ECT on
___ and continued until final ECT # 8 on ___. The team
filed a 51-A during hospitalization given child being in her
home, finding of cocaine-positive UTox on ED arrival within the
context of severe cocaine/alcohol abuse in the past, and patient
denial of cocaine use. On day of discharge, patient appeared
brighter, denied SI, reported that though she was anxious about
the future that she was feeling "better" and "less sad". She
was increasingly future-oriented, asking appropriate questions
about transportation to outpatient appointments, as well as
desire to spend time with her daughter, do work around house,
ambulate more and follow-up with outpatient providers.
-Cymbalta 120 mg PO daily
-Bupropion 200 mg PO QAM and at 2PM
-Lorazepam 0.5 mg PO BID
-Trazodone 100 mg PO qhs
-Hydroxyzine ___ mg PO QID PRN anxiety/insomnia
GENERAL MEDICAL CONDITIONS:
#)SOB on exertion/morbid obesity/severe decompensation: During
hospitalization, pre-ECT medicine consult was concerned for
dyspnea that occurred on exertion when walking around the unit.
EKG, CXR, and TTE (limited due to body habitus) were negative
for signs of CHF, ischemia, or acute pulmonary process such as
pneumonia. She was ordered for PRN albuterol nebulizer Q6hrs
for any worsening SOB on exertion, which she did not need as
breathing on exertion very slowly improved with encouragement of
increased ambulation while on unit. This was likely severe
decompensation from immobility and subsequent 60 lb weight gain
within 3 months before admission. Her breathing remained stable
throughout the hospitalization.
-Continue to strongly encourage ambulation in the outpatient
setting.
-Given morbid obesity and difficulty sleeping at night, consider
outpatient polysomnography study.
-Setting up ___ for medication compliance and care at home.
#) HTN: Patient's BP went up to max of 160s/100s and went down
afterwards on ___ was 133/83, medicine consult recommended
starting HCTZ at 12.5 mg PO daily. Lisinopril 5 mg PO daily and
nadolol 20 mg PO BID were started. Because BP had become
well-controlled, HCTZ was removed. On day before discharge, BP
decreased to 102/150, then was 120/65 and 107/53. We decided to
discontinue lisinopril on discharge. If BP goes back up,
lisinopril can be re-started again in the outpatient setting.
Discharge BP was 131/84.
-Nadolol 20 mg PO BID
-If BP becomes elevated in outpatient setting, can consider
re-starting lisinopril.
#) New Onset left arm swelling, erythema, pain by ___ site, hx
of DVT: On ___ patient had new onset of left arm swelling
and erythema by ___ within the context of ___ days of left arm
discomfort by ___ site. She had a DVT in ___, previously
requiring 6 months of coumadin. Platelets and INR from ___
were normal. There was no chest pain or worsening shortness of
breath,
though patient was previously quite decompensated related to
immobility and morbid obesity. Left arm U/S was limited but
showed no apparent DVT. Medicine team believed patient had
cellulitis, left arm PICC line was removed, keflex ___ mg PO
Q6hrs for 7 day course was started on ___ and completed.
Left arm swelling improved.
-Monitor left arm clinically in outpatient setting.
#) Bilateral hand numbness/tingling of ulnar distribution:
Patient complained of new-onset bilateral hand
numbness/tingling, exam showed ulnar distribution of symptoms,
nurse had observed patient often sleeps directly on both hands.
Mild-to-moderate ulnar nerve neuropathy was diagnosed, medicine
consult was called, Chem 10/CBC were unremarkable, bilateral
wrist splints were recommended.
-Continue with bilateral wrist splints.
#) Groin Rash/Candidiasis: patient had pruritis with
erythematous rash of groin and under breasts at baseline, was
started on nystatin cream BID PRN itching. On ___, she
complained of worsening rash, on exam showing erythematous
maculopapular satellite lesions throughout groin focused on
right side spreading to right thigh and right suprapubic region
with mild white exudate. This was believed to be likely
uncomplicated candidiasis, and after EKG was taken (NSR with QTc
397) a one-time dose of fluconazole 150 mg PO was given on ___.
She was seen by wound nurse and given critic-aid ___ topical
BID, extra large net panties and ___ pads for urinary
incontinence, and more frequent washing at site. Her groin rash
was beginning to improve at time of discharge. Her nystatin was
continued.
-Continue nystatin cream BID PRN itching
#) Access: During hospitalization, ECT team reported extreme
difficulty with access related to body habitus. A midline was
placed on left arm. Because midline did not allow for proper
medications/fluids during ECT, it was converted by IV nurse to
___ line. On ___, patient reported new-onset redness and
swelling by ___ line site. A left arm duplex U/S was acquired
to r/o DVT, especially given history of DVT in ___. Left arm
U/S limited by body habitus did not show DVT, diagnosed
cellulitis at site, PICC line on left arm was removed.
#) Leg edema: She has likely dependent edema, related to
decompensation after gaining 60 lbs over the past few months
___
depression/anhedonia). Echo from 4 wks ago, though limited,
showed intact LV function. This remained stable throughout
hospitalization.
-Encourage ambulation.
#) Back and leg pain: Chronic, well-controlled with home
medications. Gabapentin was decreased from QID to TID to allow
for better ECT seizures during hospitalization. She also had
PRN tylenol during hospitalization which was discontinued on
discharge.
-Continue gabapentin 800 mg PO TID
-Lidocaine 5% patch 2 patches TD daily PRN pain
PSYCHOSOCIAL:
#) GROUPS/MILIEU: Pt was encouraged to participate in units
groups/milieu/therapy opportunities. Use of coping skills and
mindfulness/relaxation methods were encouraged. Therapy
addressed family and social issues.
#) COLLATERAL CONTACTS: Her psychiatrist Dr. ___,
endorsed the patient having severe depression refractory to
medications, requiring her to call Dr. ___ to discuss
ECT treatment. Out-patient ECT was complicated by the fact that
patient had no means of transportation and was so
depressed/anhedonic that she had not left her house for months.
Dr. ___, and confirmed that patient
never had CHF, also discussed complex family arrangements.
#) FAMILY INVOLVEMENT: Social worker received collateral from
patient's husband, who discussed complex family situation.
Husband agreed to come in for family meeting to help with
discharge planning.
#) INTERVENTIONS:
- Medications: Cymbalta was changed to earlier in the day to
help with sleep, gabapentin and ativan decreased to allow for
more effective ECT treatments, hydroxyzine started and
increased, abilify, trazadone and wellbutrin continued.
- Psychotherapeutic Interventions: Individual, group, and milieu
therapy.
- Coordination of aftercare: Outpatient appointments were made.
-ECT: 8 treatments total
- Behavioral Interventions (e.g. encouraged DBT skills, ect):
Encouraged DBT skills, encouraged participation in group therapy
sessions, individual therapy.
INFORMED CONSENT: The team discussed the indications for,
intended benefits of, and possible side effects and risks of
starting these medications, and risks and benefits of possible
alternatives, including not taking the medication, with this
patient. We discussed the patient's right to decide whether to
take this medication as well as the importance of the patient's
actively participating in the treatment and discussing any
questions about medications with the treatment team, and I
answered the patient's questions. The patient appeared able to
understand and consented to begin the medication.
RISK ASSESSMENT:
#) Chronic/Static Risk Factors: Chronic mental illness, past
suicide attempts, past trauma, Caucasian ethnicity
#) Modifiable Risk Factors: depressed mood-medication
management, ECT, group/individual/milieu therapy, intermittent
SI-medication management, ECT, group/individual/milieu therapy,
interpersonal difficulty with close family and
friends-individual/group/milieu therapy.
#) Protective Factors: dedicated outpatient providers, desire to
follow-up with treatment
PROGNOSIS: Guarded. Patient is very agreeable to treatment. I
feel guarded about prognosis because there have been multiple
hospitalizations, multiple suicide attempts, interpersonal
difficulty with close family and friends, and very refractory
depression. She also previously had difficulty with follow-up
because of worsening anhedonia before hospitalization. However,
at this time, patient denies, is more future oriented, and she
expresses authentic desire to follow-up with treatment. If she
is able to follow-through with outpatient follow-up, especially
therapy, her condition has the chance to reasonably improve.
***. | PSYCHOSES |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient presented to the emergency department and was
evaluated by the orthopedic Hand surgery team. The patient was
found to have L thumb near complete amputation and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for:
1. Irrigation and debridement down to necrotic bone.
2. Primary IP joint arthrodesis with autograft.
3. Repair of the radial digital nerve.
4. Repair of the ulnar digital nerve.
5. Repair of the ulnar digital artery with a 3 cm vein
graft from the foot.
6. Full thickness skin graft measuring 5x1.5cm
, 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 was monitored for 24hours there w/ q1h NV exams to
his L thumb. After 24h he was transferred to the floor. The
patient was initially given IV fluids and IV pain medications
including a supraclavicular nerve catheter. He was initially
kept NPO in case there was a need to potentially take him back
to the OR for a revision. He progressed to a regular diet and
oral medications by POD#2. The patient was given ___
antibiotics and anticoagulation per routine and antibiotics were
continued while he was in house. The patient's home medications
were continued throughout this hospitalization. The patient was
discharged home with followup in 1 week. 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
NWB on the LUE, and will be discharged on ASA 162mg for DVT
prophylaxis. The patient will follow up in Hand Clinic per
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.
***. | HAND PROCEDURES FOR INJURIES |
What is the most likely Medicare Severity Diagnosis Related Group (MS-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 seen in ___ clinic on ___ for an urgent
appointment for evaluation of cough, shortness of breath,
weakness, chills and sweats. He was subsequently admitted to the
oncology service. CTA showed large right hemothorax and
pneumothorax, no evidence of active extravasation,
pseudoaneurysm or other source for bleeding. ___ was consulted,
and felt that there was no intervention to offer given lack of
identified bleeding source. R sided pleurX continued to drain
sanguinous pleural fluid. His hematocrit dropped from 42 to 22
preoperatively and he received blood transfusions. IP was
following and recommended a thoracic surgery consult.
Thoracic surgery was consulted and later that day the patient
underwent VATS washout. No active bleeding was identified, 450cc
of old blood was evacuated. The lung appeared fibrotic and
trapped. The pleurX catheter was removed and replaced with a
___ chest tube which was put to suction with minimal output.
HIs post operative course was complicated by atrial fibrillation
with rapid ventricular response in the setting of hypotension
requiring ICU transfer for rate control and blood pressure
support. He continued his recovery in the ICU. His chest tube
was removed and per IP recommendation, it was not replaced with
a pleurX catheter with plans to replace when he becomes
symptomatic from recurrent effusion. He was seen by OT who
cleared him for discharge. ___ evaluation recommended home ___
services which were set up. A visiting nurse and home oxygen
were arranged prior to discharge. At the time of discharge, the
patient was tolerating a regular diet, voiding appropriately,
and ambulating with a walker.
***. | 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.
***
The patient was admitted to the inpatient unit after completion
TAC and LAR. She was stable on the floor post-operatively. On
post-operative day one, the patient was started on sips, which
was tolerated well in the morning and was advanced to clear
liquids in the afternoon. Her pain was adequately controlled
with a Dilaudid PCA until she was tolerating a clear diet in the
evening at which point she was changed to PO pain medications.
On post-operative day two she tolerated a regular diet and was
discharged home with appropriate discharge instruction.
***. | MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ w/h/o HTN, GERD, HCV (on Ledipasvir/Sofosbuvir) allergic
rhinitis/asthma since childhood who presented with asthma
exacerbation, fever and diarrhea after several days of
progressively worsening URT symptoms found to have an asthma
exacerbation.
ACTIVE ISSUES:
# ASTHMA: Patient's asthma was suboptimally controlled. Patient
was treated with nebulizers, steroids and a 5 day course of
azithromycin with improved Peak flows (up to 250 at discharge -
self reported 'good' Peak flow was 300). Patient was also
started on Advair for maintenance therapy. She was discharged on
along taper of steroids given her prolonged symptoms and poor
baseline lung function.
# ANXIETY: Patient's hospitalization was complicated by
significant anxiety and panic attacks. Her anxiety was likely
worsened by albuterol and steroids. With reassurance and taper
steroids, her anxiety improved. She would like benefit from
outpatient mental health counselling.
# MICROCYTOSIS with IRON DEFICIENCY: Patient presented iron
deficiency in absence of anemia. Work-up was deferred as an
outpatient however would likely benefit from EGD/colonoscopy and
possible hematology referral for Hb electrophersis.
# HEPATITIS C: patient was continued on harvoni while admitted.
# Transitional Issues:
- Patient will complete a long steroid taper in the beginning of
___
- Patient will need outpatient work-up for iron deficiency.
***. | 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.
***
SUMMARY STATEMENT:
___ year-old man with a PMH of idiopathic dilated cardiomyopathy
and HFrEF (EF ___ with ventricular tachycardia s/p ablation
and ___, HTN, DM2, CKD, transferred from the ___
with intermittent slow symptomatic VT, admitted for monitoring
and quinidine washout. After more than 48 hours without slow
V-tach on telemetry the patient was considered stable for
discharge, with plan for alcohol septal ablation in near future
with Dr. ___.
ACUTE ISSUES:
============
#Nonsustained VT
#Hx VT s/p aplation ___ and ___ ___
Sxs of chest burning corresponded to episodes of slow VT. Device
interrogation showed that episodes characterized as NSVT since
they fell below the rate threshold for detection. When episodes
were detected as VT, they were terminated with 1 round ATP. In
the CDAC, the patient's detection threshold was decreased to 130
and quinidine was stopped given that it may have been slowing
his VT to a rate below the level of detection. He was sent for
direct admission from the ___ for closer monitoring after
stopping quinidine, and for possible further adjustments of his
ICD. Of note, the etiology of his increased episodes of VT was
not clear. His coronary arteries were clean per report ___ years
ago, however
with his history of diabetes and recent ___, it is likely that
he is a vasculopath. Stress test has been understandably
deferred due to his VT. His case was discussed with
electrophysiology, who recommended monitoring off quinidine. The
last run of v-tach was noted on ___ at 1015, 15-second run of
v-tach, paced-out. The patient did not have recurrence of VT
following this episode. Electrolytes were monitored and repleted
and thyroid work-up was unremarkable, as below.
CHRONIC ISSUES:
==============
#HTN
#Idiopathic dilated cardiomyopathy
#HFrEF (EF ___
Patient remained euvolemic on exam. Continued home torsemide,
lisinopril and metoprolol (fractionated during admission) and
eplerenone. Quinidine was discontinued as above.
#History of thyroiditis:
History of thyroiditis on amiodarone, followed by Endocrinology.
Recent complaint of thyroid swelling. Likely subclinical
hypothyroidism vs normal age. Thyroid panel normal this
admission: TSH 2.8, free T4 1.4, T3 89.
#T2DM
A1c 7.1% in ___. Diet-controlled, off insulin and glipizide.
Controlled on ISS during admission.
#HLD:
Continued home atorvastatin 10mg daily.
#History of ___
Continued home ASA 81mg daily and Plavix 75mg daily..
#Normocytic anemia
Hgb was 13.2 on admission and remained stable, 12.7 at
discharge; similar to recent baseline.
#CKD:
Creatinine 1.5 at discharge (baseline Cr 1.6.)
#Gout:
Continued home febuxostat 40mg daily.
TRANSITIONAL ISSUES:
[ ] Discharge Hgb: 12.7
[ ] Discharge Creatinine: 1.5
[ ] Discharge weight: 193.12 lb/87.6 kg
[ ] Baseline blood pressures: 90s-100s/50s-70s
[ ] Baseline heart rate: 60s-70s
[ ] If VT recurs, can consider trial of dolfetilide as per EP
[ ] Per EP, the best option to control recurrent VT is likely to
be alcohol septal ablation if a suitable artery can be
identified. Plan for procedure with Dr. ___ in the near
future.
[ ] Consider need for further CAD work-up, including nuclear
stress test in the outpatient setting vs. cardiac
catheterization given high VT risk
[ ] Will need Endocrinology appointment rescheduled (was
scheduled for
___ with Dr. ___
#CODE: FULL CODE
#CONTACT: ___, Wife, ___
***. | 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.
***
Ms. ___ is a ___ woman with history of
refractory epilepsy of right medial frontal lobe origin s/p
vagal nerve stimulator implant and metastatic colon cancer on
FOLFOX who presents with BRBPR.
# BRBPR:
BRBPR most likely due to colon mass or hemorrhoids. GI was
consulted in ED, and felt there was no indication for
scope/intervention at this time. After admission she had a few
additional loose bloody BMs, however these resolved. Her H/H
remained stable throughout her admission. She had no additional
abdominal pain or other symptoms above her baseline chronic
symptoms.
# Constipation.
The patient had constipation prior to admission. Throughout her
admission she had multiple loose bowel movements. She was
continued on senna, docusate and miralax PRN.
# Metastatic Colon Cancer
# Secondary Neoplasm of Liver
# Secondary Neoplasm of Lung
# Secondary Neoplasm of Lymph Nodes
During her admission the team remained in contact with the
patient's outpatient oncologist, Dr. ___. Plan is for
family meeting with Dr. ___ nutrition and palliative
care as outpatient on ___.
# Seizure Disorder
Continued on home Zonisamide, keppra, and lacosamide
# Anemia/Thrombocytopenia
Likely secondary to malignancy and chemotherapy. Her platelet
counts uptrended throughout her admission. Her H/H remained
stable.
# Coagulopathy
INR found to be elevated to 2.2, most likely secondary to
nutritional deficiency. She was treated with 10mg PO vitamin K
with improvement in INR to 1.5 by the day of discharge.
# Hyponatremia
On admission, the patient's Na level was within normal limits.
On the day of discharge she was mildly hyponatremic to 132. Her
sodium level should be followed up on her outpatient oncology
appointment on ___.
# Severe Protein-Calorie Malnutrition
She has had poor PO intake prior to admission and continued to
have very poor PO intake throughout her admission. She was
continued on her home remeron and marinol for appetite
stimulation. In discussion with outpatient oncologist, plan for
outpatient meeting with nutrition and discussion of nutrition
plan on ___.
# Cancer-Related Abdominal Pain
Continued on home oxycontin with oxycodone PRN
# Goals of Care:
She has now had 3 hospital admissions within the past month.
During last admission palliative care met with the patient and
family, who were interested in continuing to pursue
cancer-directed treatment and were not interested in hospice at
the time. Additional conversation with multidisciplinary team
planned for outpatient meeting on ___.
TRANSITIONAL ISSUES
===================
[ ] Continues with insufficient nutrition. Multidisciplinary
meeting planned for outpatient visit ___.
[ ] Discharge Na 132; Mildly hyponatremic the day of discharge.
Please recheck Chem-7 this week to ensure normalization.
[ ] Discharge Hb 8.7; Repeat CBC within 1 week of discharge to
ensure stability.
***. | 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.
***
TRANSITIONAL ISSUES
===================
[ ] Continue anti-hyperglycemic treatment with Januvia.
- Check Cr at first follow up: If GFR > 50, continue current
dose, If GFR < 50, decrease dose to 25mg PO daily
- Stop Januvia when steroids are finished
[ ] Continue planning for radiation treatment of new brain
lesion.
[ ] Continue Dexamethasone, 4mg Q6H, follow up with radiation
oncology for future taper.
[ ] Continue seizure prophylaxis with BID ___ Keppra.
[ ] F/u serum electrolytes and kidney function the week
following discharge and monitor CKD (baseline SCr 1.1-1.3,
___.
[ ] Continue follow up and care with outpatient oncology.
ASSESSMENT & PLAN:
___ is a ___ year old female with a past medical
history notable for uroepithelial bladder cancer with mets to
lung (diagnosed ___, now on Atezolizumab C2 ___,
previously on cisplatin and gemzar x2 cycles with progressive
disease in lungs), severe hematuria following tumor biopsy
(___) requiring transfusion and fulguration, hypertension,
and diabetes presenting with right hand spasm and was found to
have a new 1.8 x 1.4 cm metastatic lesion in the left frontal
lobe with associated vasogenic edema.
ACUTE ISSUES
============
#Right-sided hemorrhagic brain lesion with associated vasogenic
edema: most consistent with metastatic disease. Exam on
admission was notable for right facial droop and right upper
extremity weakness. Brain MRI re-demonstrated this hemorrhagic,
vasogenic metastasis and additional subcentimeter foci of avid
contrast enhancement within the right centrum semiovale and
right cerebellar hemisphere are concerning for additional
regions of metastasis. Has been consulted for by neurosurgery,
neuro-oncology and radiation oncology, as well as continued
involvement of her primary oncologist. The patient prefers to
pursue radiation with the intent of being able to taper off
steroids as quickly as possible so that she could resume Atezo
treatment.
While in the hospital, her neurologic status was frequently
assessed and precautions were taken to prevent deterioration,
including maintain blood pressure, seizure prophylaxis with
Keppra and treatment with Dexamethasone to reduce the vasogenic
edema. The patient was scheduled to begin radiation planning
with radiation oncology, which she will pursue as outpatient
following her discharge. She was evaluated by the physical
therapy service, received teaching in exercise specific to her
current condition and assessed to be independent for discharge
to home pending continued care.
# Sterile Pyuria:
# Hematuria:
patient with signs and symptoms of UTI including dysuria,
hematuria. UA with >182 WBCs, large leuks, large blood, but no
bacteria (may be consistent with sterile pyuria following
outpatient treatment of UTI, immunotherapy response or local
irritation d/t primary disease). Was started on CTX for UTI
symptoms pending UCx. UCx with mixed flora supports a diagnosis
of sterile pyuria. Blood cultures collected during this
admission did not grow any bacteria. The patient received three
doses of intra-venous ceftriaxone that was later discontinued
without deterioration in her condition or appearance of any new
symptoms. Her blood counts were monitored throughout
hospitalization given her history of massive hematuria, were
stable, and she did not require transfusions.
# Elevated blood glucose
While hospitalized, the patient was treated with low doses of
sub-cutaneous insulin for elevated blood glucose, most likely
secondary to steroid administration. The ___
was consulted prior to discharge to evaluate for outpatient
needs following discharge and recommended Januvia, on which the
patient is being discharged. She will likely require this
medication until her steroids are tapered off and will follow up
with her PCP and outpatient ___ clinic for monitoring.
Prior to discharge, the patient received carbohydrate counting
and nutrition teaching as well.
CHRONIC ISSUES
==============
# HTN:
Chronic HTN treated with home atenolol, has been normotensive
during hospitalization. Blood pressures were frequently
monitored and were kept below a systolic blood pressure of 160
for neurological prophylaxis. The patient was normotensive
throughout her admission and did not require any pharmaceutical
intervention for hypertension outside of her home atenolol.
# Anemia:
Anemia may be secondary to hematuria, more likely secondary to
chronic disease. Blood counts stable, TIBC low with Tsat=35%
more supportive of diagnosis of anemia of chronic disease. Blood
counts were monitored throughout the admissions and remained
stable.
# Chronic Kidney Disease:
Has had outpatient serum creatinine around 1.1-1.3 at baseline,
during her inpatient course has had creatinine elevated as high
as 1.4 with a pre-renal component (FeNa=0.5%), and elevated BUN.
Judicial hydration was given as necessary and oral intake of
fluids was encouraged. The patient will follow up her serum
electrolytes, creatinine and blood urea within a week of
discharge to monitor her CKD.
#HCP/CONTACT: ___ ___
#CODE STATUS: DNAR, DNI
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
***. | NERVOUS SYSTEM NEOPLASMS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
PRIMARY REASON FOR ADMISSION:
___ with metastatic prostate ca presenting wtih acute onset
right upper quadrant pain with imaging suggestive of worsening
tumor burden in the liver.
ACUTE ISSUES:
# Abdominal pain: The patient presented with acute onset right
upper quadrant pain. CT imaging did not show any acute pathology
but did show increasing metastatic disease of the liver. He was
continued on his home oxycontin with an increased dose of
oxycodone 10mg for breakthrough pain and symptoms were much
better controlled. He was encouraged to take the oxycontin as
prescribed (q12h standing) rather than as needed to better
provide long-acting pain control.
# Prostate cancer - patient is s/p multiple chemotherapy
regimens as well as palliative XRT. continued flomax,
finasteride, prednisone.
# Hypertension
- CHANGED metoprolol tartrate 100mg daily to metoprolol
succinate 75mg daily
- continued lisinopril
TRANSITIONAL ISSUES:
- patient to have outpatient ___ per the inpatient physical
therapy recommendations
- decreased beta blocker to metoprolol succinate 75mg daily from
metoprolol tartrate 100mg daily given borderline hypotension and
occasional bradycardia with metoprolol tartrate 25mg q6hr
- emergency contact/HCP: ___ (son) ___
- code during hospitalization - full
***. | SIGNS AND SYMPTOMS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***RIEF HOSPITAL COURSE:
================================
___ year old man with hx of HTN, obesity, DMII, left septic knee
status post washout, chronic lower extremity wounds and mild
cognitive delay presented with bilateral leg pain and swelling
consistent with superinfection of his chronic wounds,
complicated by group A strep bacteremia. He completed a two week
course of ceftriaxone/flagyl. He was also found to have severe
bilateral arterial insufficiency, left sided DVT, and
intermittent atrial fibrillation/atrial flutter for which he was
started on warfarin. His course was complicated by influenza A,
and he completed 5 day course of Tamiflu.
ACTIVE ISSUES:
================================
# Complicated cellulitis
# Chronic venous stasis and lower extremity wounds
# Severe bilateral arterial insufficiency
Patient with history of chronic bilateral lower extremity wounds
which were superinfected on admission, with exam notable for
purulent drainage and swelling ___ the setting of known venous
insufficiency and arterial disease. X-rays and MRI showed no
evidence of underlying necrotizing infection or osteomyelitis.
He was found to have group A strep bacteremia likely
translocated from wounds, and he completed a 2 week course of
ceftriaxone/flagyl per infectious disease team. Wound cultures
grew MSSA. Wound care was continued at discharge.
# Influenza A
Found to be influenza A positive. He completed a 5 day course of
Tamiflu ___ ___ - ___ AM]. Chest xray ___ showed retrocardiac
opacity, and he received 1 dose of vancomycin. This was
discontinued given low clinical suspicion for pneumonia. He
remained stable and continued to improve without additional
antibiotics. Flu symptoms mostly resolved, with mild residual
cough at discharge. He was discharged on benzonatate and
dextromethorphan for symptomatic treatment.
#Atrial flutter/Atrial fibrillation
#Second degree type I AV block
Patient with reported history of paroxysmal AFib with EKG from
___ showing AFib. He had episodes of A flutter on telemetry and
EKG this admission. CHADS2Vasc 3. Patient will need to be on
long term anticoagulation after DVT course of warfarin is
complete. He had few episodes of 1st degree AV block on
telemetry which were asymptomatic. His INR was labile at
discharge, likely due to fluctuating PO intake ___ the setting of
influenza. Last four INR and Coumadin doses as below. No
clinical signs of bleeding. This will need to be closely
monitored as outpatient and warfarin dose adjust with goal INR
___.
___ - INR 2.9 - warfarin 2.5mg
___ - INR 3.7 - warfarin 0mg
___ - INR 3.4 - warfarin 1mg
___ - INR 3.7 - warfarin 0mg
# DVT
Nonocclusive DVT found on lower extremity ultrasound ___ left mid
and distal femoral vein. ABIs confirmed bilateral severe
arterial insufficiency of lower extremities. CTA showed patent
grafts, although with focal arterial thrombus within the
proximal popliteal artery above the level of the graft, with
associated severe stenosis. Severe arterial insufficiency and
DVT likely contributed to ___ swelling and impaired blood flow,
pre-disposing to ulceration and infection. Per orthopedic,
vascular and podiatry consults, no need for surgical
intervention. He started on warfarin for DVT, which he should
continue indefinitely for paroxysmal atrial flutter/fibrilation
and CHADS-VASC 3. Goal INR ___, supratherapeutic on discharge.
Continued Tylenol for pain control. Will need active titration
of warfarin on discharge.
___:
Cr 1.3 on arrival, most recently 0.7 ___ ___. Per renal team,
original insult on admission was likely multifactorial secondary
to acute tubular necrosis and contrast induced nephropathy.
Renal ultrasounds showed no evidence of hydronephrosis.
SPEP/UPEP were negative. His ___ worsened later during
admission, which was likely due to hypovolemia ___ the setting of
poor PO intake and insensible losses with the flu. His Cr
improved with IV fluid and was 1.3 at discharge.
CHRONIC ISSUES:
================================
#Type 2 Diabetes:
Has not been on treatment, A1c 9.2%. ___ was consulted for
recommendations on starting regimen. He was initially started on
metformin and glipizide. Stopped metformin due to ___ and
___ due to hypoglycemia. He was found to have with
proteinuria so started on lisinopril 2.5mg daily, which was held
at discharge due to ___. He was discharged on insulin sliding
scale, but was not requiring any insulin during later half of
admission, likely due to poor PO intake ___ the setting of flu.
His blood sugars should be monitored closely, and oral regimen
re-started as appropriate. Patient not amenable to insulin at
home. Lisinopril should also be re-started as ___ continues to
improve.
#?CAD
#Atypical chest pain
Patient endorsing intermittent substernal exertional chest pain
prior to admission. Also says he had "5 heart attacks" ___ the
setting of surgery ___ ___ and received chest compressions at
that time. EKG without obvious ischemic changes. Trop <0.01 x 2.
TTE without without evidence of focal wall motion abnormality to
suggest prior MI, normal ejection fraction. ASCVD 14.6% based on
lipid panel. Began medical optimization by starting aspirin 81mg
daily, moderate intensity atorvastatin 40mg daily. He will
benefit from outpatient stress test.
#Macrocytic Anemia
Presented with Hgb 14.7/Hct 43.3 on ___. Developed macrocytic
anemia during admission. Possible etiologies include reduced
folate absorption ___ the setting of drug administration (ASA,
antibiotics), Folate/B12 deficiency, or marrow suppression ___
setting of underlying infection. This should be re-checked as an
outpatient to ensure resolution.
#HTN:
Patient remained normotensive off medications. Initially started
on lisinopril 2.5mg, ___ the setting of proteinuria and
uncontrolled diabetes. This was held due to ___. Please re-start
as appropriate ___ outpatient setting.
#Bright red blood per rectum:
Patient reports recurrent episodes of bright red blood per
rectum, which tend to occur when constipated. No prior
colonoscopy. His constipation with aggressive bowel regimen.
Will need colonoscopy as an outpatient.
#Folliculitis
#Cutaneous ___:
Presented with pruritic grouped papules noted on both arms and
trunk. Most likely folliculitis given distribution. No evidence
of superinfection and patient completed antibiotics course as
above. Also with erythematous rash ___ left axilla and ___ the
groin consistent with cutaneous candidiasis. Symptoms improved
with miconazole powder.
#History of positive PPD
Chest xray obtained without evidence of active tuberculosis.
Quantiferon gold ___ ___ was indeterminant, Repeat quantiferon
gold was indeterminate. Will need outpatient follow up with
infectious disease.
#History of ?partial complex seizures:
Off anti-epileptics since ___. No episodes this admission.
Discharged without anti-epileptics.
TRANSITIONAL ISSUES
==================
DISCHARGE LABS:
-Cr: 1.3
-Hgb: 9.7
-INR: 3.7
LAB MONITORING:
[] INR will need to be checked ___ and closely monitored,
with adjustment of warfarin as an outpatient. Last 4 days of
warfarin/INR below.
___ - INR 2.9 - warfarin 2.5mg
___ - INR 3.7 - warfarin 0mg
___ - INR 3.4 - warfarin 1mg
___ - INR 3.7 - warfarin 0mg
FOLLOW UP
[] Patient needs primary care doctor to coordinate care and
manage multiple medical issues as above. Please set up on
discharge from rehab.
[] Please ensure patient has access to and can afford new
medications, especially warfarin.
[] Patient needs to follow up with podiatry for foot wounds. He
will need ongoing foot care, and will likely benefit from
visiting nurses for help with this when discharged from rehab.
[] Monitor blood sugars and start oral diabetes regimen if blood
sugars become elevated, as patient is not amenable to insulin at
home.
[] Re-start lisinopril when ___ resolved, as appropriate given
hypertension and proteinuria ___ the setting of uncontrolled
diabetes.
[] Please re-check CBC to ensure resolution of macrocytic
anemia, otherwise consider additional workup.
[] Given the discrepancy ___ size of the kidneys on inpatient
ultrasound, consider repeat ultrasound as an outpatient.
[] Follow up incidental CT findings (Uncomplicated
cholelithiasis, Left-sided nephrolithiasis without evidence of
obstructive uropathy, Hepatic steatosis).
[] Consider outpatient sleep study for OSA.
[] Consider outpatient stress test for ?CAD.
[] Consider outpatient screening colonoscopy given reports of
intermittent bright red blood per rectum.
[] Consider follow up with vascular surgery for DVT and
arterial/venous insufficiency .
[] Consider follow up with cardiology for atrial flutter and AV
conduction defect.
[] Consider follow up with infectious disease for reported
positive PPD and indeterminent quantiferon gold x 2.
#CODE: Full (confirmed)
#CONTACT: Sister ___ ___, c: ___
***. | CELLULITIS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Pt. was sent to ___ over concern for abdominal distension
representing ascites. A CT of the abdomen and pelvis was
performed, and not ascites or other pathology were identified.
I discussed this with the MD from ___.
Additionally noted during this admission is that his wt. was up
to 76.9 kg (2.5 kg over his dry wt. of 74.5 kilograms). He was
given one IV lasix dose of 40 mg, and his usual dose of lasix
will be resumed on discharge.
His WBC were elevated to 13k, this has been an intermittant
phenomenon at the ___ and Dr. ___ is aware. He has no
fever, no sob to suggest pulmonary or other infection. Blood
cultures were performed by the ED for unclear reasons and are
pending at the time of discharge.
His hct was noted to be 29 on HD # 2 here, although he had no
overt bleeding. His INR was therapeutic.
Dr. ___ is aware of the leukocytosis and anemia and will
continue to monitor this at the ___ following discharge. Dr.
___ if I would discuss prognosis with pt. and
famlly, and severe nature of heart disease. I met with dtr and
pt. with a ___ Interpreter. I attempted to discuss
specifics of pt.s heart disease at this time, however, the
daughter continually asked that I not relay any specifics to the
pt for unclear reasons. I answered the patients questions.
Pt. discharged back to ___.
***. | HEART FAILURE AND SHOCK WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
*** F PMHx dementia, bipolar disorder, urinary incontinence s/p
pessary, hypothyroidism, who was discharged on ___ for
syncope thought to be ___ UTI who re-presented after recurrent
syncopal episode with ___ monitor showing sinus
arrest/junctional rhythm s/p PPM placement
# Syncope: patient has had multiple syncopal events over the
past year, thought ot be ___ infection in the setting of (+)
UTI. She was recently admitted ___ syncope; she
was found to have a UTI. She was treated with a course of
cefopoxime and was discharged with ___ monitor. Following
discharge, patient suffered recurrent syncopal episode; ___
monitor at time of syncope showed sinus rhythm followed by sinus
arrest and a junctional escape at ___ bpm, thought to be the
likely cause of syncope. Other syncopal work-up was unrevealing;
thyroid function was well controlled on current levothyroxine
dosing, her medication list was reviewed and unrevealing for
contributing medications (donepezil was recently discontinued),
and she had no new infectious symptoms. She was evaluated by EP
for palliative PPM placement; following discussion with the
patient and her family she underwent successful PPM placement on
___. She will complete x3 day course of Keflex (last day
___ for ___ protection after infection. Given
PPM placement, following discussion with her outpatient PCP, her
donepezil was restarted on discharge. She will follow up in
Device clinic and with her PCP
# UTI: Patient was diagnosed with UTI during her last admission;
urine culture with pansensitive E.coli. She was continued on her
previously determined course of cefpodoxime and completed the
regimen in the hospital (last day ___.
#Dementia, moderate: patient was started on donepezil as
outpatient due to memory impairment. Due to concern for
contribution to syncope this was stopped on admission; however,
after PPM placement and email correspondence with outpatient PCP
the decision was made to restart this medication. She will
continue on donepezil 5mg qd.
#HLD: Simvastatin was discontinued during her last admission due
to limited data to support stating as secondary prevention in
patients older than ___
#Hypothyroidism: TSH:7.4 Free-T4:1.3. She was continued on
levothyroxine 50 mcg PO daily
TRANSITIONAL ISSUES:
[] Complete Keflex ___ q8h x3 days (last day ___
[] Our discharge department is in process of making
Urogynecology appointment for evaluation of pessary
#CODE: DNR/DNI
#EMERGENCY CONTACT HCP: son ___ ___
***. | PERMANENT CARDIAC PACEMAKER IMPLANT 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 female with h/o CAD s/p CABG, DM, Asthma, presents with
worsening SOB and fatigue.
.
SYSTOLIC CONGESTIVE HEART FAILURE: Pt presents with increasing
dypsnea, BNP 57,925 and evidence of fluid overload on exam with
JVP to 12cm-all suggesting a low output state. Low output state
is also likely exacerbated by her anemia and ASD. She was
started on dopamine as well as lasix drip. Central access was
obtained on admission and discontinued on ___. Lasix and
dopamine drips were weaned following a modest diuresis. She was
discharged on increased dose of torsemide and started on
hydrochlorothiazide, with oupatient follow up scheduled.
.
CORONARY ARTERY DISEASE: On admission, she was without chest
pain, EKG unchanged, Trop 1.07 likely in setting of acute renal
failure. She was continued on aspirin, plavix. Her beta
blocker was temporarily held.
.
FATIGUE: She was admitted with significant fatigue that was most
likely multifactorial secondary to chronic heart failure, anemia
and Myelofibrosis. She was transfused 1 U PRBCs, with
significant releif of symptoms.
.
ACUTE ON CHRONIC RENAL FAILULRE: She had a creatinine of 4.2 on
admsission, thought to be likely related to poor forward flow in
the setting of a CHF exacerbation. Her creatinine improved with
diuresis and was 1.6 on discharge.
.
PNEUMOTHORAX: She developed a pneumothorax following RIJ line
placement. This was followed by serial chest x-rays and
resolved spontanously.
.
DIABETES: Diet controlled at home, she was started on an insulin
sliding scale in house.
.
ASTHMA: She was continued on her home nebs
.
MYELOFIBROSIS: She has chronic amemia and a 26 mo prognosis from
myelofivrosis. She is on Aranesp injections weekly at home,
last documented ___ and missed recent appts. She has a
chronically low Hct and, as a consequence, has been transfused
previously. Likely part of her fatigue/weakness may be ___
profound anemia. She was transfused with 1 U prbcs.
***. | 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.
***
Mrs. ___ was admitted to the hospital and taken to the
Operating Room where she underwent a right thoracotomy and
tracheobronchoplasty with mesh, bronchoscopy with lavage. She
tolerated the procedure well and returned to the TSICU in stable
condition. She was gradually weaned and extubated from the
ventilator and hr voice was strong. Her pain was controlled
with an epidural and she was using her incentive spirometer and
flutter valve effectively. Her ___ tube was removed on post op
day #2 as her drainage had decreased and there was no air leak.
She subsequently had her epidural removed. She was transferred
to the Surgical floor but within 24 hours required transfer to
the TSICU for pulmonary toilet and possible bronchoscopy. She
had notable congestion and some difficulty bring up her
secretions.
While in the TSICU she briefly improved but eventually her O2
requirements were growing and she was tachycardic to 140. There
was also a question of aspiration. She was reintubated on
___ and placed on broad spectrum antibiotics after being
pan cultured. Her WBC was 14K and she had a possible right
basilar opacity. On ___ she had bronchoscopy and modest
secretions were aspirated. her sedation was gradually weaned
and she began weaning from the ventilator. She was also
vigosously diuresed daily and her chest xray began to improve
after a negative balance was obtained. She was eventually
extubated on ___ and diuresis continued. Her O2
saturations were 92-97% on 3 LPM. She was evaluated by ENT and a
fiberoptic exam showed no gross evidence of vocal cord
paralysis.
Following transfer to the Surgical floor she continued to
progress well. She continued on schedsuled nebulizers, Mucinex
was added and she was eventually on room air with saturations of
95%. Her right thoracotomy site was healing well and she was
evaluated by the Speech and Swallow service on multiple
occasions. She was initially placed on ground solids and nectar
thick liquids but after a few days all restrictions were
eliminated. She was up and walking independently and her blood
sugars were in the 160-180 range on a reduced NPH dose. Her
antibiotics were stopped after 4 days as all cultures including
BAL were no growth.
She was discharged to home on ___ and will follow up in the
Thoracic Clinic in 2 weeks, prior to returning to ___.
***. | OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
*** w/ T1N0Mx cholangiocarcinoma, large ascites admitted or
diagnostic lap liver bx with course c/b R hydrothorax requiring
chest tube drainage (s/p chest tube removal ___, S.
epidermidis bacteremia and malnutrition requiring transfer to
Medicine.
# Cholangiocarcinoma: S/p Y-90 radioablation and portal vein
embolization ___, now status post diagnostic laparoscopy and
liver biopsy on ___. Surgery notable for no mets visible
metastasis. Liver biopsy revealed no evidence of underlying
cirrhosis or malignant cells, suggesting Y-90 was successful in
shrinking tumor. Patient was found to have marked pleural
effusions and ascites, but cytology revealed no malignant cells.
Patient significantly deconditioned with severe malnutrition, so
there are no current plans for surgery to treat her malignancy,
but Dr. ___ is optimistic she can be treated if her functional
status improves. She will continue to follow with liver clinic
and hematology/oncology as outpatient.
# Ascites/Hepatic Hydrothorax: Patient found to have hepatic
hydrothorax and ascites, likely due to obstruction of biliary
system. Liver biopsy did not reveal any evidence of underlying
cirrhosis. No evidence of malignancy cells in fluid from either
location and ascitic fluid not consistent w/SBP. Patient had
chest tube place with IP on ___ with drainage of >5L fluid
prior to removal on ___. Patient subsequently started on 40mg
PO Lasix daily and CXR on ___ showed no evidence of
re-accumulation of hydrothorax. Patient remained stable from
respiratory standpoint throughout admission and never required
supplemental oxygen. She will be followed closely by liver
clinic as outpatient.
# S. epidermidis bacteremia: Thought to be secondary to line
infection from ___. Patient had several positive cultures,
making contamination less likely. She was started on Vancomycin
1g q12h on ___ with plan for 14 day course. Last positive blood
cultures was ___. ___ placed ___ to continue IV antibiotics
as outpatient. She remained afebrile, hemodynamically stable
throughout admission.
# Severe Malnutrition: Patient was found to be severely
malnourished, so underwent placement of NJ tube with initiation
of tube feeds. She was also continued on home Mirtazapine and
Methylphenidate for appetitie stimulation. Tube feeds to be
continued as outpatient.
# Depression/Bipolar disorder: Patient has underlying
depression/anxiety and exhibited significant difficulty coping
with her diagnosis and prognosis. She was continued on her home
Bupropion, Lamotrigine, Mirtazapine 15mg QHS. We increased the
frequency of her home Ativan for significant anxiety. In
addition to medical therapy she was seen by SW and palliative
care, both of whom will continue to follow as outpatient.
Transitional Issues:
[] patient is significantly depressed and anxious. She should
continue to be seen by palliative care and consider SW follow up
as outpatient.
[] patient should complete 14 day course of Vancomycin (last day
___. PICC may be removed after course of antibiotics.
[]Patient started on 40mg Lasix daily to prevent re-accumulation
of fluid. She should be continued on this medication with
titration by outpatient liver doctor.
[] She should continue tube feeds for significant malnutrition.
Jevity 1.5 @55ml/hour continuous.
[] Patient has follow up in liver clinic (see appointments
above).
#COMMUNICATION: ___ Relationship: husband
Phone number: ___
#CODE: Full
***. | HEPATOBILIARY DIAGNOSTIC 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.
***
Summary Statement
==================
___ PMH CAD, afib on Coumadin, CHF, recent admission for
cellulitis and CHF exacerbation, p/w left leg swelling with
erythema and pain, afebrile with normal vital signs, nontoxic
appearance. She has volume overload with lower extremity edema
and laboratories consistent with HFrEF exacerbation and UTI. She
is growing E coli and Kleb in her urine with various resistances
but currently on macrobid (___). Patient with persistent
ankle pain thought to be due to gout. Ankle X ray negative.
Continues to have diarrhea--c diff negative so may be from
colchicine/CTX.
Active Issues
==============
#left lower extremity pain:
#Gout
Given patient previously unsuccessfully treated for cellulitis
of bilateral lower extremities, presentation felt to be more
consistent with chronic venous stasis than overt cellulitis. The
patient has point tenderness over the left ankle joint space
which may be more consistent with the diagnosis of gout given
her previous arthrocentesis. The patient's left lower extremity
pain decreased significantly on colchicine suggesting this is a
gout flare. The patient was transitioned to steroids after
diarrhea. Discontinued colchicine and steroids following
resolution of symptoms.
#HFrEF
#chronic systolic heart failure
Patient with an ejection fraction of 40-45% on ___ with
systolic dysfunction consistent with distal LAD territory and
mild to moderate mitral regurgitation. She has noted that she
has not been taking metolazone at home and has been increasing
her diet. She also noticed some left-sided chest pain and
worsened lower extremity edema has been present for the past
several weeks. On initial exam her lower extremities had 2+
edema although her lungs were clear to auscultation and her JVP
was difficult to assess. Her chest x-ray shows mild/moderate
pulmonary edema. Her BNP was almost 9000 in the emergency
department. She was given Lasix 20mg, 40mg IV in ED. The patient
was transitioned back to her home diuretic which she tolerated
well. Recommend further adjustment of diuretic on outpatient
follow up.
#Normocytic anemia
Patient is a long-standing history of anemia there is been
thought to be due to chronic kidney disease and acute
inflammation. The patient presented at her baseline of near 8
but down trended to the mid sevens. There is no active signs of
ongoing bleed. The patient's iron studies are suggestive of iron
deficiency anemia. Would consider further evaluation in the
outpatient setting.
#Urinary tract infection
Patient complains of dysuria as well as frequency of urination
consistent with her previous urinary tract infections. A Foley
catheter was placed in the emergency department. The patient was
initially started on empiric CTX. The patient's urine speciated
to be E. coli and Klebsiella that was sensitive to
nitrofurantoin. She will complete a 7-day course with
nitrofurantoin (last dose = ___.
#DMII
Patient with a history of insulin-dependent type 2 diabetes who
was last discharged with Glargine 20 nightly, and Humalog 10
with each meal. Blood sugar levels increased during current
hospitalization in the setting of treatment with steroids.
Therefore, switched to NPH, but transitioned back to lantus and
Humalog prior to discharge. Discharged on lantus 20u qhs and
Humalog 3 units with breakfast and lunch, and 5 units with
dinner. On this regimen, pre-prandial blood sugars were well
controlled between 140 and 190. She will need further adjustment
of her insulin regimen in the outpatient setting as needed.
#Diarrhea
Patient has had multiple episodes of watery diarrhea since
admission. This occurred in the setting of starting colchicine
for gout flare as well as ceftriaxone urinary tract infection.
Given patient's recent clindamycin course, there was some
concern for C. difficile. However, C-diff was negative. Resolved
prior to discharge.
#Hypokalemia
Patient with hypokalemia in the setting of active IV diuresis.
Repleted prn.
Chronic Issues
===============
#Afib
Patient was a history of atrial fibrillation currently on
warfarin with a goal of INR ___. Discharged on home Warfarin 2.5
mg daily.
#CKD
Last discharge summary notes Cr 1.2. Stable
#CAD
Continued on home atorvastatin and metoprolol
#HTN
Continued on home losartan 50mg Daily. Held amlodipine given
normal to only slightly elevated blood pressures. Outpatient
follow up recommended.
#Hypothyroidism
Continued on home levothyroxine 150
#GERD:
Continued on home omeprazole 40
Transitional Issues
====================
[] Completing 7-day course with nitrofurantoin (___) for
UTI
[] Follow up volume status and adjust diuretic accordingly
[] Changed insulin regimen of lantus 20u qhs and Humalog 3 units
with breakfast and lunch, and 5 units with dinner. Please follow
up blood sugar measurements and adjust insulin regimen
accordingly.
[] Held home amlodipine in the setting of normal to only
slightly elevated blood pressure measurements in the hospital.
Please follow up blood pressure and adjust blood pressure
regimen accordingly
[] Given the patient's age and iron deficiency anemia, the
patient would likely benefit from follow-up colonoscopy
[] F/u INR and dose accordingly
Code: FULL
Contact: ___ ___
***. | HEART FAILURE AND SHOCK WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient was admitted to the podiatric surgery service from.
The emergency room for a left ___ digit infection on ___. On
admission, he was started on broad spectrum antibiotics. He was
taking to the ___ for Left ___ digit amputation on ___. Pt
was evaluated by anesthesia and taken to the operating room.
There were no adverse events ___ the operating room; please see
the operative note for details. Afterwards, pt was taken to the
PACU ___ stable condition, then transferred to the ward for
observation.
Post-operatively, the patient remained afebrile with stable
vital signs; pain was well controlled oral pain medication on a
PRN basis. The patient remained stable from both a
cardiovascular and pulmonary standpoint. He was placed on
vancomycin, ciprofloxacin, and flagyl while hospitalized and
discharged with oral antibiotics. His intake and output were
closely monitored and noted to be adequtae. The patient received
subcutaneous heparin and pneumatic boots throughout admission;
early and frequent ambulation were strongly encouraged.
The patient was subsequently discharged to home on ___ with
infection resolved. Patient seen and evaluated by physical
therapy. Patient was instructed to remain partial weight bearing
to left heel. Patient was given a prescription for augmentin.
Patient will follow up within 1 week of discharge The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
***. | AMPUTATION OF LOWER LIMB FOR ENDOCRINE NUTRITIONAL AND METABOLIC DISORDERS WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
SUMMARY/ASSESSMENT:
Mr. ___ is a ___ yo M with MDS ___ chronic neutropenia and
transfusion-refractory thrombocytopenia, GIST, PMR,
hypothyroidism, and HTN who presented to
___ fever and RUQ abdominal pain and was transferred to
___ for management of cholecystitis ___ febrile neutropenia
and abscess vs. perforation now s/p perc chole placement.
ACUTE/ACTIVE PROBLEMS:
# Febrile neutropenia
# Cholecystitis with pericholecystitis collection:
ACS and ___ consulted on admission. Due to the risk of surgery in
the setting of his transfusion-refractory thrombocytopenia, ___
performed a percutaneous cholecystostomy.
As far as antibiotics, he received cefepime/Flagyl
(___). Cultures from
___ fluid collection aspiration grew
mixed bacterial flora. On ___ he was transitioned to Augmentin
to take through ___ (to complete 7 days of treatment after
source control). Blood cultures had no growth to date. He was
given instructions for drain care and monitoring. Once the drain
is putting out <10 mL/day for 2 consecutive days, he was
instructed to call ___ so the drain can be evaluated/possibly
removed. He was given contact information to follow up in acute
care surgery clinic with Dr. ___.
# MDS
# Chronic neutropenia on filgrastim
# Chronic thrombocytopenia refractory to platelet transfusion
He received 1 pool platelet transfusion during ___ procedure and
was given pre-treatment due to his prior transfusion reactions
(diphenhydramine 50 mg IV x1 and famotidine 20 mg IV x1). He was
continued on his home acyclovir ppx. He received one dose of his
weekly Zarxio 480 mcg given ___.
# Cervical rash: no s/s superinfection. Awaiting outpatient Bx
path. Sutures were removed.
CHRONIC/STABLE PROBLEMS:
#GIST/GERD: continued home sucralfate, PPI
#PMR: continued home prednisone 5
#HTN: initially held home atenolol I/s/o infection; this was
resumed on discharge
#hypothyroid: continued home levothyroxine
>30 minutes spent on complex discharge
***. | DISORDERS OF THE BILIARY TRACT WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ w/ ESRD on HD, HTN, cardiomyopathy with dCHF, SLE, BOOP,
DCIS s/p lumpectomy, seizure d/o (___), R renal transplant and
removal, who presented w/ recurrent SOB and blood-tinged sputum.
#HCAP: Recently discharged ___ for DOE (started Levoflox for
RLL infiltrate), but left AMA to attend nephew's funeral.
Returned ___. On ___, she was febrile and started Vanc/Cef for
HCAP based on physical exam and CXR findings of persistent RLL
infiltrate. She was broadened to Vanc/Zosyn for anaerobic
coverage on ___ for continued fevers. CT chest ___
demonstrated a R-sided effusion, which was tapped and found to
be non-complicated exudative effusion. She completed an 8-day
course of antibiotics and her cough and blood-tinged sputum had
resolved by discharge.
#Dyspnea: Patient admitted with symptoms of SOB on exertion with
elevated BNP with differential diagnosis including fluid
overload, PNA, SLE vasculitis, PE (normal d-dimer). Most likely
etiology was fluid overload, but evaluation difficult with new
HCAP. She had a negative ANCA, negative Anti-GBM, normal SPEP,
and a CT without evidence of vasculitis. It is likely that her
dyspnea was a combination of fluid overload and PNA
concominantly.
#AMS: Upon readmission on ___, she was noted to be acutely
encephalopathic, with word finding difficulties and extreme
emotional lability. She was transferred to the MICU, where she
returned to baseline MS (___) and received brain MRI per neuro
recs (no acute stroke, but chronic microvascular disease). She
had sick euthyroid (TSH 9.1 but normal T4 1.6) and sedating meds
were held (i.e. Zolpidem). EEG from ___ (after patient returned
to baseline) was abnormal suggestive of a focal cerebritis or
focal infectious process, but neuro felt this was nonspecific
and could be related to her prior stroke. The most likely
etiology of her AMS was hyperactive delirium secondary to toxic
metabolic encephalopathy (possibly due to HCAP, however, the
inciting factor is unclear), however seizure is also possible.
Neurology recommends 24 hour EEG should another such episode
occur. She was discharge ___, relating appropriately.
#FUO: Of note, Ms. ___ has been having low grade fevers since
___ with no clear etiology. She was admitted twice previously,
and was seen by GI (who on her admission had noted liver
hemosiderosis on MRCP, considered cardiac hemosiderosis for her
SOB, no clear source for fever) and ID (who considered
prosthetic joint infection). A skin biopsy on ___ prior to
this admission revealed a leukocytoclastic vasculitis. Although
Dr. ___ steroids for presumed lupus flare with
vasculitis, she never took prednisone, and the lesions resolved
on their own. In this admission, she continued to be febrile to
as high as 103 while on Vanc/Zosyn, for several days, which
prompted us to consult hematology and perform a CT
Abdomen/Pelvis, which revealed extensive para-aortic LAD that
had increased in size from a prior CT in ___. She received
CT-guided LN biopsy on ___. Results were pending at the time of
discharge.
#Abdominal pain: She also has chronic abdominal pain (RLQ),
which had been ongoing for ___bdomen/pelvis
revealed what appear to be post-surgical changes in the RLQ,
without anything else to explain her pain.
CHRONIC ISSUES:
#ESRD: Ms. ___ also received HD while she was in the hospital
and we continued here on her home CKD medications (Nephrocaps,
Epoetin, Sevelamer. Her elevated Alk Phos is most likely ___
renal osteodystrophy.
#SLE: Followed by Dr. ___. ANCA neg, anti-dsDNA negative,
ESR 58, CRP 27.4, C3 165, C4 49, negative HFE. Of note, her
ferritin was ___.
#Shoulder pain, bilaterally: Ms. ___ has a history of
avascular necrosis, torn rotator cuffs, and osteoclastic
activity in her shoulders bilaterally. She was treated with low
doses of IV Dilaudid and PO Oxycodone.
#Thrombocytopenia: H/o HIT with positive PF4 in ___ but neg on
follow-up, h/o TTP in ___.
- Stable on this admission
#Normocytic Anemia: On epoetin at HD, h/o autoimmune hemolytic
anemia, positive anti-E Ab against RBC, thalassemia trait based
on microcytic indices and peripheral smear review (teardrops) by
Dr. ___.
-Stable on this admission
#Hypertension: We continued home antihypertensives (Lisinopril
80 mg daily, Metoprolol 100 mg TID and Nifedipine CR 90 mg
daily)
TRANSITIONAL ISSUES:
[] Please make sure to follow up on pathology results of LN
biopsy
[] Consider further work-up for patient's FUO, which may be due
to underlying malignancy, as she is at an increased risk for
Lymphoma given her diagnosis of SLE and previous
immunosuppresive therapies (for failed R kidney transplant)
[] Pt needs stress echo and PFTs as outpatient (which are
scheduled)
[] Med changes: Re-started patient on Aspirin 81 for cardiac
protection. Decreased dose of Hydromorphone to 1 mg q8h PRN to
avoid sedation/confusion. Discontinued Zolpidem as it appeared
to precipitate an episode of delirium/confusion.
***. | OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is a ___ yo M with h/o melanoma s/p wedge resection
and IL2, who presents with generalized weakness and dyspnea on
exertion, and is found to have too numerous to count new lung
nodules, liver nodules, and a new lesion in T9.
# Metastatic melanoma: He has wide spread metastatic disease
that has progressed on IL2. A new right frontal parafalcine
lesion was noted on MRI but is not causing him to have any
symptoms. His clinical status improved and he was started on
dabrafenib and trametinib. Palliative care and social work
followed him regarding his end of life issues and concerns. His
symptoms of nausea, pain, and anxiety were treated.
# ? Pneumonia: He was afebrile, without leukocytosis but he
developed a new productive cough and was hypotensive. He was
initially started on vanc/cefepime and flagyl given concern for
postobstructive PNA. He was transitioned oral levofloxacin and
his cough resolved. He completed his antibiotic course on
___.
# Right sided pleuritic chest pain: Most likely due to lung
pathology on the right side (s/p wedge resection) as well as
enlarged liver compressing on diaphragm. Oxycontin and oxycodone
helped control the pain. On ___ he had a new onset of chest
pain. EKG at the time was normal and cardiac enzymes were
negative. His chest pain resolved after several hours and did
not return.
# Failure to thrive: Improved with Ensure, Megace, and a bowel
regimen.
# Atrial fibrillation: He went into Afib with RVR on ___. His
heart rate at the time was 130-140s with hypotension to ___.
Cardiology was consulted and recommended discontinuing his home
diltiazem and switching him back to sotalol (which was
discontinued prior beginning treatment with IL-2). He
spontaneously converted to normal sinus rhythm on sotalol.
Anticoagulation was held because his CHADS2 score is zero.
# Hypotension: Multifactorial but the exact etiology was
unclear. Differential diagnoses included dehydration, adrenal
crisis in setting of illness requiring higher doses of steroids,
pericardial effusion given low voltages on EKG (echocardiogram
normal) and/or afib w/ RVR (may have exacerbated but not the
primary cause). He has history of chronic adrenal insufficiency
and hypopituitarism for which he is on chronic prednisone. His
prednisone dose was increased and he was given fluid boluses
with minimal response. Fludrocortisone was also added with
minimal effect. The fludrocortisone was discontinued and his
blood pressure improved on midodrine. He will follow up with his
outpatient endocrinologist regarding midodrine and tapering his
prednisone.
# Transaminitis/hyperbilirunemia: Most likely from metastatic
disease to the liver. He does not report alcohol use. His liver
function should be monitored as an outpatient.
# T9 vertebral metastasis: No symptoms of neuro compromise now,
no evidence of fracture on CT imaging. Continued home pain
regimen and vitamin D. He will discuss with his oncologist about
starting bisphosphonates as an outpatient.
# Hypothyroidism: Continued home levothyroxine
TRANSITIONAL ISSUES:
=======================
[] monitor for adequate nutrition and hydration
[] new T9 lesion: address need for bisphosphonate initiation
[] adrenal insufficiency and hypotension: prednisone taper and
midodrine dose will need to be adjusted by his outpatient
endocrinologist
***. | RESPIRATORY NEOPLASMS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
*** with PMHx of Hep C, MVA s/p splenectomy, and Hodgkins
lymphoma in remission ___ years who was discharged ___ from
___ after a month long stay for fungal endocarditis requiring
aortic root reconstruction, AVR and MVR who presented from rehab
with hypotension.
BRIEF HOSPITAL COURSE
======================
# Respiratory Failure
On readmission to the MICU he developed tachypnea and hypoxemia
requiring intubation. This was felt to be secondary to bilateral
pleural effusions, respiratory muscle weakenss in the setting of
malnutrition, and volume overload. He had chest tubes replaced
and was eventually extubated successfully on ___. Patient
required reintubation on ___ for worsening hypoxia, found to
have necrotizing Klebsiella infection. Patient able to be weaned
from vent, but required several reintubations secondary to
respiratory muscle weakness, decreased functional parenchyma,
and restrictive lung physiology. Family meeting held, at which
time wife, daughter and other family members decided to make
patient DNR and CMO. Patient passed on ___ after terminal
extubation.
# Septic Shock
He presented with leukocytosis, tachycardia, and finitially
fluid responsive hypotension. Multiple infectious etiologies
were considered, and he was treated for HCAP with an 10-day
course of vancomycin/meropenem and JP drain placement into a
deep pelvic abcess. He continued to have fevers and leukocytosis
with concern for lack of source control. Bilateral thoracenteses
showed culture-negative pleural effusions, blood cutlures were
initially negative, and urine culture was negative. He had BAL
twice without evidence of recurrent pneumonia. He eventually
defervesced and was transferred to the medical floor. After
completion of treatment he had recurrent hypotension and fevers
requiring readmission to the MICU and he was found to have VRE
bacteremia treated with linezolid. JP drain was reassessed and
removed on ___ given resolution of pelvic abscess. Pressors
were weaned. Subsequently on ___ he was noted to have worsening
respiratory status and hypotension requiring four pressor
support. Patient able to be weaned off pressors.
# Pulmonary Embolism and Right Subclavian Artery Thrombus
CTA on ___ showed PE in the RML segmental arteries. He also
developed right arm swelling and was found to have a right
subclavian artery thrombus. Vascular surgery consulted and given
his multiple comorbidities, no intervention was planned. He was
started on a heparin drip, eventually bridged to warfarin.
# Anemia
Anemia was multifactorial secondary to chronic desease and
gastritis. He required intermittent blood transfusions. He had
no evidence of DIC or hemolysis.
# Hypothyroidism:
He was noted to have elevated TSH > 20 during hypotension
work-up. Endocrine consulted and concerned about hypothyroidism
beyond normal fluctuation seen in the ICU. started on IV
synthroid 50 mcg and later uptitrated to 75 mcg daily (PO
interfered with by tube feeds).
# Ileus
Dilated bowels seen on imaging, and patient with abdominal pain,
thought to be in setting of sepsis/narcotic use. This resolved
with bowel rest, TFs later reinitiated. C diff sent and negative
when having loose stools.
# Malnutrition
Poor PO intake previously and had been made NPO for aspiration.
speech and swallow consult prior to last discharge recommended
strict NPO, concern for continued aspiration. Video swallow on
___ was without evidence of aspiration, however, he was
placed on ground food restriction due to absence of teeth. His
appetite was poor, which required NGT placement on ___ for
tube feeds. Patient subsequently reintubated due to necrotizing
Klebsiella pneumonia, most likely due to aspiration event. Tube
feeds reinitiated.
# Hepatitis C
LFTs stable during previous hospital stay and overall stable
throughout this hospital course
# Endocarditis s/p repair of MV and replacement of AV
Patient was fungemic with cultures growing canidida sensitive to
fluconazole. Patient will continue fluconazole. Patient has not
been spiking fevers however has been hypotensive and tachycardic
with downtrending leukocytosis. He was transitioned to PO
fluconazole after his extubations.
Transitional Issues
-------------------
Patient expired
***. | SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
# Bacteremia: Admission cultures grew group G strep bacteremia.
The infectious disease team was consulted was consulted and
recommended six weeks of IV ceftriaxone therapy. We had concern
for endocarditis given pt's already damamged and vulnerable
valves, so TTE was performed and was negative for vegetations.
It was decided not to perform TEE as the results would be
unlikely to change management as pt would already receive six
weeks of IV antibiotics. After initiation of ceftriaxone, pt was
never febrile and his blood pressures were stable. He received a
PICC for post-discharge antibiotic administration.
# Clavicular osteomyelitis: Pt complained of pain in his right
shoulder and clavicle. After blood cultures returned positive
for group G strep, ID recommended MRI of this area. MRI showed
osteomyelitis of R clavicle with edema at SC joint. Orthopedics
was consulted and the SC joint was tapped. Gram stain was
negative as was the joint fluid culture. Orthopedics did not
feel that washout or debridement of the SC joint for clavicle
was necessary. Thoracic surgery was consulted and agreed that no
surgical intervention was required. Patient's pain slowly
improved and this area was less tender to palpation at time of
discharge.
# Cellulitis: Pt presented with severe cellulitis of left lower
extremity with swelling and erythema extended from ankle to
below the knee. The ankle architecture was not able to be
visualized due to swelling, and although pt has full range of
motion without pain at this joint, MRI was obtained to rule-out
septic joint and osteomyelitis. MRI showed only soft tissue
involved without effusion at the ankle joint. Pt received IV
ceftriaxone for his infection and the swelling, erythema,
warmth, and pain in the area declined greatly. He was treated
with tramadol and acetaminophen for pain.
# Elevated INR: Mr. ___ INR became supratherapeutic
several days after admission, so coumadin with withheld. Despite
this, his INR continued to rise for three days, peaking at 6.0,
before beginning to trend down again. DIC was considered, but
fibrinogen was elevated. He had no signs or symptoms of
spontaneous hemorrahge. On ___, he was given a small dose of PO
vitamin K (2.5mg) so that INR would be in acceptable range for
placement of PICC line on ___. INR became subtheraputic and he
was re-started on coumadin with lovenox bridge until he again
becomes theraputic.
# Atrial fibrillation: Patient remained in atrial fibrillation
throughout hospitalization and was monitored on telemetry. His
beta-blocker was held due to concern for possible sepsis, but he
was never tachycardic. Coumadin being restarted with lovenox
bridge.
# Chronic diastolic CHF: Lasix and acetazolamide were initially
held due to concern for possible sepsis. Home Lasix was
restarted ___ when blood pressures were able to tolerate a
diuretic. BPs were stable after addition of this medication.
Acetazolamide was held throughout admission to avoid making
patient hypotensive but will be restarted upon discharge.
# Gout: Initial concern for possible ankle joint effusion
related to gout, but no effusion was shown on MRI and Mr.
___ uric acid level was within normal limits. Allopurinol
was continued throughout admission and disease was inactive.
Colchicine was held for concern for renal damage.
# Incidental thyroid nodules on CT: Mr. ___ was without
signs of hypo or hyperthyroidism. TSH was within normal limits.
Will require outpatient follow-up.
# L wrist tumor: Lesion noted on wrist highly suspicious for
basal cell ___ need to be followed as outpatient.
TRANSITIONAL ISSUES:
# Thyroid nodules: Will need to follow as an outpatient. Discuss
with PCP
# ___ blood cultures: pending; will require follow-up
# Medications held: Colchicine not given during admission.
Please determine when it will be appropriate to restart this
medication.
# IV ceftriaxone and labs: Pt will be followed by infectious
disease in outpatient antibiotic clinic.
# L wrist tumor will need to be investigated as outpatient.
***. | 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.
*** with h/o of non-epileptic seizures, depression, anxiety and
mild developmental delay who is brought to the ED by EMS after
reporting two seizure-like episodes. She was found to have 2
scalp lacerations which were sutured and multiple thoracic spine
fractures.
#Non-epileptic seizure disorder: She was evaluated by neurology
and had an EEG. Neurology concluded that the events are
non-epileptic in nature and do not require any change in
management.
#Cervical and Spinal Fractures: A CT spine of the neck and
thorax was done and she was found to have fractures in T1-T4. An
MRI of the cervical and thoracic spine ruled out major
ligamentous injury or compresion to the spinal cord. Orthopedics
considers that the fractures are stable and there are no
limitations to physical therapy.
#Auto-aggressive behavior: The pseudo-seizure events do not
clearly explain a high energy trauma mechanism that could cause
vertebral fractures, there is concern for auto-aggressive
behavior to which the patient does not admit. It is the opinion
of the team that she will not be safe in an independent living
situation for now. This assessment is shared by the neurology
consulting team and her outpatient providers.
TRANSITIONAL ISSUES
#Deconditioning/Vertebral Fractures: As evaluated by ___ she
would benefit from rehab.
#Disposition / Living situation: Due to concern for the
patient's safety a conference was held with the representatives
from ___, ___, ___
___, ___ and the medical team. It was consensual
that her previous living situation was no longer a safe option.
It was agreed that she would go to ___ for <30 days and
then transition to suitable living arrangement such as a group
home.
FAMILY CONTACT: Multiple attempts to contact ___,
patient's sister were made, with no success. No voicemail was
left as there was no identification on the phone number listed.
___ (sister) - ___ (primary contact)
___ (mother, HCP) - ___, ___
___ (care coordinator) - ___
DDS Director ___ ___
___ ___
# Health care proxy: Patient currently has her mother listed as
health care proxy, who apparently has progressive dementia.
Patient would like to make her RN at ___.
Please continue to address in coordination with DDS and the
family.
***. | MEDICAL BACK PROBLEMS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year old woman with history of NASH cirrhosis c/b esophageal
varices s/p banding, hypertension, diverticulitis, with ___ week
history of abdominal pain, nausea, and diarrhea with negative
work-up and grossly normal endoscopy/colonoscopy.
# Abdominal pain/diarrhea: Patient reported history of loose
stools since ___ that became watery after beginning antibiotics
on ___ associated with lower abdominal pain and epigastric
pain. CT A/P done on ___ showed unchanged chronic fat
stranding extending from the sigmoid colon to the left adnexa
with trace surrounding free fluid which was thought to be due to
a prior episode of diverticulitis and fibroid uterus, also
unchanged from prior. UA was positive for moderate leuks and few
bacteria with 1 epi, but she complained of increased urinary
frequency so she was empirically treated with IV ceftriaxone for
3 days. UCx was negative. Abdominal/Pelvic Doppler was done to
r/o mesenteric ischemia. It was a technically limited study, and
only a small segment of the superior mesenteric artery was
visualized and this artery was patent and demonstrated normal
velocity. However, radiology commented that the
contrast-enhanced CT of ___ shows patency of the
mesenteric vessels. TTG was negative, C diff, fecal culture,
gram stain, O+P, Giardia were negative. Lipase was mildly
elevated to 146, concerning for mild pancreatitis. Endoscopy and
colonoscopy were performed. EGD was grossly normal, biopsies
taken. Colonoscopy significant for edematous sigmoid colon
without any gross lesions, unable to pass colonoscope so gastric
scope used and only advanced to distal end of ascending colon.
Biopsies are pending. Patient's diet was advanced to regular and
she was discharged with GI f/u in 1 month.
# Increased urinary frequency: Patient had increased urinary
frequency and a UA with moderate leuks and few bacteria. She was
treated with 3 days of IV ceftriaxone empirically but UCx was
negative. Low probability that patient had a true UTI.
# Vaginal/anal itching: 1 day prior to discharge patient had
vaginal and anal itching that she says was similar to previous
yeast infections. Exam showed external erythema on vulva and
near anus. Given 1 dose Diflucan and ketoconazole cream for
symptom relief.
# NASH cirrhosis: continued nadolol.
# Diabetes: was on basal-bolus regimen.
# Hypertension
- continued losartan
#CAD
- continued simvastatin
TRANSITIONAL ISSUES:
- Patient will have GI appointment ___ to follow up
EGD/colonoscopy biopsy results
- Patient complained of vaginal and anal itching. Given Diflucan
and ketoconazole cream. Follow up symptoms.
- do a f/u UA. Pt had microscopic hematuria (RBC 6) on admission
UA.
***. | 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.
***
___ with history of remote breast and esophageal cancer in
addition to progressive lung cancer who presents with dyspnea on
exertion.
#DYSPNEA ON EXERTION
#ACUTE HYPOXIC RESPIRATORY FAILURE likely secondary to acute
systolic heart failure, improving
#New Cardiomyopathy EF 18%
#LUNG CANCER:
Patient came in with sudden worsening in dyspnea on rest and
exertion, exam in ER notable for diffuse ronchi. Felt better
after methylprednisone and nebulizer treatments.
In the light of this new low EF, etiology now seems to be acute
systolic heart failure leading to sudden worsening of her
dyspnea
on exertion. She hasn't had any chemotherapy since ___ and her
EF was around 50% in ___.
Regarding her malignancy, she is planned to start immunotherapy
this month following her PET-CT. Discussed with oncology
covering
service for Dr. ___ they have moved up her staging to
expedite initiation of immunotherapy.
-ACS ruled out with trops negative times 2, no chest pain now
-received IV Lasix, now euvolemic, PO Lasix just as prn for home
per cardiology
-stress test came out abnormal, underwent angiogram with no
significant CAD and no stents were neeed
-Etiology of her heart failure is though be secondary to her
LBBB and dys-synchrony. She will be following with Dr. ___ as
outpatient, would need further workup as outpatient including
maybe a cardiac MRI and consideration for a pacemaker placement.
-Lisinopril 2.5 mg and Metoprolol 25 mg PO XL to continue
through discharge
#Hypomagnesaemia: repleted
Her Oncologist Dr. ___ has been in the loop with these
development, she plans to follow her as outpatient.
Plan discussed with patient and cardiology team today. Patient
agreeable with the discharge plan.
Time spent on the discharge process, spent in counseling patient
and discharge coordination is great than 30 mins.
***. | 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.
***
Ms. ___ underwent a ___ total abdominal hysterectomy
and bilateral salpingo-oophorectomy ___. Please see OMR for
full operative note with surgical details. She was admitted to
the gyn oncology service post-operatively. Her post-operative
course was uncomplicated. She was discharged home on
postoperative 1 when she was tolerating a regular diet, voiding
spontaneously and had her pain was controlled on oral pain
medications. Her pathology was consistent with Stage IIIA
endometrial cancer.
***. | 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.
***
___ yo male with ischemic cardiomyopathy s/p ___ 2 to LAD
complicated by cardiogenic shock and multi-organ failure, s/p
Centrimag to Heartware implant. S/P Orthotopic heart transplant
on ___ (PHS increased risk), with biopsy that showed 2R/3A
moderate rejection ___, s/p 3 days pulse dose steroids
___, with subsequent biopsies in ___ and ___ showing ISHLT of 0R, 1R.
He was admitted from home after surveillance endomyocardial
biopsy on ___ showed evidence of Grade 2R rejection. He was
asymptomatic and echocardiogram demonstrated normal
biventricular function. He was admitted ___ for 3 days
of intranvenous pulsed-dose steroids, and is being discharged
with planned follow up ___ RV biopsy and steroid taper. Review
of his biopsy specimens with Dr. ___ of ___
revealed that there were areas consistent with a large ___
lesion as well as regions consistent with cellular rejection
sufficient to satisfy 2R criteria with 2 areas of myocardial
damage. Of note during hospital stay iron studies were checked
which were normal. Home oral iron stopped given infection risk
with concurrent immunosuppressives.
TRANSITIONAL ISSUES:
=================
- Patient to be on 50 mg prednisone on ___ and ___, 40 mg on
___ and ___, 30 mg on ___ and ___, and then 25 mg
prednisone standing starting ___.
- Stopped home oral iron given normal iron studies in house
- F/U with endocrinology ___ for bone health given steroid
exposure
- EBV quant PCR and CMV viral load pending at d/c; Donor
Specific Antibodies drawn and sent to B&W.
***. | 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.
***
Mr. ___ was admitted to the psychiatry inpatient service
for further care. He was maintained on his home regimen of
Effexor 150 mg daily and Neurontin 1200 mg daily. He was also
continued on Depakote but his dose was increased from 750mg PO
Qday to 1500mg PO Qday. He was also started on risperdal 1mg po
BID. Screening labs including TSH, RPR, and valproic acid level
were also all checked on admission. These labs were notable for
an elevated TSH, however the FT4 was wnl.
Mr. ___ initially slept over the course of hospital day #
1. Then he was noted to have improved mood the following morning
however by the afternoon he reported significant anxiety. He was
then treated with Clonazepam 0.5 mg PRN for his anxiety which he
found helpful. His mood improved over the following 24 hours and
he participated in groups. Klonopin was d/c'd and he was
monitored for another 24 hours to evaluate if his mood and
anxiety remained stable. His long-standing OP psychiatrist, Dr.
___ was also contacted and per his description the patient was
felt to be close to his baseline. The patient was discharged in
stable and improved condition. He will follow-up with Dr. ___
___.
Legal: ___
Disposition: The patient was discharged to home, in stable and
improved condition. Outpatient follow-up was arranged with Dr.
___ at ___ at 3:15PM.
***. | PSYCHOSES |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
# Cervical stenosis s/p C3-7 posterior fusion
___ is a ___ yo M who presented ___ for elective
C3-C7 posterior fusion. The OR was uncomplicated, please see OMR
for detailed operative report by Dr. ___. He was extubated
in the OR and transferred to PACU for post-anesthesia
monitoring. He remained hemodynamically and neurologically
stable on post-operative check. He was transferred up to the
floor on ___. A JP drain was placed intraoperatively, and
was removed ___. AP/Lateral C-spine XR performed on ___
after drain removal and showed intact C3-7 posterior fusion and
no evidence of retained drain.
Patient had acute pain post operatively and was started on home
tramadol and other pain medications were titrated to treat pain.
Acute pain consulted on this patient. He was started on
Oxycontin for long acting pain relief, with oxycodone for
breakthrough with plans to down titrate as appropriate. He was
started on Tramadol, Gabapentin, Tylenol and Valium in addition
to this. On ___: Recommending down titrating diazepam from 5mg
to 2mg if patient becomes somnolent after administration. Pt
currently with no somnolence - will not require down titration
today prior to discharge.
# Urinary retention
A foley was placed intraoperatively, and was removed ___.
Patient required straight catheterizations x3 for retention.
Foley was left in place ___ on the ___ straight cath attempt
per patient request. Patient was started on Flomax QHS. Foley
was removed on ___ and patient was able to void independently.
# Dispo
OT evaluated the patient on ___ and recommend an additional
evaluation with ___ on the following day. ___ and OT evaluated the
patient on ___ and recommended discharge to rehab.
***. | CERVICAL SPINAL FUSION WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ F with hx of CAD, dCHF with EF 50-55%, poorly controlled
DM2 c/b retinopathy and neuropathy, hyperthyroidism s/p
resection presented to ___ for AMS in ___,
transferred to ___ where there was a concern for cardiac
arrest and seizures prior to transfer here.
# R/O Post-Cardiac Arrest; Unclear per OSH whether truly loss of
pulse versus cyanosis. Could be ___ to seizure and then
post-ictal and difficulty palpating pulse. However, patient may
have also had respiratory arrest leading to PEA arrest. Patient
is complaining of chest pain likely ___ to CPR. Normal
electrolytes at time of discharge. Remained normothermic in the
ICU. Primary cardiologist aware, no suggested intervention at
this time. No further inpatient workup requested. Outpatient
follow up scheduled.
- Monitored on Tele with no events
- Lidocaine patch and oxycodone for pain control
# Possible seizures: Patient with episodes of possible
tonic-clonic seizures. Unclear if real seizure or not, could be
___ to metabolic encephalopathy given recent DKA. Also treated
with levofloxacin which can lower seizure threshold. No history
of seizures, no infarcts on MRI. Electrolytes stable, not
hypoglycemic. Patient also with small ischemic vessel disease
(HTN, HLD, DM). EEG here did not show seizure activity. MRI
brain with high T2 signal in the left temporal cortex, adjacent
to the sulci.
- LP was unremarkable. Cytology negative for malignant cells,
HSV and ___ PCR negative, cultures prelim negative.
- Consulted Neurology, recommended outpatient follow-up
- No antiepileptics indicated given unconvincing history of
seizures
- MRI lesion of unclear etiology, will discuss at neurorad
conference and follow up in clinic.
# CAP: Patient with LLL vs retrocardiac opacity. Transferred on
ceftraixone. No cough, fevers.
- Completed course of ceftriaxone x 7 days and azithromycin x 5
days
# DKA: Patient remarks very erratic sugars in the home, ranging
from 70-500. Diabetes is managed by PCP, though patient was
previously seen at ___.
- Consulted ___, appreciate recs:
- Glargine 42 units QAM, 26 QHS. 12 units humalog with
breakfast, 10 units with lunch and dinner.
- Insulin sliding scale in house.
- Consider patient high risk, will need close f/u with PCP and
___. Home ___ for Diabetes management arranged.
# Hypertension: Patient is having anti-hypertensives held in the
setting of cardiac arrest.
- Continue to monitor blood pressures and restart as indicated.
- Started lisinopril 2.5 mg daily for renal protection.
# Diastolic dysfunction, EF 50-55%: no signs of acute
exacerbation. ECHO with mild to moderate global left ventricular
hypokinesis (LVEF = 40-45 % which is new from previous. Will
need f/u with Dr. ___ cardiologist) to continue to
___. Likely will require ECHO as outpatient for interval
resoultion. Likely related to toxic metabolic insult in
post-arrest setting and chest compressions. Cardiac enzymes
flat, no ACS.
# Hyperparathyroidism s/p resection; Patient had OSH PTH and
calcium which returned normal.
# CAD s/p PCI: Patient had EKG non-specific T wave changes in
lateral leads. Trops and CKMB negative.
- Continued home aspirin and simvastatin
TRANSITIONAL ISSUES:
[ ] will need f/u of blood pressure control and likely
resumption of home anti-hypertensives. Discharged on lisinopril
2.5 mg daily. Titrate up as needed.
[ ] neuro follow up for contrast-enhanding left temporal T2
hyperintensity noted on MRI, as well as other patient concerns
[ ] ___ follow up for continued management of T2DM, patient
given contact information to make an appointment
[ ] Home ___ for diabetes management
[ ] Consider life alert bracelet
[ ] f/u with Dr. ___ cardiologist, for repeat TTE
# Communication: ___ (nephew, HCP) ___
# Code: Full
***. | SEIZURES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient was admitted to the plastic surgery service on
___ after he underwent L side rib fracture repair. The
patient tolerated the procedure well.
.
Neuro: Post-operatively, the patient IV pain medication 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. She was also started on a bowel
regimen to encourage bowel movement. Intake and output were
closely monitored.
.
ID: Post-operatively, the patient was started on IV cefazolin
___. The patient's temperature was closely watched
for signs of infection.
.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
.
At the time of discharge on POD#2, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
***. | 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.
***
___: Admitted to thoracic surgery service s/p right
thoracotomy and right lower lobectomy for stage IIIA non-small
cell lung cancer. She was extubated in the operating room,
monitored in the PACU prior transfer to the floor. On POD2 she
developed respiratory distress and required tranfer to the SICU.
A chest CT was negative for pulmonary embolism. With diuresis,
aggressive pulmonary toilet, nebs she improved. She transfer
back to the floor in stable condition.
Respiratory: With aggressive pulmonary toilet, schedule nebs,
incentive spirometer and ambulation she titrated her oxygen
requirement to 4L nasal cannula with oxygen saturations of 94%.
She was discharged home on supplemental oxygen.
Chest-tube: 2 anterior basilar and posterior apical on suction
converted to water-seal without leak
Chest films: serial chest films showed right lower lobe effusion
(see reports)
Cardiac: She had intermittent atrial fibrillation with rates of
140-150 and hypotensive. Her cardiac enzymes were negative for
ischemia. She was started on diltiazem drip once rate control
hypotension resolved. IV lopressor was given and she converted
to sinus rhythm 79-80s with blood pressure of 120's. Once stable
her home dose of 240 Diltiazem and Atenolol 25 bid were
restarted, she remained in sinus rhythm 70-80's. She was started
on Aspirin 325 mg daily.
GI: mild nausea immediate postoperative which resolved with
antinausea medication.
PPI and a bowel regime were continued
Nutrition: diabetic diet was restarted, she tolerated.
Endocrine: type 2 diabetes BS were well controlled 103-140 with
insulin sliding scale. She will resume her home regime once
discharged.
Renal: Foley was removed when Epidural was removed. She voided
without difficulty.
Her renal function remained normal
Pain: Bupivacaine Epidural and Dilaudid PCA with good pain
control was managed the acute pain service. Once removed she
converted to PO pain medication with good control.
Disposition: she was seen by physical therapy who deemed her
safe for home with physical therapy for pulmonary rehab. She
was discharged to home with her husband and ___ on oxygen 4L and
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.
***
Mr. ___ was admitted to the Neurology Service for further
workup of his multifactorial gait disorder. His MRI showed
slightly increased ventriculomegaly from his exam in ___, however he does not have any other signs of NPH including
dementia/cognitive decline nor urinary retention. Upon
admission he was found to be orthostatic likely due to
dehydration secondary to recent URI. The orthostasis resolved
after rehydration. CXR was performed and was not concerning for
Pneumonia. Pt was evaluated by Physical Therapy and was deemed
stable for discharge home with a rolling walker and with home
___.
The patient should follow up with his PCP ___ 1wk. He will
have followup in Neurology Clinic on ___.
***. | 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.
***
Ms. ___ is a ___ yo woman with hx migraine and remote R
zoster opthalmicus c/b residual R V1 numbness and OD mydriasis
who presents to the ED with one day of vertigo superimposed on
months of increased clumsiness and walking into walls.
#Peripheral vestibulopathy
___ is a ___ year old female with a history of migraines
without aura and remote R zoster opthalmicus c/b residual R V1
numbness who presents with acute dizziness (vertigo) as well as
gait instability for several months. Her initial exam was
notable for L dysmetria, mismeasuring and overshoot on
mirroring. Of note, no nystagmus and chronic right V1 sensory
loss. There were no vesicles in either ear. Gait was notable for
cautious with some sway. Given the acute onset and dysmetria,
there was concern for a cerebellar process There was concern for
a brainstem or cerebellar process such as vascular or
demyelinating lesion. Given her additional more subacute issues
w/ gait instability there was also concern for a mass. MRI with
and without contrast was obtained which showed no acute process
on preliminary review. Otherwise, she had unremarkable labs
including UA without infection.
Before next steps could be addressed patient left against
medical advice.
TRANSITIONAL ISSUES:
===================
[] Trend symptoms of dizziness as outpatient. If symptoms do not
improve, consider referral to ENT.
[] Patient expressed wish to possibly transition off of
gabapentin given possible side effect of unsteadiness. She would
be willing to trial ___ or other medication for her bipolar
disorder. Please continue to discuss as outpatient.
***. | DYSEQUILIBRIUM |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Patient was admitted to the general surgery service on ___
for management of a small bowel obstruction. The patient was
made NPO and on IVF. Vital signs and intake/output were
monitored closely. She remained afebrile and hemodynamically and
clinically stable. Serial abdominal exams were performed to
monitor her clinical status, and her bowel function was
monitored closely. Her pain was managed by IV-pain medications,
and she was given anti-emetics for occasional nausea. She
required several doses of ativan secondary to anxiety and
nausea.
Patient's diet was advanced when appropriate, which she
tolerated well.
Patient received subcutaneous heparin and SCD boots for DVT
prophylaxis.
At the time of discharge, the patient was tolerating PO,
ambulating independently, voiding independently, and alert. She
was able to verbalize understanding and agreement with the
discharge plan and instructions.
***. | 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.
***
___ with h/o asthma, Grave's presenting with severe chest pain
and vomiting last night now with trops at OSH elevated at OSH
concerning for NSTEMI.
#NSTEMI: New diagnosis for patient, EKG without significant ST
changes although anterior leads possible submm changes, trops at
0.18 at OSH now down at 0.03 -> 0.01. MB not trended in ED, but
low at 4 on arrival to ED. Chest pain sounds typical:
substernal, qhour, lasts minutes. Non-radiating no associated GI
symptoms. Has not happened to patient before. Discussion of
stress test in ED but will HELD off given that NSTEMI has
already been ruled in. PCI done in left main, continued on
aspirin, atorva 80 (after clarifying that pravastatin led to
allergic reaction). Also continued on metop and Plavix.
#headache: notably mild headache in setting of NPO but resolved
at discharge.
Controlled on Tylenol while hospitalized.
#Chronic
#asthma: continued advair
#allergic rhinitis: continued zyrtec, Flonase
#depression: continued Prozac
#OSA: continued home CPAP
#Graves: continued on synthroid
***Transitional issues***:
- patient instructed to continue losartan 50 mg, this does not
have the same cardioprotective effects as an ACE inhibitor.
However she also does not have a reduced EF. ___ discuss
switching to lisinopril or titrating losartan dose as blood
pressure allows in the outpatient setting.
- discharged on 80 mg atorvastatin, monitor for adverse side
effects. Confirmed with PCP's office that adverse reaction was
to pravastatin.
- patient will need to continue on ASA indefinitely and Plavix
for at least ___ year (may consider life-long after weighing risks
of bleeding)
- A1C checked during this hospitalization: 5.5%
- metoprolol increased to XL 25 mg qd
***. | 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.
***
1. Acute cholangitis with pan-sensitive E. coli septicemia
- s/p unsuccessful ERCP. The etiology of the obstruction was
unclear. He was admitted and maintained on IV antibiotics,
transitioned to PO cipro/flagyl. He underwent abdominal CT as
above. He underwent PTC with ___ on ___, and the drain was capped
on ___. Repeat blood cultures were negative.
2. Portal vein thrombosis:
Appears related to site of biliary obstruction on OSH imaging.
He was maintained on IV heparin goal PTT 60-85. Would have
transitioned to coumadin, however as the patient is changing
PCP's and does not even have a follow up appointment, coumadin
is too risky. He is recommended to start this with his new PCP,
and will be reffered to a hepatobilliary specialist.
3. Complete heart block s/p DDD pacer, Benign Hypertension
- Home antihypertensive was held although low dose beta blocker
was started perioprocedurally.
***. | 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.
***
PRIMARY REASON FOR HOSPITALIZATION:
___ yo ___ speaking male from ___, here vising family
presented to the Emergency Department with L-sided chest pain,
found to have bilateral PEs on CT scan.
ACTIVE ISSUES:
#Pulmonary embolism:
CTA performed in Emergency Department consistent with bilateral
nonocclusive PEs. Patient described chest pain for several
weeks prior to flying ___ from ___. Had been
treated for presumed pneumonia in ___ without resolution of
chest pain. He had no personal or family history of blood clots
or blood disorders. In the ED as well as throughout his
admission he was hemodynamically stable. He was initially
started on a heparin drip, which was discontinued once he
arrived to the floor. He was then put on Lovenox and warfarin.
His symptoms diminished and on hospital day 3 he was discharged.
He was seen that day in Health Care Associated primary care
clinic and will followup in the ___ clinic here to
establish a therapeutic INR. We stressed the need for his close
followup with a PCP once he returns to ___.
CHRONIC ISSUES:
#Hemochromatosis:
Patient reported having a disorder in which he has too much
iron, which was presumed to be hemochromatosis. He normally is
phlebotomized every 2 months. We did not address this issue
during his hospitalization.
TRANSITIONAL ISSUES:
-Has followup scheduled with ___.
-Advised to followup closely with PCP in ___, patient
acknowledged understanding.
***. | PULMONARY EMBOLISM WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ woman with PMHx CAD s/p CABG, HTN, depression was
initially admitted for fever, chills, and body aches with
subsequent development of multi-organ failure requiring transfer
to ___ MICU. There she was discovered to most likely have
disseminated adenovirus as underlying cause for her
presentation, subsequently improving on steroids with plan to
complete ___ week taper following discharge.
# DISSEMINATED ADENOVIRUS
# MULTIORGAN FAILURE
Initially presented to ___ for mild confusion, poor PO
intake, fevers, chills, body aches, and lightheadedness. There
her clinical status was initially tenuous with subsequent
development of multi-organ failure with ferritin ___ raising
concern for possible HLH. Subsequently transferred to ___
where she was started on high dose steroids with improvement.
The etiology of her pro-inflammatory state was not entirely
clear, however, per hematology, she did not meet the criteria
for HLH despite positive IL-2 given absence of persistent
fevers, splenomegaly, normal triglyceride level, no cytopenias
and decreasing ferritin level. The leading hypothesis at this
time is that her acute decompensation was secondary to
disseminated adenovirus for which she was supportively managed.
Given her improvement she was transferred to the medicine floor
team where she continued steroids with plan to complete taper
gradually over the ___ weeks following discharge. Steroid plan
as directed by rheumatology service. Started on atovaquone,
vitamin D, and calcium for steroid prophylaxis.
# ACUTE RENAL FAILURE
Developed worsening renal function due to acute tubular
necrosis. Remained on CRRT while in MICU, later transitioned to
intermittent hemodialysis while on floor. Her urine output
subsequently improved and she was determined to no longer
require hemodialysis. Temporary HD line was removed on ___.
Discharge Cr 2.7 and down-trending.
# TOXIC METABOLIC ENCEPHALOPATHY
MICU course notable for severe encephalopathy. Extensive workup
included MRI brain, LP, and multiple CT heads were reassuring.
Initially was on IV Keppra BID given concern for seizure
activity (lip smacking) while intubated, however this later
resolved. Latest EEG demonstrated rare generalized epileptiform
discharges but no electrographic seizures. Her mental status
improved over later course of hospitalization though still had
intermittent episodes of near-somnolence. Initially on Zyprexa
and Seroquel for agitation; later discontinued Zyprexa and
Seroquel. Mental status at time of discharge was oriented to
self and location as "hospital", easily arousable to voice and
interactive.
# RESPIRATORY FAILURE
Initially intubated due to encephalopathy and multi-organ
failure with concern for inability to protect airway. Required
mechanical ventilation for approximately 2 weeks. Subsequently
improved and so was extubated with gradual improvement in
respiratory status during remainder of hospitalization.
# ATRIAL FIBRILLATION
New onset during this hospitalization. CHADs-VASc 4. Initially
received amiodarone load later transitioned to metoprolol.
Remained in normal sinus rhythm during the days prior to
discharge. Initiated anti-coagulation with warfarin until her
true burden of a-fib can be further evaluated as an outpatient
following resolution of acute illness.
# SEVERE PROTEIN CALORIC MALNUTRITION
# DYSPHAGIA
Following extubation was noted to have significant dysphagia
with inability to protect airway. Made NPO with Dobhoff placed
for tube feeds. Evaluated by Speech & Swallow on ongoing basis
with gradual improvement in dysphagia. At time of discharge was
cleared for pureed (dysphagia) diet with thin liquids. Continued
tube feeds for adequate nutritional support and for PO
medication administration.
# HYPERGLYCEMIA
In setting of high-dose steroids. Received sliding scale
insulin.
# ANEMIA
Multifactorial. Likely poor production from anemia of
inflammation in setting of recent illness. Large amount of
phlebotomy over recent weeks. Required 1u pRBC ___ with more
than adequate bump in Hgb. No evidence of acute blood loss and
hemodynamically stable.
CHRONIC / STABLE ISSUES
=================================
# CAD s/p CABG
- Atorvastatin 40 mg PO/NG QPM
- aspirin 81 mg daily
# HYPERTENSION
Held home Lisinopril
TRANSITIONAL ISSUES
=================================
[ ] Steroid plan:
___ - Prednisone 20 QD
___ - Prednisone 15 QD
___ - Prednisone 10 QD
___ - Prednisone 5 QD
___ - Prednisone 4 QD
Starting ___ please drop by 1 mg weekly
[ ] STARTED warfarin for anti-coagulation in setting of new
atrial fibrillation during acute illness. Please titrate for
goal INR ___. Please see attached anti-coagulation sheet for
details.
[ ] Once steroid course is completed please discontinue or
re-evaluate need for PPI, Vitamin D, calcium supplements.
[ ] Once steroid dose is less than 10 mg prednisone daily please
discontinue atovaquone.
[ ] Please obtain repeat echocardiogram in ___ weeks following
discharge to ensure resolution of acutely reduced LVEF while in
the medical ICU.
[ ] Recommend event monitor following resolution of acute
illness to determine burden of atrial fibrillation. If resolved
would re-consider need for ongoing anti-coagulation.
[ ] Please repeat Chem-10 in 1 week to ensure continued
improvement in renal function. Discharge Cr: 2.7.
[ ] Persistently anemic at time of discharge. Please repeat
Hgb/Hct in ___ days to ensure stable. Discharge Hgb: 7.8.
[ ] Discovered to be hepatitis B non-immune. Consider repeat
vaccination course following resolution of acute illness.
[ ] When able to tolerate taking PO medications, please stop
metoprolol TARTRATE 12.5mg Q6H and start metoprolol SUCCINATE
50mg daily
[ ] If SBP persistently greater than 140 and renal function back
to baseline, then please restart lisinopril 10mg daily. If
hypertensive, but renal function not back to baseline, then
please start amlodipine 5mg daily.
#CODE STATUS: full (confirmed)
#CONTACT: ___ (HCP, son) ___, ___ (son) ___
***. | SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ female with array of risk factors for coronary
atherosclerosis and remote history of left MCA aneurysm, left
ICA aneurysm complicated by TIA, and chronic kidney disease
stage IV admitted for NSTEMI. Coronary angiography revealed
culprit RCA lesion.
#) NSTEMI, type I: while features of her chest pain were
atypical, rising cardiac enzymes and new T-wave inversions in
anteroseptal precordial leads on background said risk factors
were suggestive of true unstable plaque rupture in probable LAD
distribution. She was empirically heparinized when cleared by
neurosurgery. TTE was obtained, which instead demonstrated
hypokinesis of the
basal inferior and inferoseptal segments, but globally preserved
biventricular systolic function. She thus proceeded with
coronary angiography, which revealed 100% occluded RCA with well
established left to right collateralization, which was not
intervened upon, as well as non-obstructive LCx (50% stenosis)
and D1 (40% stenosis) disease. She received periprocedural
hydration as prophylaxis against contrast induced nephropathy.
She was also pre-medicated for idoniated contrast allergy per
___ protocol. Heparin was later discontinued in favor of
aspirin and clopidogrel. Metoprolol was converted to carvedilol
12.5 mg BID for better alpha antagonism in the absence of home
lisinopril, which was held for renal insufficiency above
baseline and impending contrast load.
#) Cerebral aneurysm: once deemed an absolute contraindication
to
anticoagulation and antiplatelet therapy. Surveillance head CT
obtained after therapeutic PTT was unremarkable. MRA head
revealed a single 3 mm left ICA aneurysm, which was considered
at minimal, and thus, acceptable risk of hemorrhage. No
intervention was warranted. Neurosurgery cleared patient for
heparin and dual-antiplatelet therapy in that regard.
___ on chronic kidney disease, stage IV: presumably secondary
to hypertensive nephropathy. Creatinine 2.8 on arrival from
baseline creatinine 2.0-2.5. She received gentle hydration in
anticipation of catheterization, which was then continued for
low-normal LVEDP, albeit minor contrast load. Lisinopril was
held at discharge for unchanged creatinine.
#) Alcohol use disorder: notably, has history of withdrawal
seizures. Last drink reportedly evening prior to admission.
Monitored on CIWA without benzodiazepine needs.
CHRONIC/STABLE ISSUES:
#) Anemia: near-macrocytosis at baseline 10-range. Presume
secondary to chronic kidney disease and alcohol myelotoxicity.
#) Hypertension: home lisinopril 5 mg held, as above. Carvedilol
12.5 mg BID added for alpha antagonism.
===================
TRANSITIONAL ISSUES
===================
NEW MEDICATIONS
-Aspirin 81 mg daily
-Atorvastatin 80 mg daily
-Carvedilol 12.5 mg BID
-Clopidogrel 75 mg daily
CHANGED MEDICATIONS: none.
HELD MEDICATIONS:
-Lisinopril 5 mg daily
DISCONTINUED MEDICATIONS:
-Pravastatin
[ ]Ensure follow-up with cardiology and neurosurgery (see
appointments above).
[ ]At discharge, creatinine = 2.8; recommend repeat chem-10 at
primary care follow-up on ___.
[ ]Consider titrating carvedilol and/or resuming lisinopril, if
renal function has returned to baseline.
[ ]Facilitate smoking and alcohol cessation.
#CODE: Full, presumed
#CONTACT: ___, daughter (___)
***. | ACUTE MYOCARDIAL INFARCTION DISCHARGED ALIVE WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with Stage IIIB CRC (s/p right hemicolectomy (___) on
FOLFOX (today C2D15), who presents for a third round of
oxaliplatin desensitization. She tolerated the infusion well
without any side effects.
She will return for her next round of oxaliplatin
desensitization per protocol on ___.
***. | 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.
***
___ with FLT3+ AML s/p allo MUD SCT (___) with early relapsed
disease, s/p treatment with sorafenib, DLI and MUC1-inhibitor +
decitabine in past, also with recent admissions for pseudomonas
and recurrent VCRE infection, on chronic suppressive therapy,
and recent admission for rising blasts and LFTs complicated by
hemolysis and mucositis. She was admitted for diarrhea and found
to have supratherapeutic digoxin level.
# diarrhea: Patient presented with 2 days diarrhea after having
started digoxin. She was supported with fluid resuscitation and
her digoxin held. An infectious workup was negative including C.
Diff PCR, and she received loperamide to good effect. She was no
longer having diarrhea at the time of discharge and tolerating
her baseline PO intake.
# fluid overload: The patient who has baseline depressed LVEF
was given ample fluid resuscitation in the setting of diarrhea.
She became mildly fluid overloaded on exam which was treated
with ___ IV Lasix several times during her inpatient stay.
She had mild desaturation to low ___ with good response
post-diuresis. She received diuresis on day of discahrge, and
will be evaluated as outpatient during follow-up visits on ___
and ___ for additional volume reduction.
# thrombocytopenia: In setting of receiving hydroxyurea and AML
the patient had low and downtrending platelets throughout her
stay. Requiring HLA matched platelets for effect, she received
intermittent platelet infusion but continued to downtrend. With
mild mucositis she was infused on day of discharge and blood
bank was alerted she would be evaluated on ___ and ___ for
potential transfusion.
# AML (FLT3+ post allo MUD SCT): Patient with FLT3+ AML s/p allo
MUD SCT (___) with early relapsed disease, recently s/p 4
cycles of decitabine and recent cycle of decitabine + Ara-C.
Patient had been awaiting initiation on new clinical trial but
since clinic visit for diarrhea was found to have increased
blasts (65% blasts, WBC 16.3). She was started on Hydrea 1g PO
BID which was increased as high as 3g PO BID. After several
doses of Hydrea 3g PO WBC and blasts downtrending. Switched to
Hydrea 1g PO daily. She was placed on IVF first to support
through diarrhea, then to prevent TLS and monitor TLS labs. Bone
marrow biopsy performed ___, and IPT showed blasts in marrow.
Patient to begin Trial ___ with Revlimid.
# Chemotherapy-related cardiomyopathy: Patient has LVEF 40%,
evaluated by Echo this admission. In setting of IVF she had
pulmonary edema by CXR during this hospitalization and received
Lasix ___ IV several times to good effect. Low voltage EKGs
raised concern for malignant effusion, and repeat Echo showed
preserved EF at 40% and no effusion. Patient enrolled in study
___ with EF>40% no disease related effusion.
# Adrenal insufficiency: Patient continued on home dose
hydrocortisone 15mg PO QAM and 5mg PO QPM through admission.
# History of recurrent Pseudomonas, VRE: Patient continued on
home daptomycin/cipro suppressive therapy. Dapto IV and ethanol
locks continued upon discharge.
TRANSITIONAL ISSUES:
- new medications: loperamide 2mg QID PRN diarrhea
- stopped medications: digoxin - held w/ supratherapeutic levels
- appointments: ___ and ___ in ___ please check
CBC/diff, BMP, TLS markers, and LFTs and contact Dr. ___
the ___ attenting/fellow if any issues or sick appearing
- please transfuse PRBC and platelets as needed at clinic visits
- please diurese with IV Lasix as needed at clinic visits
- finalize re-admission date for ___ or ___
- check HCG on ___ for trial
- Code: Full
- Contact: ___ (HCP/Husband) ___
***. | 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 orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
1. Hypotension requiring pressors in PACU- resolved on its own
and patient successfully managed on floor.
2. Patient kept in a locked ___ brace as her operation
required both a patellar tendon and quad tendon repair.
3. Post op blood loss anemia - POD2 Hct 20.7 -> Transfused 2u
PRBCs with good effect.
4. Lovenox bridge to coumadin
5. Constipation - POD3 hypoactive bowel sounds and -RF -> KUB
showed no ileus. POD4 Increased bowel regimen with good effect.
+BM ___ prior to discharge. Please continue to minimize
narcotics.
Otherwise, pain was initially controlled with a PCA followed by
a transition to oral pain medications on POD#1. The patient
received Lovenox and Coumadin starting POD1 for DVT prophylaxis.
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. 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 in a locked ___ brace.
She is being discharged on Keflex x 7 days for infection
prophylaxis.
She is discharged to rehab in stable condition.
***. | REVISION OF HIP OR KNEE REPLACEMENT 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 transferred to the ED with a right chest tube and
multiple known rib fractures. Following evaluation int he
___ emergency department, he was admitted to the trauma
service. He had an MRI on ___, and on ___ his c-spine was
clinically cleared. His chest tube was continued on wall
suction.
He had serial hematocrits drawn, which showed an intial drop,
but then were stable. On the morning of ___, his hematocrit
decreased to 20. Patient was consented and transfused 2 units
PRBCs with appropriate response (Hct 20 -> 26.9), and taken to
interventional radiology for embolization of a presumed pelvic
vessel, as extravasation had been seen on the initial CT. The
embolization attempt was unsuccessful, and patient had a large
O2 requirement following extubation and was transferred to the
ICU. There he had continued nebs. ___ patient went to OR
with orthopedics for ORIF R hip/pelvis and was transfused 2
units PRBCs (Hct 25.8 ->26.9). He was kept intubated overnight
and extubated on ___.
Pain Control:
The acute pain service was consulted for pain control. A
thoracic epidural catheter and a right sided lumbar pain pump
catheter were utilized. They were both removed on ___ and
the patient had his pain well controlled on PO Dilaudid with IV
Dilaudid for breakthrough. He was also started on neurontin.
Events in the TSICU:
___: tx'd from OSH, admitted to TSICU
___: C-spine cleared, tx'd to floor, reg diet
___: Hct 20, ___ unable to find bleeder, tx'd 2U PRBC, tx'd to
TSICU postop for resp distress
___: epidural placed
___: ORIF of pelvis, 100 cellsaver, 2U PRBC, EBL 1000, left
intubated, bronch: showing thick secretions, CT d/c'd
___ extubated, Lasix 10 x 2, lumbar plexus catheter, inc RISS,
adv diet
Pleural effusion: the patient was found to have a right pleural
effusion and some peripheral edema. Diuresis with lasix and
acetazolamide began ___, and continued through his discharge.
His foley catheter was removed on ___. A UA at that time was
suspicous for a UTI and he was started on PO Cipro 500 mg BID.
He received one dose at ___ and should continue for 3 days.
The patient was discharged to a rehab facility on ___.
***. | OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Transitional Issues
====================
[] No definitive source for patient's bleeding was found. ENT
felt this was most likely due to nasopharyngeal dryness. Please
monitor for symptom resolution with saline nebs. Counseled
patient to return immediately to ED in case of recurrent
significant bleeding. If bleeding recurs, consider repeat
laryngoscopy and CT angiogram to identify source.
[] Left thyroid nodule measuring up to 2.5 cm. Ultrasound follow
up recommended.
[] Patient was normotensive during hospitalization off home BP
meds. Held HCTZ on discharge, restart as needed.
[] Consider colonoscopy in ___ months after resolution of
diverticulitis to assess for underlying malignancy.
[] Patient is taking otic antibiotics and steroids for unclear
indication. Please clarify when patient should stop this.
[] Continue to encourage smoking cessation. Prescribed nicotine
patch.
[] Consider replacing buproprion with alternative
anti-depressant. ___ be worsening patient's anxiety.
[] Fluticasone IH discontinued since redundant with
Fluticasone-Salmeterol IH.
SUMMARY STATEMENT
==================
This is a ___ with PMH of lung adenocarcinoma in remission,
COPD, transferred from ___ for further evaluation of
intermittent pharyngeal bleeding of unclear etiology. There was
initially concern for carotid-pharyngeal fistula as the patient
was noted to have left oropharyngeal fullness that was pulsatile
on fiberoptic exam performed by ENT. CTA of the head and neck
was performed which showed no active extravasation but did
demonstrate medialized left carotid. The patient remained
hemodynamically stable throughout her hospital stay.
ACUTE ISSUES
============
#Nasopharyngeal bleeding
The patient was transferred from ___ as
providers were concerned about carotid-pharyngeal fistula. The
patient was seen by ___ who performed a fiberoptic exam which
demonstrated left oropharyngeal fullness that was pulsatile. CTA
performed here demonstrated a medialized left carotid artery but
no evidence of active extravasation. ENT recommended nasal
saline for likely venous source in the posterior nasal cavity.
The case was discussed with ___ and ___ who felt
that there was no role for additional carotid imaging or
interventions. After starting nasal saline, the patient's
bleeding resolved. The patient remained hemodynamically stable
with stable hemoglobin during her admission.
CHRONIC ISSUES
==============
#Recent Diverticulitis
Previously treated for diverticulitis with course of
amoxicillin. Still endorsing mild LLQ pain that continues to
improve. No indication to image and no signs of toxicity.
#Ear Pain:
Continued outpatient steroid + antibiotic otic regimen.
# MDD/Anxiety
- bupropion, escitalopram
- Ativan PRN 0.5 mg PRN
- Ativan 1 mg QHS daily
#COPD/Asthma
Not on O2 at home.
-albuterol
-Home Advair 500/50
-Discontinued home Fluticasone IH (redundant with Advair)
-PRN home duoneb
#HTN
-Holding amlodipine, HCTZ
-Continue metoprolol
#GERD
Continue home pantoprazole
#ECZEMA
Continued Clobetasol for elbows
#SPINAL STENOSIS
History of chronic pain, had been prescribed hydrocodone-APAP,
but no longer taking. Continued Tylenol.
#Tobacco use: nicotine patch
***. | OTHER EAR NOSE MOUTH AND THROAT 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.
*** year old female with history of hypertension, GERD, hiatal
hernia, anxiety, s/p CCY (___) presenting with chest pain
for one day.
# Chest pain: right-sided shoulder pain seems consistent with
her known rotator cuff injury, which has been a persistent
problem for many years. With respect to her left-sided shoulder
and arm pain, it is not reproducible on exam, but has fully
resolved by the time of her arrival to the floor. EKG and
cardiac biomarkers x 2 are both without evidence of ischemia,
and description of burning pain without associated shortness of
breath, nausea, diaphoresis argues against cardiac etiology.
Suspect potential musculoskeletal component, although pain is
not reproducible on exam at time of arrival to the floor. Her
pain was not present the following morning, and exam was again
unremarkable. Diet was advanced. She was continued on her home
statin. She is no longer on her home beta blocker due to
hypotension and bradycardia, and her aspirin has also been
discontinued. She has been advised to follow up with her PCP in
one week.
# Dilated intrahepatic ducts: Per CT done in ED, there is
suggestion of modestly dilated intrahepatic ducts. Exam is
entirely reassuring. Of note, she had a very similar pattern of
very modest LFT elevation in the past - ___: ALT/AST 88/46,
alk phos 131; ___: ALT/AST 109/28, alk phos 134; Tbili
always WNL. She underwent MRCP on ___ which did not reveal
any pathology of the remnant biliary system at that time. LFTs
were downtrending at the time of discharge. There is currently
no indication for MRCP. This issue should be followed up as an
outpatient with repeat LFTs, and possibly further imaging.
# Low back pain: Chronic pain, followed by Dr. ___ with pain
___.
- Continue home gabapentin, lidocaine patches, tylenol, and
vicodin - vicodin is apparently prescribed by Dr. ___
who has now retired, and patient is aware that she will need to
find a new outpatient prescriber for this medication, if it is
to be continued
# Hypertension: continued home amlodipine and lisinopril with
hold parameters
# GERD/hiatal hernia: continued home PPI and ranitidine
# Hypothyroidism: continued home levothyroxone 50 mcg daily
# Constipation: continued home docusate and polyethylene glycol
PRN
# Anxiety/depression: continued home escitalopram, olanzapine,
and diazepam
# Chronic nausea: Has been extensively evaluated by GI for this
issue. She was continued on her home ondansetron.
# Code status: DNR/DNI - confirmed on admission
# Follow-up: patient should follow up with her PCP within one
week, at which time LFTs should be repeated and chest pain
should be re-evaluated.
***. | CHEST PAIN |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Please see discharge summary from yesterday. EMS sent patient
back during transporation to his rehab because of a leakage from
J tube. The J tube stopcock was left open and was simply closed
on the floor without any more leakage. The ED could have simply
done that. His tube feeding was restarted without any problems
such as leakage or residuals. In regards to his anemia, he has
known abdominal hematoma that previously required transfusion.
CT abdomen from yesterday with stable hematoma size. Patient was
hemodynamically stable with stable hematocrit and nio signs of
internal or external bleeding. During this 24 hour admission, he
was changed to ___ antibiotics to finish his course of pneumonia
treatment.
***. | OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
====================
PATIENT SUMMARY:
====================
Mr. ___ is an ___ year old ___ speaking man with PMH of
HTN, non-insulin dependent DM2, HLD, referred by his PCP at
___ (Dr. ___, who presented to the ED with
BLE weakness of 2 weeks' duration, found to be profoundly
hyponatremic to 110, likely secondary to hypovolemia and SIADH
perhaps due to an underlying pituitary mass.
====================
ACUTE ISSUES:
====================
#Hyponatremia: The patient was profoundly hyponatremic on
admission with Na of 110. There was almost certainly some
component of hypovolemic hyponatremia initially given the robust
initial response to IVF. However, given sustained elevated urine
Osms and lack of continued response to volume resuscitation
alone, the continued hyponatremia was likely driven by SIADH.
The etiology for SIADH is also unclear, though possibly related
to pituitary mass (discussed below). There was also likely some
component of Type IV RTA secondary to Lisinopril use, and
Lisinopril was held which we continued to hold on discharge. The
patient continued treatment for SIADH with 1L free water
restriction and TID ensure shakes with a high salt diet as well
as 20mg PO Lasix. The patient was refusing ensure shakes while
in the hospital, however we discharged him with TID shakes and
recommended that he continue to take these with every meal. His
TSH and AM cortisol (x2) were normal. He was discharged with
primary care follow up and should have his sodium checked at his
first follow up.
#Pituitary lesion: MRI showed 14mm lesion in the anterior
pituitary with ddx including cystic macroadenoma with possible
subacute hemorrhage vs Rathke's cleft cyst (less likely based on
location of lesion). Macroadenoma may be non-functioning or
functioning (with excess secretion of LH/FSH vs ___ vs prolactin;
TSH or ACTH-secreting microadenoma is less likely given normal
TSH and AM free cortisol on this admission). Unclear if this
lesion is responsible for hyponatremia leading to excess ADH
secretion but so far there is no other possible explanation for
SIADH. Visual field testing normal by ICU team and ophtho.
Neurosurgery consulted and given no optic chiasm compression no
need for intervention at this time. Will need f/u MRI as
outpatient in 6 months and neurosurgery follow up.
___ Weakness/fall, resolved
Neuro exam intact. Good rectal tone. No spinal tenderness. Most
likely Hyponatremia related as improved with treatment. Of note,
he was found to have some orthostatic hypotension though was
asymptomatic and was ambulating well with physical therapy.
#Metabolic Acidosis, resolved
#Ketonuria, resolved
Patient with bicarb 16, gap 16, pH 7.34, 10 ketones urine,
normal lactate. Given poor diet most likely some element of
starvation ketosis. His blood sugar was 400 on initial check,
but has been low 200s on repeat checks, and type II diabetic not
on SGL-2 inhibitor, less concern for DKA/HONK.
#Abdominal distension
#Constipation
Abdominal exam benign. Likely due to constipation. TSH normal.
Given bowel regimen.
#Urinary retention/incontinence
Normal rectal exam, less concern for neurological process.
Sugars have been more elevated lately, so could be symptomatic
from glucosuria/osmotic diuresis. Improved.
====================
CHRONIC ISSUES:
====================
#HTN: Held Lisinopril i/s/o hyperkalemia on admission. Blood
pressure was normal during admission. If needs better BP control
as outpatient, would recommend starting on a non-Ace inhibitor
regimen.
#DM: Held home oral medications and gave sliding scale insulin
during hospitalization. Restarted home meds on discharge.
#Microcytic anemia: Unknown baseline. Iron studies consistent
with anemia of chronic disease. Consider colonoscopy as
outpatient
====================
TRANSITIONAL ISSUES:
====================
[ ] 14 mm pituitary mass: Will need f/u MRI as outpatient in 6
months and neurosurgery follow up.
[ ] Lisinopril held with stable blood pressure due to
hyperkalemia on admission as well as possible contribution to
Type IV RTA, can consider starting different antihypertensive if
needs better BP control as outpatient
[ ] Found to have mild asymptomatic orthostatic hypotension. Can
consider midodrine if develops issues with pre-syncope/syncope
[ ] Found to have stable microcytic anemia. Ensure he is up to
date on colonoscopies.
- New Meds: lasix
- Stopped/Held Meds: lisinopril
- Changed Meds: none
- Follow-up appointments: PCP, ___, neurosurgery
- Post-Discharge Follow-up Labs Needed: chem 10
- Incidental Findings: pituitary mass
- Discharge weight: 194 lb.
- Discharge creatinine: 0.9
# Communication: ___ (son, lives with him) ___
___ (son) ___
# Code: Full confirmed
***. | ENDOCRINE 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.
*** Pt underwent APR, cystectomy, RP, ileal conduit, bilateral
gracilis flaps. Post operatively pt remained electivley
intubated and was transferred to the ICU where he remianed NPO,
IVF with PRN boluses.Neosynephrine was titrated to keep MAP >65.
Epidural was placed in conjunction with PCA to aid in pain
contol. NGT to LWS.Tight glycemic control, TID HCT. Famotidine
was started for Gi porphylaxis.
.
___ Neosynephrine weaned off. Pt hemodynamically stable. ___
extubated . Toradol added to epidural for better pain relief.
NGT dc'd. Pt allowed ice chips. Pt transfused 1 Unit PRBCfor
HCt of 23.4.
.
___: Pt required increased FIO2 after fluid resuscitation.
Lasix 20 mg started with good diueresis. ___ consult placed. Pt
transitioned from PCa to IV dilaudid. Epidural remianed in
placed. Neosynephrine briefly restarted for SBP in the ___
after pain medication administration and then dcd again once
pressures were >110/50s.
.
___: Pt had improved oxygenation with diueresis. Transferred
to floor. Cxr showed mild pulmonary congestion.
.
___: Diet advanced to clear liquids for breakfast,
tolerated well. Medications converted to all PO's. Restarted on
most home medications. Epidural removed per Acute pain service.
Pain well controlled with oral medication. Flatus and stool
production noted in ostomy. Diet advanced to regular food for
dinner. Tolerated well. Continued to work with Physical Therapy.
Steady on feet, but deconditioned. Continues to benefit from
___ rehab. Awaiting bed availability. Plan to discharge
to Rehab on ___.
.
___: Developed Nausea, vomiting, and abdominal distention.
Ostomy continues to function, but decreased amount. NGT inserted
with over 1 liter of thick, bilious output. IV fluid restarted,
and made NPO. Medications converted back to IV. KUB revealed
ileus. Urine output stable.
.
___: NGT removed. Started on clears. Tolerated well. Ostomy
output increased. Abdominal distention decreased. Continued to
ambulate with nursing & RW. Minimal assist. Otherwise stable.
Repeat abd xray revealed resolving ileus. Diet advanced to
regular food in evening. Tolerated well.
.
___: Tolerating regular food. Denies N/V. Adequate ostomy &
urine output. Ambulating with minimal assist using walker.
Re-screened per ___, cleared for discharge home with services.
.
___: Vitals stable. Abdominal incision, ostomy, ileal conduit,
and gracilis flaps intact. Pain well controlled with oral
medication. Hemodynamic status stable.
___ Ureteral stents removed. Pt discharged to home with ___,
___, & home health aide. Also with planned follow-up with Dr.
___ in a few weeks, and with Dr. ___ Service in 10
days for assessment of groind JP drain output, and readiness for
removal. In addition, patient will see Dr. ___ in ___
weeks.
***. | RECTAL RESECTION 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.
***
___ woman with a history of DMII not on insulin, CKD,
OSA, HTN, HFpEF, CAD w/ MI who presents with 1 month of
worsening nausea/vomiting and abdominal pain after eating and
weight loss, found to have gastritis and constipation.
ACUTE/ACTIVE ISSUES:
====================
# Gastritis
# Nausea/vomiting
Most likely presentation from constipation and gastritis. EGD
identified gastritis but no PUD or obstruction; Pantoprazole 40
mg daily initiated ___. Malignancy unlikely given no findings on
CT or EGD, however not definitively ruled out. CT did reveal
increased stool burden and she was initiated on Miralax,
Bisacodyl, Polyethylene Glycol, and Senna. Gastroparesis was not
assessed during admission but will follow up with outpatient
gastric emptying study. CTA not pursued to assess for chronic
mesenteric ischemia in light patient's ability to eat without
pain. Patient to be continued on optimized bowel regimen to
reduce pain contribution secondary constipation. TSH and
cortisol within normal limits. At this time, H. Pylori biopsy
test pending. For symptomatic management of nausea, patient was
treated with Zofran. Per nutrition recs, patient was initiated
on multivitamin. Of note, patient with gram negative rods in
urine but asymptomatic so was not started on treatment.
# Unintentional weight loss
Suspect secondary to nausea/vomiting and abdominal pain causing
reduced appetite. EGD procedure did not demonstrate concerning
mass or other obstructive lesion. Patient was evaluated by
nutrition and initiated on multivitamin.
# Pyuria
Asymptomatic.
CHRONIC/STABLE ISSUES:
======================
# Irregular Heart rate:
One episode of "single period of Wenckebach second degree AV
block possibly high-grade (and likely vagal)." on Ziopatch but
no CHB or AF. AV conduction delay seen on EKG. Cardiology
follow-up scheduled and no events on telemetry.
# CAD
# HFpEF
Was continued on home medications: aspirin, clopidogrel,
atorvastatin, isosorbide dinitrate 10 mg PO TID, metoprolol
succinate. Nifedipine held on discharge given normotension.
# DMII
Recent A1C reportedly 7.3%. Has not required insulin. Held home
duraglutide, metformin and was put on insulin sliding scale
while inpatient. Resumed metformin/glipizide on discharge.
Dulaglutide held given family concern that contributing to
nausea/vomiting.
# Hypertension
Home regimen includes Losartan 100 mg PO daily, Nifedipine ER 30
mg PO daily
but was held during hospitalization due to stable BPs. Losartan
resumed prior to discharge.
# Osteoporosis
Held alendronate during admission and given Lidocaine patch and
Tylenol as needed.
# Obstructive sleep apnea
CPAP contraindicated while patient has nausea and vomiting, so
was held on first night but resumed on second night.
# Depression
Continued on citalopram 40 mg PO daily
TRANSITIONAL ISSUES:
=====================
[] follow up H. Pylori biopsy results
[] please perform gastric emptying study as outpatient
[] continue bowel regimen for constipation
[] initiated on Pantoprazole for gastritis, continue to assess
need for PPI as symptoms improve
[] establish care with GI specialist
[] monitor blood pressures, resume nifedipine/other blood
pressure medications as needed
[] dulaglutide held on discharge given concern from
patient/family that contributing to nausea/vomiting, please
monitor A1c and consider alternatives
# CODE: full (presumed)
# CONTACT: ___ (daughter) ___
***. | 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.
***
The patient was admitted to the orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
1. post op delerium -> ___ consult. minimize narcotics and
sedating meds. encourage family by bedside for frequent
orientation
2. urinary retension -> pt pulled his own foley out on POD1.
failed void trial several times requiring multiple straight
caths. currently with foley in. repeat void trial at rehab
sun/mon.
3. hypokalemia -> K 3.1 on POD4 -> gave 60meq x 1
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. 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.
Mr ___ is discharged to rehab in stable condition.
***. | MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ was admitted to the thoracic surgery service
after endobronchial valve placement x3 to the LUL by
interventional pulmonology on ___ (please see operative note
for details). She tolerated the procedure well. Post
operatively, CXR showed no evidence of pneumothorax. She was
started on her home nebulizers and home meds on POD1. Per IP,
she was started on prednisone 20mg daily, and azithromycin 250mg
daily. Diet was advanced as tolerated. On POD2, she desaturated
to mid ___ while ambulating on room air, but quickly recovered
with rest, and otherwise was satting well on room air for the
remainder of her post op course. Pain was well controlled. She
had daily CXR done to monitor her progress. On POD4, CXR was
stable, she was ambulating independently without desaturating,
tolerating a regular diet, had normal bowel function, and pain
was well controlled on oral medications, and was therefore ready
for discharge to home. She was instructed to continue taking her
home medications as she was previously was, until further
instruction at her 1-month follow up with IP, and to wear her
pneumothorax risk alert bracelet for the next 2 weeks.
Azithromycin and higher dose prednisone were stopped at
discharge.
***. | 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.
***
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a R Vancouver B3 periprosthetic femur fx and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for R periprosthetic
femur 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 was co-managed by the Medicine
service for intermittent agitation, most consistent with
hospital-acquired delirium She required IV Haldol on POD1 but
otherwise was managed by PRN Seroquel and frequent
reorientation. The Medicine team also decided to hold the
patients home Diovan until her follow-up appointment with her
PCP because of relatively low blood pressures. The patient
worked with ___ who determined that discharge to rehab was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
protected weight bearing in the right lower extremity, and will
be discharged on subcutaneous heparin twice daily 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.
***. | 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.
***
___ yo female with h/o IVDU, hepatitis C, EtOH abuse, HTN and
right knee tibial plateau fracture with hardware initially
presenting to ___ orthopedics with tibial hardware drainage,
found to have MSSA infection treated with nafcillin, complicated
by hepatic encephalopathy.
# HEPATIC ENCEPHALOPATHY: On HD #5 (POD #4 from removal of
tibial hardware), ___ became increasingly obtunded and
encephalopathic, and developed severe asterixis of her bilateral
upper and lower extremities. Her AST, ALT, AP and Tbili all
acutely trended up. She was transferred to medicine service,
where she had a right upper quadrant ultrasound which did not
show ascites, portal vein thrombosis/distension, or
liver/gallbladder abnormalities. She had head CT which did not
show any acute intracranial abnormalities. She was started on
lactulose and began putting out copious liquid stools, with
gradual resolution of her asterixis and clearing of her mental
status over the next several days. Hepatology was consulted and
recommended the addition of rifaximin, which was started on HD
#6. Neurology was also consulted for concern that pt's severe
asterixis was actually myoclonus and that she was suffering
nonconvulsive status epilepticus; they examined the ___ and
found this to be unlikely, and did not make any recommendations.
As ___ has h/o HCV (viral load 16,300,000), IVDU and EtOH
abuse, it is believed that she most likely has cirrhosis
although this has not been confirmed with biopsy. An extensive
liver fibrosis workup was performed: thus far she has found to
be HBsAg negative, HBsAb negative, HBcAb negative, AMA negative,
___ negative, IgG 707. Alpha 1 antitrypsin, ceruloplasmin, and
liver fibrosis panel are all currently pending. It is still
unclear what acutely precipitated ___ hepatic
encephalopathy, but most likely she had a transient bacteremia
at some point which exacerbated her liver pathology and caused
her to become encephalopathic. In addition, as ___ had been
started on nafcillin for her MSSA infection 4 days prior to
becoming encephalopathic, it was believed that ___
liver injury may have also precipitated her hepatic
decompensation. Therefore, nafcillin was stopped and replaced
with IV cefazolin on HD#6. Opioid withdrawal was also considered
as an additional etiology aggravating ___ symptoms, given
that she was actively abusing PO morphine up until day of
hospitalization and did receive opiates ___ she also had
dilated pupils, tachycardia and hypertension which further
supported this diagnosis. ___ mental status, neurologic
function and liver function tests gradually improved over the
course of hospitalization on the lactulose and rifaximin. On
HD#13, she was back to her baseline and her LFTs had almost
completely normalized (with the exception of alk phosph, which
remains elevated), so the lactulose and rifaximin were
discontinued. ___ continued to complain of diarrhea after
this, and C. diff toxins A+B and C. diff PCR were all negative,
so she was started on prn loperamide.
.
# LEUKOCYTOSIS: ___ developed fever, tachycardia,
hypertension and leukocytosis with left shift on HD#7. The
leukocytosis peaked at 17.5 on HD#9. She had extensive workup by
primary team and infectious disease team, with negative blood
cultures, urine cultures and chest ___. Knee ___ was also
done to assess for potential osteomyelitis, and this was
negative. As ___ primary complaint once her mental status
cleared was diffuse abdominal pain, ___ infection,
abscess, and pancreatitis (due to elevated lipase/amylase) were
all considered, so ___ had a CT abdomen with contrast on HD
#11 (unable to perform this earlier as ___ pulled out her
PICC several times, had poor IV access, and it took several days
to get power PICC placed by ___ in order for her to get IV
contrast). CT abdomen was also unrevealing, although potentially
may have missed something as it occured late in hospital course.
C. diff was also considered as symptoms developed ___
course, and ___ was started on PO vancomycin for empiric
coverage. However, C. diff toxins A+B and C. diff PCR ultimately
all returned negative, so vancomycin was stopped on HD#13.
Ultimately, ___ white count trended back to normal, her
fevers resolved, and she became normotensive again. However, she
remains tachycardic on discharge - this is most likely secondary
to her extensive history of anxiety which she does endorse.
.
# RIGHT KNEE MSSA INFECTION: pt admitted to the Orthopedic
service on ___ for right leg hardware removal and I&D after
being evaluated in Dr. ___ on ___. She
underwent hardware removal and I&D without complication on
___. She was extubated without difficulty and transferred to
the recovery room in stable condition. In the early
___ course Ms. ___ did well and was transferred to
the floor in stable condition. The infectious disease service
was consulted to help manage and recommend treatment course for
the ___. With cultures pending, the ___ antibiotic
course began with Vancomycin 1000 mg IV Q 12H. A PICC line was
ordered for ___ antibiotic use. Cultures returned showing
MSSA, so antibiotics were switched to Nafcillin per ID
recommendations. When pt developed hepatic encephalopathy, she
was switched to Cefazolin 2 grams IV q8 hours due to concern for
___ liver injury. Per ID, she will need to complete a 6
week course of Cefazolin (last day ___.
.
# ACUTE KIDNEY INJURY: Creatinine rose to 2.0 on HD#5, with UA
unrevealing and FENa 1.1 indicating intrinsic renal damage.
Workup did not show any clear etiology of her renal failure, and
renal function was restored to normal by end of hospitalization.
Most likely etiology at this point is believed to be prerenal
insufficiency secondary to infection.
.
# TACHYCARDIA: Pt became tachycardic on HD#7, the same time at
which she developed fever, hypertension, and leukocytosis. She
also developed tachypnea on HD#8. Pulmonary embolism was
considered initially as ___ had been sedentary for several
days, but LENIs were negative and CTA could not be performed due
to poor IV access at that time. Pneumonia was considered as
well, but CXR was negative. She was found at that time to have a
respiratory alkalosis and metabolic acidosis, for which numerous
etiologies were all worked up and found to be negative,
including salicylate toxicity. Ultimately, all of her vital
signs and labs returned to normal, but her tachycardia still
persists at discharge. Etiology of this is unclear, but felt to
be likely to either her pain, anxiety (which pt strongly
endorses) or some continued amount of withdrawal from opioid use
(less likely).
.
# HEPATITIS C: ___ has viral load of 16,300,000. An HCV
genotype was sent and results are currently pending.
.
# SUBSTANCE ABUSE: ___ states that she has not abused
alcohol in several years. She takes antabuse at home. She also
denies IVDU for the past several years. However, she does admit
to taking high doses of morphine bought on the street, and to
frequenting many ERs in order to obtain IV dilaudid. She states
that she is very interested in quitting. During hospitalization
she received social work consult to help her find resources at
home to assist with drug rehab and support groups.
.
# HYPERTENSION: ___ has history of essential hypertension.
She was taken off her home lisinopril during hospitalization;
was restarted on final day with no complications.
.
# DEPRESSION: stable on home buproprion and fluoxetine.
.
# HYPERLIPIDEMIA: ___ zocor was discontinued during
hospitalization secondary to her acute liver injury. She remains
off it at discharge, and will need lipid panel checked as
outpatient to determine whether statin should ultimately be
restarted.
.
TRANSITION OF CARE
- liver fibrosis panel labs need to be followed up by hepatology
and PCP
- HCV viral load currently pending; needs to be followed up by
hepatology and PCP
- ___ does NOT have a PCP in ___
has offered to set her up with a PCP during rehab (confirmed
with ___ case management). Please make sure that this happens
while she is there.
- ___ has back pain secondary to her long convalescence at
the hospital. We are treating this with acetaminophen. Please
avoid opioids due to ___ history of opioid abuse.
- We stopped pt's zocor secondary to her liver injury; will need
lipid panel checked by PCP in future to determine whether statin
should be restarted
- ___ is currently on neurontin 600mg qHS, but home dose is
900mg qHS. This may need to be uptitrated at rehab as she does
still have some neuropathic pain (did not return to home dose
here due to concern for altering mental status)
- we discontinued seroquel 100mg qHS during hospitalization in
order to avoid altering mental status. Reason for seroquel
prescription is unclear but may be for sleep. Can call pt's
outpatient psychiatrist Dr. ___ at ___
___ Counsel (___) for further info.
***. | LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATIOM DEVICES EXCEPT HIP AND FEMUR 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.
***
Pt was admitted to the SICU ___ for resp compromise d/t rib
fractures, clavicular fractures.
Neuro: awake, alert on arrival. head CT neg for acute process.
Sedated after intubation. Presently wake conversant and approp.
Resp: Required intubation on HD#3 after failing BIPAP and CPAP
support.
Failure to wean from the vent d/t ARDS and required trach and
peg on ___.
Weaned from vent. Trach down sized ___. Passey muir valve
placed and ___ well.
CTA was done to r/o PE which was neg. IVC filter was placed
prophlactically given relative risk on ___.
Right hemothorax was drained and a chest tube was placed for
continued drainage and PTX. Chest tube was removed ___
after resolution of PTX and fluid collection drained.
COR: approp tachy initially controlled w/ betablockaide.
TEE nl w/ EF 60%
intermittant lasix diuresis and pressor requirement.
OF note, during removal of arterial line - line cut and slipped
into artery. plastics consulted and line tip retrived w/adeq
profusion.
Nutrition: ___ placed for nutritional support and then peg
tube placed. currently ___ TF and reg diet after being seen by
speech and swallow pathology. Can wean from tube feed after
approp po nutrition established.
Heme/ID: Transfused PRBCs for HCT 23.1 w/ approp stabilzation
of HCT- presumed source of loss - right hemothorax.
Cipro was started prophlactically and d/c'd after neg culture
data. Pt spiked on HD #8 pan cultured and started on broad
spectrum IVAB for suspected VAP- vanco, cipro, ceftaz.
sputum ___- staph coag postive- sensitive to vanco. cipro
cetaz d/c'd and completed vanco course.
Pain:An epidural was placed for pain control, PCA and toradol
were added.
Now on metadone w/ good coverage.
Rehab: working w/ ___ to return to baseline level of functioning.
***. | ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PDX EXCEPT FACE MOUTH AND NECK WITH MAJOR O.R. PROCEDURE |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ yo male with a history of CAD (s/p CABG ___, sCHF (EF 50%
___, PAD, hypercholesterolemia, hypertension, ventricular
ectopy, sinus bradycardia who presented with left sided weakness
and falling x3, here for pacemaker placement.
# Left Sided Weakness: Concerning for TIA given risk factors of
HLD, PAD, CAD, HTN and history of CEA. Pt had normal CT head on
___ and CTA/CTP with showed no perfusion abnormalities.
Toxic-metabolic workup has been negative. Neuro consulted, and
is considering possiblity of watershed areas caused by
bradycardia, vs baseline hypoperfusion from history of
CEA/orthostatic hypotension. Non contrast MRI completed ___,
no evidence of acute stroke, recommend follow up outpatient.
D/C'd plavix 75 mg daily ___ given stroke risk factors.
Continued home ASA 325 daily, rosuvastatin 40 mg daily.
# Sinus Bradycardia: Pt found to have HR in the ___.
Here for pacemaker placement. Pt is now symptomatic s/p falls
3x. An MRI compatible pacemaker was placed ___.
# CAD: Pt is s/p CABG in ___, DES in RCA. He is currently
without chest pain. Troponin <0.01 on admission. Was on home
carvedilol which was d/c'd two weeks prior due to concerns of
bradycardia. Continued home ASA 325mg daily, home SLN prn,
rosuvastatin 40 mg daily.
# Systolic HF with preserved EF: EF of 50% on ECHO ___. Home
carvedilol held 2 weeks prior due to bradycardia. Pt allergic
to ACE-Inhibitors (angioedema--so also not on an ___.
# Hypertension: Pt was on home Carvedilol, but was discontinued
2 weeks prior due to bradycardia. He has a reported allergy to
ACE-Inhibitors, which was angioedema. He was normotensive on
this admission.
# Hypercholesterolemia: Continued home rosuvastatin 40 mg daily.
Lipid panel ___: ___ Total Chol: 103 LDLcalc: 35 LDLmeas:
51 HDL:44.
Transitions of Care:
Full code
#Plavix is being held going forth
#He will follow up with neurology in 6 weeks
#He will follow up with the device clinic on ___
***. | PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ is a ___ year old male who presents for elective
craniotomy for clipping of MCA aneurysm.
#MCA Aneurysm
The patient underwent left sided craniotomy. The procedure was
complicated by significant calcification of the aneurysm and was
unable to be clipped. For further procedure details, please see
separately dictated operative report by Dr. ___. He was
extubated in the operating room and transported to the PACU for
post-procedure monitoring. Post-operative NCHCT showed mild
diffuse subarachnoid hemorrhage. Once stable, he was transferred
to the ___. On ___, the patient complained of significant
headache that was uncontrolled with oral and IV pain
medications. He was given steroids x 24 hours. On ___, he
remained neurologically intact with better control of the
headache. He was transferred to the floor. The patient was
discharged to home on ___.
#Pneumonia
Post-operatively, the patient had an episode of O2 desaturation
to the high ___. He was placed on high flow oxygen and a chest
xray revealed right middle lobe pneumonia. He was placed on a
seven day course of Levaquin. Oxygen was weaned as tolerated.
***. | CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL 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.
***
___ year old man with PMH of CAD, end-stage CKD, HTN, DM 2, here
with ___ edema, weight gain, dyspnea concerning for acute
decompensated heart failure. Initially, the edema improved with
IV diuretics; however, his kidney function worsened, requiring
operation for AV graft and a tunneled HD line to initiate
dialysis.
ACTIVE ISSUES:
====================================
# Acute decompensated heart failure, LVEF 37%
He presented with weight gain and lower extremity edema,
dyspnea, refractory to outpatient treatment. Patient had an ECHO
during a prior admission which showed an EF of ~35%. His
systolic dysfunction was thought to be related to ischemic
injury as his p-MIBI results showed evidence of focal wall
motion abnormalities also during the last admisison. His
afterload was maintained with hydralizine and isordil which were
increased for goal MAP 65. He was started on aggressive diuresis
with Lasix gtt, and later transitioned to po torsemide. He was
continued on carvedilol. Unfortunately, his edema worsened and
he had to be transitioned back to iv Lasix boluses. His kidney
function worsened iso cardiorenal syndrome and decision was made
to transition the patient to HD for fluid removal. Prior to
discharge, he was started on 10 mg lisinopril daily and
hydralazine/isordil were discontinued. As an outpatient, can
continue to uptitrate lisinopril as needed. He had torsemide 40
mg started for non-HD days for additional diuresis.
# CKD, end-stage
Mr. ___ has end-stage kidney disease; he initially declined
dialysis but later agreed after his BUN/Cr and electrolytes
worsened. He received an AV graft in his L arm. He was continued
on nephrocaps, sodium bicarbonate, calcitriol, and sevelemer.
His sevelamer was held on discharge as per renal recs due to low
phosphate and his bicarbonate was held due to normal bicarb
levels. He should continue to receive calcitriol and EPO with HD
as per renal recs. Unfortunately, his electrolytes worsened
while his graft was still maturing, requiring a tunneled HD line
for dialysis. He was started on dialysis session #1 on ___,
session #2 on ___ and session #3 on ___. He was switched
to a ___ schedule and he received his
first session of this schedule on ___. His
creatinine improved and was 3.0 on the day of discharge. He
should take torsemide 40 mg every other day on non-dialysis
days. PPD placed and read as negative. Hepatitis serologies also
negative. Patient given the first Hepatitis B vaccine during
hospitalization.
#Hyponatremia: Initially thought to hypervolemic hyponatremia
iso decompensated heart failure. Sodium improved to the 130s
with diuresis. His Na on discharge on 129. It was unclear if
this was hypovolemic vs. hypervolemic as a decline was seen with
initiating torsemide along with HD. Renal recommended continuing
to monitor this outpatient with removal fluid with HD and
possibly uptitrating torsemide. If his sodium worsens with this,
consider discontinuing torsemide.
#CAD, HLD: He was maintained on his home atorvastatin 80 mg and
home ASA 81 mg.
# HTN: His hypertension was controlled with hydralizine and
isordil as above. Hydralazine was discontinued prior to
discharge and he was started on 5 mg lisinopril daily. As an
outpatient, lisinopril can be further uptitrated and isordil can
be discontinued if his blood pressures tolerate it.
# DM Type 2: His home glipizide was held in the hospital and he
was initiated on SSI.
# Pulmonary Hypertension: Monitored.
TRANSITIONAL ISSUES
====================
[ ] DISCHARGE WEIGHT: 73.2 kg (possibly unreliable)
[ ] DISCHARGE DIURETIC: 40 mg torsemide on non-HD days
[ ] FOLLOW UP LABORATORY TESTING: Continue to monitor serum Na,
Cr at dialysis sessions.
[ ] MEDICATION CHANGES:
[ ] NEW: torsemide 40 mg QOD on non-HD days, lisinopril 10 mg
daily
[ ] STOPPED: hydralazine, isordil
[ ] CHANGED: holding sevalamer, holding sodium bicarbonate,
calcitriol to be dosed with HD, EPO with discharge
[ ] Given hepatitis B vaccine for negative serologies, 1st dose
given ___. Please complete course.
[ ] Decreased glipizide to 2.5 mg PO daily as patient
transitioned to HD. Recommend repeat glucose check at next PCP
follow up and titration of glipizide if tolerated, with addition
of other DM medications as needed.
[ ] Consider weaning off omeprazole / PPI as outpatient with
up-titration of H2 blocker as needed for GERD symptoms.
#CODE STATUS: Full (confirmed)
#CONTACT: Wife ___ ___
***. | OTHER CIRCULATORY SYSTEM O.R. 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.
***
ASSESSMENT AND PLAN: This is a ___ yo female with progressive
breast cancer metastatic to the liver, bones, with ascites and
right sided hydronephrosis currently on eribulin (C1) now
admitted for rising T bili.
# Rising T bili: RUQ US showed no biliary obstruction. The exact
etiology was unclear but thought due to liver dysfunction from
metastases +/- hemolysis. Her bili peaked at 4.9 (2.8 direct,
2.1 indirect) and then improved to 3.3 on day of discharge. if
this is all related to liver failure, might expect transaminases
and synthetic function to be worse than they are. The hepatology
service was consulted regarding this question and they felt that
her LFT abnormalities are most consistent with infiltrative
liver metastases. There is a possibility that some level of
hemolysis may be contributing, see below. Lactulose was
considered but she had no evidence of hepatic encephalopathy
during this hospitalization so not started.
# anemia: hgb 6.2-->9.3, responded to 2 unit PRBC transfusion
___. She was admitted approx 1 week from last eribulin, so much
of this likely chemo related. however, many nucleated reds on
peripheral smear raises possibility of a marrow infiltrative
process or RBC destructive process. she was mildly
thrombocytopenic but WBC and hgb were normal on metastatic
presentation in ___. She has been on chemo since which
makes interpretation more difficult. LDH high, hapto low, retic
4%. could be related to hemolysis, though malignancy could
explain high LDH and liver dysfunction could cause low
haptoglobin. Coomb's test was negative so even if she has
hemolysis it does not seem to be autoimmune. review of
peripheral smear showed many nucleated reds, moderate
reticulocytosis, anisocytosis, rare spherocytes and
schistocytes, normal appearing myeloid cells.
# thrombocytopenia: likely chemo related. held pharmacologic DVT
prophylaxis
# shortness of breath: R base dullness on exam. last CT shows R
effusion. likely malignant but no diagnostic thoracentesis has
been done yet. CXR ___ possibly increasing effusion. symptoms
only with climbing stairs so she does not want to pursue
thoracentesis at this time. explained that we may see
improvement if this is malignant and responds to chemotherapy,
otherwise will need thoracentesis if symptoms worsen.
# breast cancer: Stage IIB (T2N1M0) infiltrating carcinoma with
predominantly lobular features, ER+/PR+/Her2 non-amplified,
with three of four positive lymph nodes of the R breast, S/p
chemo, b/l mastectomy and xrt, found to be widely metastatic
___. treated with Xeloda, did not tolerate. Evaluated for
trial at ___ but ineligible due to LFTs. started eribulin
___. Her case was discussed with outpatient oncologist Dr.
___. though she has increasing bili and significant
cytopenias, we think that given her underlying disease burden
and the possibility that some of her current lab abnormalities
may be related to advancing malignancy, we should go ahead with
chemotherapy. however, we gave reduced dose 0.4mg/m2 = 0.75mg
Eribulin for C1D8. She will resume treatment as an outpatient.
Greater than 30 minutes was spent in discharge planning
***. | MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is a ___ year old man with a hx of metastatic
osteosarcoma s/p chemotherapy with neadjuvant Cis/Adria,
followed by surgical resection, then etoposide/ifosfamide for
metastatic disease. He was recently admitted for DVT/PE and
discharged 2 days ago. He re-presents with fever of 101.7 and
chills. His elevated WBC suggests infecious etiology.
ACTIVE DIAGNOSES:
=================
# Fever: Differential includes infectious etiologies, new
pneumonia seen on CXR, worsening DVT or PE, or metastatic
osteosarcoma. He has no respiratory symptoms of pneumonia,
although he does have an opacity on CXR and fever. He has no
symptoms to suggested worsening PE and his HR was elevated the
last admission as well. PNA treated as below. Blood and urine
culturs with no growth. DVT/PEs treated with lovenox as below.
C. diff negative. Etiology of fevers never fully elucidated, at
time of discharge he had been afebrile >24 hours.
# PNA: Patient with new consolidation on CXR not present on
recent CT, consistent with PNA. Started on vanc + cefepime in
ED. Pt was febrile to 101.6 on admission, has been afebrile
since although with intermittent elevated temp. Pt also with DOE
worse than baseline when working with ___, likely related to PEs
vs PNA. Patient was transitioned to PO Levaquin on ___.
Leukocytosis on ___ to 12.5, on day of discharge downtrending to
11.8. Levofloxacin continued on discharge to complete a ___HRONIC DIAGNOSES:
==================
# Anemia: Patient with anemia at baseline, likely
multifactorial. Crit has been relatively stable between 22.4 to
25.3. On discharge, crit= 21.8. No concern for acute bleed.
Patient may have symptomatic benefit to transfusion, however
would be transient. Not transfused on this admission.
# DVT/PE: found on last admission, pt currently on lovenox BID
which was continued in house. Factor Xa level ordered with
concern of anemia as above, and pt not supratherapeutic.
# Osteosarcoma: Stage III osteosarcoma s/p 4 cycles of
neoadjuvant chemotherpy followed by surgical resection of the
primary tumor at ___ by Dr. ___ on ___. Pt received
adjuvant chemotherapy with etopaside and ifosfamide ___.
Cycle 2 adjuvant chemo with etopaside and ifosfamide started
___, ___nded ___. Pt did have significant CNS side
effects and renal toxicity. Previously, plan was to rescan him
this week and tentatively admit for high dose MTX during the
week of ___ however now with metastatic disease progression and
plan to be seen for second opinion/trial at ___ on ___.
# Hip pain: Chronic right sided hip pain ___ osteosarcoma and
resulting resection/transplant. Patient does not feel that pain
is currently much different from baseline. Exam notable for area
of induration and significant tenderness on anterior R thigh,
unchanged from prior admission where CT showed large seroma. may
actually be improving. Per Dr. ___ says no utility of
draining seroma as it will rapidly reaccumulate. Patient's home
meds were continued for pain control, morphine sulfate ER 45mg
PO q8h, oxycodone 20 q6h PRN, gabapentin, and tylenol prn with
good relief.
# Tachycardia: Sinus tachycardia, patient has chronic
tachycardia with baseline HR in the low 100s. Likely ___ PE,
pain, anemia, and pro-inflammatory state. Controlled pain
control with home meds, however pt remained tachycardic on this
admission.
TRANSITIONAL ISSUES:
====================
- Unclear source of fevers, patient is likely to be readmitted
with fever which may very well be from his malignancy vs. PEs
vs. infectious
- Patient has appointment to ___ on ___ for possible
enrollment in trial
- Contine levofloxacin at home to complete 10 day abx course
***. | 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.
***
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an open L tib/fib fx and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for I&D, open reduction, and application of external
fixator, 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 worked with ___ who determined that discharge to rehab
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 NWB in the LLE extremity, and will
be discharged on lovenox 40mg x2wks 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.
*** year old woman with a history of pAF on warfarin, sick sinus
syndrome s/p pacemaker, GI bleed ___ antral polyps, who
presented with several weeks of constipation and abdominal pain,
and found to have rectal mass on exam. Underwent colonoscopy
with biopsy on ___.
# Rectal mass: CRS consulted, concerning, advised colonoscopy
with biopsy; required 2 days of prep to become clear. Underwent
colonscopy with biopsy on ___. Will f/u closely in ___ for
further evaluation and treatment of this rectal mass. She had
minimal bleeding post-biopsy (blood on toilet paper, no overt
bleeding). Warfarin was held at discharge but can be resumed on
___ if bleeding has resolved
# Severe Constipation w/ fecal impaction: resolved manual
disimpaction by GI followed by aggressive bowel regimen and
then, ultimately, with nearly 48 hours of colonoscopy prep
# Abdominal pain: resolved with resolution of constipation
Discharged on bowel regimen. Advised that she titrate to ___ BMs
per day and to call her MD if ___ had a BM for 48 hours.
# 2 weeks of decreased appetite + night sweats: suspect due to
yet unconfirmed rectal malignancy (primary vs. metastatic)
# pAFib/SSS/pacer: held home Coumadin on admission due to
reports of BRBPR. She did not have significant BRBPR during this
hospitalization (nor significant blood loss anemia), but
coumadin continued to be held given the plans for colonoscopy
with biopsy. Her INR did not decline significantly despite
holding coumadin for several days, which we suspect was related
to decreased PO intake recently in setting of abdominal pain and
severe constipation with resulting poor nutritional
status/decreased Vit K intake. Coumadin held at discharge given
she had some mild post-biopsy bleeding (CHADSvasc of 4, 4.8%
yearly risk of stroke). She will need repeat INR on ___,
and can resume anticoagulation at that time if Hg is stable and
bleeding has resolved. Discussed risks and benefits of holding
anticoagulation with the patient. She is in agreement to hold
and has previously held warfarin in the past
# Pancreatic mass: 12 mm hypodensity on prior imaging. Patient
reportedly did not attend GI follow up appointment and/or MRCP.
This will need additional evaluation going forward.
# Difficulty getting to appointments: based on our discussions
with her, there seems to be a complex psychosocial history to
this issue, originating from patient's facial birthmark which
she says she is very ashamed of (since childhood) leading to
chronic self-induced isolation from others, as well as, I
suspect, fear of receiving bad news. SW was involved and
discussed resources that were available to help her get to
appointments. The patient generally goes to the gym each
morning (5 days per week), so is definitely physically capable
of leaving her house and getting to appointments.
Transitional Issues:
- needs INR and Hg checked on ___. She will call
___ clinic on ___ to receive guidance on dosing
- warfarin held at discharge, can resume on ___ if Hg stable and
mild post-biopsy rectal bleeding has resolved
- biopsy of rectal mass pending at discharge. She will follow up
in ___ clinic. The clinic will call her to schedule an
appointment
> 30 minutes spent on discharge coordination and planning
***. | 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.
***
___ with history of severe asthma (s/p 4 prior intubations, one
hospital admission last year) who presented with dyspnea due to
an asthma exacerbation. Prior to admission, patient did not
improve on home nebulizers and prednisone 50mg PO x 5 days,
after reaching out to her pulmonology team. On admission,
patient remained afebrile, had no leukocytosis, and had a chest
x-ray not concerning for infection. She was treated with a
steroid burst (prednisone 70mg PO x 5 days, followed by a
taper), Mg 2mg IV, albuterol and ipratropium nebulizers, in
addition to her home regimen (montelukast, azithromycin). Her
home regimen prior to admission
#Asthma Exacerbation: Patient has FEV1 0.81L, 40% of predicted
at last exam (___). On admission exam, patient had poor air
movement and wheezing with vital signs stable. Patient continued
her prednisone burst of 70mg PO x 5 days, to be completed
outpatient with a taper. She was also placed on
Ipratropium-Albuterol Neb 1 NEB NEB Q6H, Albuterol 0.083% Neb
Soln 1 NEB IH Q2H:PRN dyspnea, and continued on home Montelukast
10 mg daily, Cetirizine 10 mg PO DAILY, Azithromycin 250 mg PO
QD, Flovent HFA (fluticasone) 110 mcg/actuation inhalation 4
puffs BID, Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID.
Patient was clinically improved on ___ with improvement of peak
flow to 275cc, total resolution of dyspnea (patient reports
being at baseline w/ breathing) and improved pulmonary exam.
# Insomnia: Continued home Trazadone 50 mg PO ___ tablet QHS PRN
Insomnia.
# Obstructive Sleep Apnea: continued home CPAP, after tolerating
nebs >2hr apart.
# GERD: Continued home Omeprazole 40 mg capsule, delayed release
PO BID.
# Misc: Continued home Aspirin 81 mg PO DAILY. Held Ascorbic
Acid ___ mg PO DAILY and Vitamin D3 (cholecalciferol (vitamin
D3)) 2,000 unit oral.
TRANSITIONAL ISSUES:
- steroid taper as below:
Prednisone 70mg daily x 5 days total (last dose ___
Prednisone 60mg daily x 2 days (___)
Prednisone 40mg daily x 2 days (___)
Prednisone 20 mg daily x 2 days (___)
Prednisone 10mg daily maintenance dose per prior regimen
- patient already has scheduled pulmonary function assessment
***. | BRONCHITIS AND ASTHMA WITH CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient presented pre-operatively on ___. Patient was
evaluated by anaesthesia. The patient was taken to the
operating room for a laparoscopic sleeve gastrectomy for
obesity. There were no adverse events in the operating room;
please see the operative note for details. Pt was extubated,
taken to the PACU until stable, then transferred to the ward for
observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a PCA. Pain was
very well controlled. The patient was then transitioned to
crushed oral pain medication once tolerating a stage 3 diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO. Afterwards, the
patient was started on a stage 1 bariatric diet, which the
patient tolerated well. Subsequently, the patient was advanced
to stage 2, and then stage 3 diet which the patient was
tolerating on day of discharge.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a
bariatric stage 3 diet, ambulating, voiding without assistance,
and pain was well controlled. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
***. | O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ yo M who is nonverbal at baseline who comes from group home
with L hand cellulitis.
# Cellulitis
He was started on vancomcyin but contiued to have low grade
temps and thus cefazolin was added. An X ray was negative for
fracture. US was negative for abscess.He was seen by hand
surgery who agreed with the management of hand elevation. He was
not given a splint since he appeared comfortable. He was
switched to oral abx on ___ and observed for more than
24hrs with continued improvement. He was discharged to complete
a 10 day course of keflex and bactrim. He can be started on
florastor supplementation to prevent cdiff.
# Glaucoma
-His home meds were continued.
.
# ASA use:
Discussed with his PCP and given his many ecchymoses in the L
hand surround the cellulitis and his history of easy bleeding
(coags normal) his ASA was held. He does not have a history of
CAD per PCP.
.
# Osteoporosis
He was continued on vitamin D and calcium. He received fosamax
on ___ prior to admission.
.
# HLD:
His statin was continued.
FEN - pureed diet, no thin liquids
PPX - sqh
Code - FULL code per RN at group home.
***. | CELLULITIS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
A ___ yo male with PMH ESRD and DM1 here with recurrent left
flank pain that began during dialysis and found to have
apparently new L>R ansiocoria.
# Flank pain: Patient reports similar to previous episodes which
have also occurred in association with dialysis and have
resolved after ___ days. The etiology has never been identified.
It has been previously thought to be diabetic thoracic
polyneuropathy gastroparesis or chronic mesenteric ischemia.
Pancreatitis was considered unlikely given that lipase was not
elevated on admission. ACS was considered given the elevated
troponins on admission however the patient is anuric and on
dialysis which elevates troponins, EKG was unchanged and repeat
troponins did not trend up. His pain was managed with Morphine
___ PRN and Oxycontin 10mg BID. Lidocaine patch did not
provide relief. His pain improved overall throuhgout his
admission but was still present at discharge. As his pain
improved, he was transitioned to PO oxycodone and discharged
with a prescription for Ultram.
# Hypertensive urgency: Patient was admitted from dialysis due
to pain and elevated SBP. At dialysis, his SBP was 185 and it
increased to 200 at the time that he left dialysis and was not
treated. He complained of blurry vision and headache while in
dialysis. In the ED, a head CT was performed which was negative
for acute bleed. On arrival to the floor, he was noted to have
apparently new ansiocoria with an unractive left pupil. Concern
for stroke was raised and neuro was consulted who recommended
maintaining his SBP between 140-160 until etiology of ansiocoria
was determined. Once the ansiorocia issue was addressed, his
home BP meds were resumed at their usual dose with better
control of BP.
# L>R ansiocoria: On arrival to the floor, patient was noted to
have apparently new left sided ansiocoria in the setting of
hypertensive urgency. His left pupil measured ~6mm and was
unreactive to light. Possible etiologies included hypertensive
retinopathy, stroke or aneurysm. Neurology was consulted who did
not note any additional neurological deficits aside from
decreased visual accutiy and recommended ophthalmology consult
and MRA. MRA was negative for aneurysm or other concerning
findings. Ophthalmology was consulted who obtained additional
history revealing that patient sustained traumatic injury to the
eye earlier that year. This is likely the cause of ansiocoria
Left > Right ansiocoria.
# ESRD: Patient continued to go for hemodyalisis while in
hospital, he was maintained on a renal diet and his Renagel was
continued.
# Diabetes: Mantained home insulin regimen (Humalog Mix ___ 6
units QAM and 6 units QPM) and metoclopramide for history of
gastroparesis, will continue metoclopramide.
# Depression: Continued Citalopram 20 mg PO Daily and Doxepin 25
mg PO HS
***. | 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.
***
Ms. ___ is a ___ y/o female with a past medical history of
depression who presents with chest pain secondary to stress
induced cardiomyopathy.
# Chest pain: presented with chest pain on exertion, initially
concerning for unstable angina v. stress induced cardiomyopathy.
She did report a significant amount of stress over the past few
months. TTE was notable for an EF of 35-40%, with mild to
moderate regional left ventricular systolic dysfunction with
near-akinesis of the distal ___ of the left ventricle. EKG
initially revealed deep T wave inversions in the precordial and
lateral leads. Three sets of troponins were negative. She was
managed with aspirin, atorvastatin, metoprolol, and a heparin
drip. She subsequently developed 2mm ST elevations in V1-V3, and
went for emergent cardiac catheterization, where she was found
to have clean coronaries consistent with a Takotsubo stress
cardiomyopathy. Aspirin and atorvastatin were stopped. She was
continued on metoprolol, and started on lisinopril given newly
reduced EF. She was also started on warfarin with a lovenox
bridge given wall motion abnormalities and concern for embolic
risk.
# L facial droop: On evening of admission she was noted to have
a left sided facial droop. She had normal activation of CN VII,
and no other cranial nerve deficits. Strength was full and
symmetric. Heparin was stopped and non-contrast head CT was
obtained, which was negative for any acute hemorrhage. Heparin
was then restarted. MRI/MRA head was notable for an area in the
R parietal lobe consistent with a small acute to subacute
infarct, likely embolic in nature. She was evaluated by
neurology, who felt that this was unrelated to her symptoms.
They felt that her facial droop was most likely secondary to
Bell's palsy, and she was started on a 10 day prednisone taper.
She will require Lyme serologies post discharge.
# Depression: continued home lexapro 10 mg daily
Transitional Issues:
- started on metoprolol XL 25mg daily and lisinopril 5mg
- given distal near akinesis and concern for embolic potential,
started on warfarin with lovenox bridge. Needs INR check on ___
___
- will check chem-7 on ___ as well given lisinopril started.
- discharged on prednisone, 60mg for five days finishing on
___, then decreasing by 10mg per day. Taper will finish on ___
- needs Lyme serology given Bell's palsy
- will need cardiology follow up, and repeat echo in ___ months.
If EF has normalized then anticoagulation can be discontinued
- if any questions, call Dr. ___ at ___
***. | 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.
***
Mr. ___ is a ___ who underwent a laparoscopic sleeve
gastrectomy on ___. There were no adverse events in
the operating room; please see the operative note for details.
Pt was extubated, taken to the PACU until stable, then
transferred to the ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a preoperative
TAP block and postoperative gabapentin, acetaminophen and
ketorolac.
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. CPAP was utilized while
sleeping per OSA protocol.
GI/GU/FEN: The patient was initially kept NPO with a nasogastric
tube in place for decompression. On POD1, the NGT was removed
and the patient underwent both a methylene blue dye test and UGI
series, which were both negative for leak. Therefore, the
patients was started on a stage 1 bariatric diet, which the
patient tolerated well. Subsequently, the patient was advanced
to stage 2.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none. There was oozing from
one of his laparoscopic incisions which was resolved via an
additional SC suture.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a
bariatric stage 2 diet, ambulating, voiding without assistance,
and pain was well controlled. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
***. | O.R. PROCEDURES FOR OBESITY 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 an ___ woman with a long-standing hiatal
hernia, who was transferred from an outside hospital with acute
abdominal and chest pain, and the inability to vomit. CT scan
disclosed a massively dilated intrathoracic stomach, and we were
unable to pass a nasogastric tube in the emergency room. She was
fluid resuscitated in the Emergency Department and then brought
her urgently to the operating room for repair of the hernia, and
endoscopy to decompress the stomach. She had an Emergency
laparoscopic repair of hiatal hernia, Repair of esophageal
perforation, Buttressing of esophageal perforation with adjacent
tissue and Esophagoscopy with endoscopic-directed placement of
nasogastric tube. She tolerated the procedure and was taken
directly to the ICU for close postoperative management. IV
antibiotics were started for her Esophageal perforation. Her
pain was managed with IV fentanyl and IV dilaudid. On
Post-operative Day #1, she was extubated and did have demand
ischemia with elevated troponins but no EKG changes. She was
started on TPN and placed on a lasix drip for fluid management.
Her troponins and CK trended downward. The lasix drip was
stopped on POD #3. By POD # 5, the patient was ambulating in her
ICU room with assistance. On POD# 6, and esophogram revealed a
persistent contained leak. Her A-line was removed. Her mental
status had improved. On POD #8, she was transferred to the
floor, her PICC was placed and her CVL was dc'd. Her foley was
DC'd on POD #9 and she was able to void without difficulty. She
had yeast on a bronchial washing which was treated with
fluconazole when her CXR began to worsen on ___. Her WBC also
spiked on the ___ to 16.2 on Vanc/Zosyn/Fluconazole. However,
this WBC drifted down over the next few days without a new
source being identified. On ___, POD #13, she had a
persistent leak in gastrofaffin swallow. LFT's were ordered due
to persistant R sided abdominal pain. Her amylase and lipase
were elevated at 262 and 401, but a RUQ ultrasound only
demonstrated gallbladder sludge with no ductal dilation and her
enzymes trended down without treatment. On POD #14, the patient
slipped off her chair, but did not have any evident injuries. A
T-spine x-ray was obtained which demonstrated no acute injury.
On POD #15, GI was consulted for an EGD for evaluation of the
leak for possible clipping. Clipping could not be completed, but
they identified ulcerations and 2 fistulous areas. Her NGT was
removed without difficulty as the bile output had significantly
decreased. The two JP's were kept in place and there was no
increase in output without the NGT in place. A CT scan was
obtained on ___ that did not show any evidence of
esophageal perforation. Because the patient would require long
term nutritional support, on POD#21, the patient was taken to
the OR for a laparoscopic J tube placement and EGD. There was no
perforation visualized on EGD. She tolerated the procedure
without difficulty and was started on Tube Feeds 24 hours later.
Once tube feeds were at goal, the TPN was discontinued. On
___, a esophagram was attempted, but not completed due to
patient cooperation. The limited study showed a small leak. She
was advanced to sips of water for comfort on ___.
The Chronic pain service was consulted due to her longstanding
issues with headaches and neck pain. She actually is seen by a
pain physician on the outside. Unfortunately many of her pre op
medications could not be restarted due to her inability to take
oral medications, nor could they be crushed and placed down her
J tube. Only liquid medication can go through the J tube. The
pain service recommended restarting Gabapentin in liquid form
and a Lidoderm patch which seemed effective. She is also
receiving Roxicet through her J tube. These are helpful but her
baseline issues persist. She will be following up with her pain
doctor at ___ in ___ later this month.
___ Physical Therapy service worked with Mrs. ___ on many
occasions to improve her mobility and endurance and recommend a
short term rehab prior to returning home. She will be
discharged to rehab today and will remain on tube feedings via
her J tube. Please do NOT put any crushed medication down the J
tube, liquid medication is acceptable. Mrs. ___ will return
on ___ for a barium swallow to assess the esophagus
***. | STOMACH ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ yo male with pmh of CAD s/p CABG, atrial flutter, DMII, COPD,
prostate cancer s/p XRT, CKD, MDS with newly found generalized
LAD concerning for lymphoma s/p LN biopsy showing necrosis
presented with 3 days of abdominal pain.
# Generalized LAD/concern for lymphoma/history of MDS/CMML: The
patient has a history of MDS and ? of CMML with pancytopenia at
baseline. He was recently found to have generalized LAD and
underwent a biopsy which only showed necrosis. He underwent a
biopsy of a LN in his neck during this hospitalization for to
allow for further diagnosis. He also had an infectious workup
sent including HIV Ab (neg), and HIV VL, Hep B, Hep C, and RPR
which are pending. Heme/onc were contacted, however they prefer
to follow up with him as an outpatient.
# Abdominal pain: The patient describes abdominal pain
radiating to his back, constant, causing his to avoid food. He
underwent a CT abd/pelvis in the ED which showed no cause for
his pain. His lipase was WNL. His pain was controlled with his
home pain regimen as below and dilaudid prn. The patient's pain
slowly improved. It is unclear what had caused his pain.
# Atrial flutter: The patient was found to be in atrial flutter
during a recent hospitalization and was to undergo ablation in
the near future when his lymphadenopahty was discovered. His
heart rate was well controlled on his outpatient meds. His
Toprol was decreased from 150 mg daily to 100 mg daily given a
few low blood pressures. His coumadin was held and he was given
5 mg po vitamin K and FFP to reverse his INR for the biopsy. He
was discharged off coumadin and asked to follow up with his
cardiologist prior to restarting it due to bleeding risk while
thrombocytopenic.
# CAD: The patient has a history of 3 vessel disease previously
in ___ and s/p CABG in ___. No chest pain during this
admission. His ASA was held for biopsy and he was discharged
off ASA and asked to follow up with his cardiologist prior to
restarting it due to bleeding risk while thrombocytopenic. He
was continued on metoprolol (dose decreased prior to discharge
as above).
# Chronic renal failure: The patient's Cr on admission was 1.4.
His basline Cr appears to be 1.0-1.2, but during a recent
admission he had ARF with a Cr of 2.0. Since then 1.4 is the
lowest value it has reached. His Cr remained 1.3-1.5 during
this admission.
# Anemia: The patient's Hct on admission was 35.2. He has a
history of chronic anemia related to his MDS and has receives
___ as an outpatient. This appears to be at his baseline.
He was due for an ___ shot during this admission, but it is
not on formulary so he was given an equivalent dose of epo in
its place and asked to make an appointment for his next shot
which is due on ___.
# DMII: The patient is on nph and SSI as an outpatient. He was
continued on his home medications and monitored with qid
fingersticks.
# Pain: The patient has diabetic neuropathic pain. He was
continued on his home regimen of a fentanyl patch, neurontin,
and percocet prn.
# Chronic arthralgias and myalgias: Patient on 2.55 mg of
prednisone daily as an outpatient for muscle aches. This was
stopped during this admission due to concern that it could be
interfering with the biopsy results.
# CODE: Full code
***. | OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with PMHx of Alzheimer's dementia, Herpes Zoster presenting
from ALF with fever, cough, generalized weakness, and
encephalopathy, likely consistent with community-acquired PNA
with delirium.
# Fever:
# Rhinorrhea:
# Cough:
# Generalized weakness:
# Encephalopathy:
# Community-acquired PNA:
Presented from ALF with rhinorrhea, cough, generalized weakness,
encephalopathy, and fevers. No leukocytosis or hypoxia, but CXR
with possible bibasilar opacities, consistent with
community-acquired pneumonia with likely delirium superimposed
on baseline dementia. Possibly viral pneumonia given concurrent
rhinorrhea, but flu A/B negative and cannot exonerate bacterial
infection vs superinfection. CURB65=2, c/w 6.8% 30d mortality
warranting inpatient treatment. Legionella Ag negative, BCx and
Strep Ag pending at discharge. Was unable to produce sputum
sample. Treated with CTX/azithromycin ___. She
defervesced on this therapy, and her respiratory symptoms were
improving at the time of discharge. Her encephalopathy
fluctuated during her admission with intermittent sundowning,
consistent with improving delirium that will likely benefit from
return to familiar surroundings. Antibiotics were transitioned
on ___ to cefpodoxime 400mg BID and azithromycin 250mg daily
to complete a 5d course through ___ (will require cefpodoxime
400mg ___ ___ and 400mg BID on ___ and azithromycin 250mg on
___ medications were faxed to pharmacy to allow for blister
pack delivery to ALF on day of discharge). She was seen by ___,
who recommended using a walker for a few days (provided) and
home ___. ___ appointment with PCP scheduled for ___.
# Encephalopathy:
# Alzheimer's dementia:
Presented with increased confusion, likely in setting of PNA as
above with delirium superimposed on baseline Alzheimer's
dementia. No headache or meningismus to suggest CNS infection,
and no obvious medication culprits. Mental status fluctuated
during her hospitalization, with intermittent sundowning, but
was overall improving at the time of discharge (AOx2, pleasant,
oriented to Trump). Suspect that she will benefit from return to
a more familiar home environment. Home mirtazapine and
galantamine were continued during her hospitalization. Ramelteon
QHS was added in hospital and on discharge to assist with
regularization of sleep/wake cycle. She should ___ with her
outpatient cognitive neurologist after discharge (currently
scheduled for ___.
# Atypical cells on CBC differential:
# Mild lymphocytosis:
CBC w/diff on the day of discharge revealed WBC of 5.8 with 17%
lymphs (1450 abs lymphs, WNL) and 8% atypical cells (hematology
review pending at discharge). Suspect artifact (given diff
previously normal ___ and ___ vs atypical lymphocytosis
from viral infection. Lower suspicion for infectious
mononucleosis in absence of pharyngitis or lymphadenopathy or
pertussis given improving cough. Will need to ___ hematology
review and would consider repeat CBC w/diff at PCP ___.
# L scapular excoriations:
Presented with pruritic excoriations on L scapula. No vesicles
or pustules to suggest recurrent Zoster or bacterial infection.
Resolved with topical moisturizer.
# Opacity R lung apex:
CXR revealed "vague opacity at the right lung apex," for which
outpatient CT could be obtained to further evaluate if within
patient's GOC.
# Microscopic hematuria:
Consider outpatient UA to document resolution.
# Contacts/HCP/Surrogate and Communication: ___ (daughter)
___
# Code Status/Advance Care Planning: FULL (confirmed with
patient
and HCP on day of discharge); would address further as
outpatient in setting of dementia
** TRANSITIONAL **
[ ] cefpodoxime 400mg BID and azithromycin 250mg daily to
complete a 5d course through ___ (will require cefpodoxime
400mg ___ ___ and 400mg BID on ___ and azithromycin 250mg on
___
[ ] ___ hematology review of atypical cells on differential from
___
[ ] ___ BCx, pending at discharge
[ ] ___ Strep pneumo Ag, pending at discharge
[ ] consider non-emergent outpatient CT chest for further
assessment of "vague opacity R lung apex" if within ___
[ ] consider outpatient UA to document resolution of microscopic
hematuria
[ ] ___ sleep wake cycle on ramelteon QHS (new med on discharge)
***. | 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.
***
___ ___ male with PMHx of GERD who presents with 4 days of
headache, photophobia, neck stiffness, myalgias, fevers &
chills, and lumbar puncture consistent with a viral meningitis.
.
# Aseptic Meningitis: Patient with 4 days of headache,
photophobia, neck stiffness, myalgias, fevers/chills, and CSF
with elevated WBC & elevated protein, consistent with aseptic
meningitis. In the context of a painful, erythematous, somewhat
vesicular rash in the ___ dermatomal distribution over left
hip, varicella zoster virus felt to be most likely diagnosis.
Given recent sick contact with ___ illness in his
child, enteroviruses are also a possibility. ID team was
consulted for recommendations on management. Symptomatically
improved in 24hours after initiation of IV acyclovir.
Meningismus and photophobia resolved at time of discharge - pt
was also afebrile >24 hours. Plan to treat empirically with IV
acyclovir for VZV meningitis for 7 days. Lyme serology negative.
Parasite smear of CSF negative. He was discharged home with
short course of ___ morphine, bowel regimen. Home infusion
services set up for dispo with acyclovir to be administered at
home.
Labs pending at time of discharge: HIV antibody, HIV viral load
PCR, HSV and VZV pcr, CSF lyme, ___ (serum and CSF samples
sent to state lab), Anaplasma/ehrlichia of CSF all PENDING.
Plan for tests to be followed up at PCP office ___ with NP ___
___ ___. Patient was discussed with ___
___ over phone and DC summary was faxed to Dr. ___
office at time of discharge.
.
# GERD: Continued home lansoprazole.
.
#FEN: No IVF, replete electrolytes prn, regular diet
#Access: PIV, picc
#PPX: heparin sq, bowel regimen (colace/senna/miralax)
#Code: FULL CODE (confirmed)
#Contact: wife (___)
***. | VIRAL MENINGITIS WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient presented as a same day admission for surgery. The
patient was taken to the operating room on ___ for revision
ORIF of left humerus fracture, which the patient tolerated well.
For full details of the procedure please see the separately
dictated operative report. The patient was taken from the OR to
the PACU in stable condition and after satisfactory recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB, ROMAT in the left upper extremity, and will be discharged
on aspirin 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 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.
***
___ was admitted to the Epilepsy Monitoring Unit for
weaning of her medications and characterization of her events.
She was noted to have interictal activity, more prominent during
sleep, with epileptiform discharges. Her topiramate was
gradually weaned. She had no increase in epileptiform activity
and no clinical or electrographic seizures. Her lamotrigine
level had been low prior to arrival, so her dose was increased.
Her zonisamide was continued unchanged.
She complained of urinary frequency. She had multiple urinalyses
performed due to contaminated specimens. Multiple cultures were
notable for e coli and she was treated for a urinary tract
infection with bactrim. Her symptoms improved. She was
discharged to complete a seven-day course for complicated
urinary tract infection given her history of urinary retention.
Her TSH was noted to be slightly elevated and her free T4 level
was low. She was instructed to follow up with her primary care
provider regarding adjustment of her levothyroxine.
For her atrial fibrillation she was continued on warfarin. Her
INR became supratherapeutic and her warfarin dose was decreased.
She was discharged on the lower dose to follow up with her
___ clinic.
She was seen by the EMU psychiatry service who recommended
increasing her cymbalta dose. She was seen by social work who
discussed coping mechanisms with her. She will continue to work
with her outpatient therapist after discharge.
***. | 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 pre-op on ___. Pt was
evaluated by anaesthesia and taken to the operating room where
she underwent a laparoscopic sleeve gasrtrecotmy and Tru-Cut
liver biopsy. There were no adverse events in the operating
room; please see the operative note for details. Pt was
extubated, taken to the PACU until stable, then transferred to
the ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization.
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.
GI/GU/FEN: The patient was initially kept NPO with a nasogastic
tube. On hospital day 1, the nasogastric tube was discontinued
and the diet was advanced sequentially which was well tolerated.
Patient's intake and output were closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.Her coumdain was held.
Prophylaxis: The patient received subcutaneous heparin during
this stay and was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a diet,
passing gas, 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.
***. | 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.
***
___, patient was admitted initially to Podiatry service for
non-healing ulcer, Vascular surgery was consulted. Started on IV
broad spectrum antibiotics. Routine labs, ECG and wound care.
Foot x-ray was done-did not show acute osteomyelitis.
___, patient continued on IV broad spectrum antibiotics.
NIAS was done- showed monophasic waveforms suggestive of inflow
disease. Arterial duplex of RLE was done that confirmed NIAS
showing- Patent right femoral-to-dorsalis pedis bypass graft
with monophasic inflow suggesting proximal occlusive disease and
possible distal anastomotic stenosis. Ulcer not responding to
antibiotics therapy, scheduled for TMA in the next day. Patient
was pre-oped and consented for procedure, made NPO after MN and
IV hydrated.
___, patient underwent R TMA, tolerated procedure well,
recovered in the PACU then transferred back to ___ 5 floor w/
telemetry. Pain was well controlled w/ oral pain medications.
Diet and oral meds resumed.
___, patient remained on bedrest. HCT was down to 25,
transfused with 1 unit PRBCs. Dressing taken down, incision well
anastomosed, IV antibiotics d/c'd, switched over to Bactrim that
the patient will be discharged on. Rehab screening started. Home
meds resumed except for Lisinopril, held due to rising
creatinine 2.7.
___, creatinine coming down, 2.4, patient's baseline is 2.2,
Lisinopril continued to be held, to ___ w/ PCP to monitor
creatinine and BP. Patient worked with physical therapy,
recommended rehab placement-since non-weightbearing for 3 weeks.
Rehab bed became available. Patient was discharged to rehab in
good condition, ___ with Dr. ___ in 4 weeks. Patient
was also instructed to ___ with PCP after discharge from rehab.
***. | AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with PMH of HTN, HLD and thoracic and abdominal aortic
aneurysms who presented after an episode of L arm heaviness,
found to have R Frontal lobe stroke likely embolic.
CTA showed occluded right vertebral artery at the origin, which
appears chronic and is unlikely contributing to her
presentation. Right frontal stroke likely cardioembolic in
origin. Started ASA/Clopidogrel per POINT trial. Discharged with
ZIO Patch for atrial fibrillation monitoring. Noted to have
frequent junctional premature beats on telemetry. New diagnosis
of diabetes with an A1c of 6.7. LDL was 59. Started on metformin
500 mg twice daily. Just prior to discharge the patient had an
episode of hypoxemia. Therefore to have acute bronchitis and was
started on a course of azithromycin.
TRANSITIONAL ISSUES
-Discharged on DAPT (ASA/Clopidogrel) for 3 months followed by
ASA 81 mg only thereafter per POINT trial.
-Follow-up with ZIO Patch monitoring for evidence of
supraventricular arrhythmia. Patient noted to have frequent
junctional premature beats on telemetry, but no evidence of
atrial fibrillation.
-Please continue to monitor A1c/blood sugar and titrate diabetes
medications as appropriate.
-Discharged on a 5-day course of azithromycin for acute
bronchitis
-Refilled hydrochlorothiazide/valsartan on discharge due to
slightly low blood pressures. Please resume when ___ to be
tolerated.
-Please ensure follow-up with stroke neurology.
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?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 59) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] 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? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] 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: (x)
Antiplatelet - () 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 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.
***
Mrs. ___ was taken to the operating room by Dr.
___ on ___, where she had a VATS left upper lobe
wedge resection which revealed adenocarcinoma on frozen,
therefore Dr. ___ to left upper lobectomy and
lymph node dissection.
The patient recovered in the PACU, and then transfered to the
floor. She progressed well in her recovery with foley which dc'd
on POD 1 with good urine output. Her chest tube was placed to
water seal on POD 2, and dc'd with stable postpull film. She
ambulated well, tolerated meals, passed gas and had adequate
pain control on po pain medication. Verbal and written discharge
instructions were given which she verbalized understanding. She
went home with her husband and will followup in outpatient
clinic in 2 weeks.
***. | 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 is a ___ retired hemato___, ___, h/o
HTN, afib, RA on prednisone, secondary adrenal insufficiency
recently discharged ___ on 10 day course of oral cipro for
bacteremia secondary to UTI, presenting with nausea, vomiting,
and diarrhea.
# Abd pain/cramping/N/V:
Ms. ___ was admitted with N/V/D, abd pain, leukocytosis
(WBC 13.8) and abd CT showing fat stranding on the L
hemiabdominal location. Given recent PO cipro, C.diff colitis
was considered a possibility - however, the fat stranding was
localized to the small bowel, making this less likely. Ischemic
etiology (i.e. emboli from afib) were also considered unlikely
since she was already on Apixaban. She was observed and given
supportive care (IVF, antiemetics, low dose Tylenol) with
improvement in her overall status. The leukocytosis resolved
without any intervention. Stool cdiff was ordered but Ms. ___ had
no more diarrhea to be sent for studies. She did have a small
formed bowel movement prior to discharge. KUB was unconcerning.
These self-limiting sxs most c/w viral gastroenteritis.
# Hyponatremia
# ___ Cr 1.4:
Ms. ___ was admitted with Na 122, Cr 1.4 in setting of poor PO
intake, nausea and GI losses. Both Na and Cr improved with
hydration. Both Na, Cr normalized on the day of discharge.
# Recent bacteremia ___ UTI: Pt was hospitalized ___
for UTI with pansensitive E. coli bacteremia. She received her
first dose of antibiotics (aztreonam - given anaphylaxis to
penicillins) on ___, then transitioned to ciprofloxacin), so
has received total course of 12 days of antibiotics.
# Erosive arthritis, fibromyalgia: Followed by Dr. ___,
appears to be at baseline.
- Continued home tramadol, prednisone
# Afib: Pt requesting to resume atenolol. It appears that this
medication was held in the setting of recent bacteremia. The
atenolol was held since HR continued to be low in the 50-60s.
She was continued home apixaban.
# Hypertension: Home triameterene/hctz was restarted on
discharge.
# Hypothyroidism:
- Continue home levothyroxine
# Advance Care Planning/Code status: FULL, presumed
# Contact:
Health care proxy chosen: Yes
Name of health care proxy: ___: son
Phone number: ___
Greater than 30 minutes were spent on discharge planning and
coordination.
***. | 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.
***
Patient is a ___ yo F with HTN, HLD, PAF on coumadin also with
history of tachycardia induced cardiomyopathy who has had
difficult to medically control symptomatic A.Fib with RVR who
presents to ___ for pulmonary vein isolation.
# A.Fib: Patient admitted in sinus rhythm, though tachycardic.
She does have anxiety treated with clonazepam at home and she
endorsed feeling anxious about procedure. Tachycardia was
treated with PO Diltiazem 90mg QID. Patient received pulmonary
vein isolation afternoon of ___ which was successful and
she is discharged in sinus rhythm at ~100bpm continuing
disopyramide. There was concern for hematoma/retroperitoneal
bleed after procedure because patient was orthostatic on exam
and had a crit drop (after 1.5L bolus). Repeat crit improved and
CT abd/pelvis did not show bleed but did show hematoma, US of
groin did not suggest pseudoaneurysm. She was not orthostatic on
exam and her groin sites exam were benign on day of discharge.
# Hypertension: Chronic, Well controlled as an outpatient,
patient does report she has hypertension in the AM and when she
is anxious. She was hypertensive on the floor though on manual
recheck her BP is ~130 systolic. She was treated with Diltiazem
90mg QID as above and Valsartan 40 mg PO/NG BID
# Asthma: Chronic, well controlled, no recent severe
exacerbations or intubations. Continued Albuterol-Ipratropium 2
PUFF IH Q6H:PRN SOB
TRANSITIONAL ISSUES:
- Discharged on Disopyramide
- She will be followed by EP as an outpatient and will need a
Holter monitor to be set up in 2 weeks.
***. | PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with history of chronic abdominal pain possibly secondary to
crohn's vs celiac disease, GERD, gastritis, pancreatitis,
presenting with sudden onset of hypoxia during EGD today, and
found to have infiltrate on CXR.
# Aspiration pneumonitis/pneumonia: Per report from GI, patient
thought to have been observed aspirating during EGD. After the
event, he was hypoxic, tachycardic, febrile, with leukocytosis.
He initially received antibiotics for empiric treatment of
aspiration pneumonia. Because he rapidly improved his
antibiotics were discontinued as his hypoxia was likely due to
aspiration pneumonitis rather than pneumonia. He was told that
he should call his PCP if he develops fever, cough or shortness
of breath as he would require evaluation for aspiration
pneumonia. Additionally he should have his WBC count checked as
an outpatient to ensure that it is trending down.
# Chronic abdominal pain: He did not have have any abdominal
pain during hospitalization. EGD revealed no abnormalities and
biopsy samples were within normal limits. He was started on
mesalamine per GI and continued on amitritptyline. He will
follow up with GI as an outpatient.
# GERD/gastritis: The patient was continued on his home
omeprazole.
***. | RESPIRATORY INFECTIONS AND INFLAMMATIONS 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.
***
This is a ___ old female with past medical history of
chronic abdominal pain attributed to chronic pancreatitis
admitted ___ w acute on chronic abdominal pain and nausea,
being managed conservatively, clinically much improved and
discharged home
# Epigastric Abdominal Pain / Chronic Pancreatitis /
Pancreatitic Insufficiency - patient admitted ___ with
abdominal pain, similar to prior episodes that have been
attributed to her chronic pancreatitis: predominantly in the RUQ
and right flank with associated nausea. Labs and exam were not
suggestive of acute intra-abdominal process. Patient was seen
by her outpatient gastroenterologist Dr. ___ case was
discussed with her PCP ___. Patient managed
conservatively with IV fluids, pain control, and NPO. Based on
review of prior labs and PMP, there was concern for prior
inappropriate use of opiates. Per discussion with PCP ___.
___ felt safe with tapering patient to Oxycodone 5mg PO
q8 hours prn pain, with plan for further outpatient tapering.
She was able to be tapered with her diet concurrently advanced
to liquids with toast and crackers, with demonstration of her
ability to stay hydrated at home. Per discussion with
outpatient GI, patient felt comfortable continuing to slowly
advance diet at home. Continued creon, prn diazepam for nausea,
prn oxycodone as above (discharged with 7 day supply), prn
Zofran.
# Depression - continued home escitalopram
# ADHD - continued home amphetamine-Dextroamphetamine
# Tobacco Abuse / Dependence - on nicotine Patch while inpatient
Transitional Issues:
- Discharged with new prescriptions for oxycodone (7 day
supply) and Zofran (at 4mg dose per patient request)
***. | DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is a ___ y/o F with history of chronic diarrhea,
ischemic colitis s/p partial colectomy, recurrent UTI's and
psychogenic seizure disorder presenting with 2wks of diffuse
diarrhea and RLQ abdominal pain, who was found to have acute
renal failure and pyelonephritis. In summary, her pyelonephritis
was treated with ceftriaxone, which was d/c'd after repeat UA
was negative. While her chronic diarrhea continued, her C-diff
tests were negative X2, and her chronic diarrhea will be
followed on an outpt basis.
.
ACTIVE ISSUES:
.
# Sepsis ___ pyelonephritis: Patient initially met SIRS criteria
with leukocytosis (with left shift and 1% bands) and fever to
101; an infectious source was identified as pan-sensitive
klebsiella on urine Cx ___ and with evidence on CT of
pyelonephritis. C. diff toxins came back negative, and CT
Abd/pelvis did not show evidence of colitis, diverticulitis, or
bowel inflammation. There was concern for relative hypotension
as the pt is normally has SBP 150-160s. However, her lactate was
normal and decreased to 0.6 after admission. She was volume
resuscitated with 3L in the ___, and has been euvolemic and
hemodynamically stable throughout her admission.
For her pyelonephritis, the patient was initially given
aztreonam for Proteus coverage which was cultured in her urine 2
months prior. She also received Vancomycin for empiric gram
positive pyelonephritis coverage, an for presumed C.diff, flagyl
was started in ___. Later as per pharmacy recommendations, the
pt's cephalosporin allergy was found to be anxiety and she had
received a cephalosporin several months prior with no reaction.
Thus, she was started on ceftriaxone for pyelonephritis. Vanc
was d/c'd once her urine grew GNR's, and flagyl was d/c'd once
the c-diff toxin test was negative. She had a negative Urine Cx
on ___, and her condition remained stable. Her urine Cx
speciated as pan-sensitive klebsiella. She was treated with
ceftriaxone.
She continued to have occasional low-grade fevers, and further
w/u including CXR, renal U/S, and repeat Cx's was unrevealing.
As per infectious disease recs, all antibiotics were stopped as
she had a negative repeat UA and there was concern for drug
fever. She had several low-grade fevers up to 100.4, which have
resolved and were likely due to drug fever or possibly mild
atelectasis from bedrest. Infectious disease signed off as there
was no further evidence of current infection. Blood Cx and urine
Cx were pending as of ___.
.
# Acute on chronic diarrhea: Pt has a h/o chronic diarrhea and
?h/o Crohn's (Dx was later cancelled as per pt). She p/w about 2
wks of watery, nonbloody diarrhea as well as RLQ pain. She
received empiric flagyl treatment for c-dif given recent
aztreonam administration for UTI, which was d/c'd after her
c-dif toxins came back negative x2. Her diarrhea was nonbloody
and was guaiac negative. CT scan showed no diverticulitis or
colitis, her lactate was normal, and a KUB showed no evidence of
obstruction. Her diarrhea waxed and waned throughout admission.
While her RLQ pain occasionally persisted, her abdominal exams
remained benign and nonfocal and her WBC remained stable, and
her pain regimen was adjusted to keep the patient comfortable.
.
# Acute on Chronic Renal Failure: Her baseline Cr is 1.4-1.7. On
admission Cr was 4.2, down to about 2.1 throughout admission.
After liberal fluid administration, her Cr trended down and her
___ was likely mostly prerenal with a volume contracted state in
the setting of poor PO intake and increased diarrhea. She
received aggressive hydration in ___ and was euvolemic throughout
admission. Some renal failure could be related pyelo as well,
given CT scan findings and pyuria on UA. There was no evidence
of muddy brown casts on urine analysis to suggest ATN. She did
have positive urine eos, which supported the decision to d/c Abx
as above.
.
# Metabolic Acidosis: Present in previous admissions in ___.
Likely secondary to chronic diarrhea, but patient may also have
possible RTA as suggested by urine electrolytes. Normal lactate
(although this was obtained after received fluid). ABG on
admission showed 7.___, and a bicarb drip of two amps was
given; her acidosis improved throughout admission. SPEP/UPEP
were both negative. She may take a tablespoon of baking soda
daily as an outpatient following her discharge from rehab.
.
# Contact dermatitis: On ___ patient developed a pruritic,
erythematous rash on her left arm in the distribution of the
tape that had been used to secure her left PICC in place. Rash
was felt to be secondary to contact dermatitis from
chlorhexadine wash. PICC was d/c'd, and the area was closely
monitored. There was no evidence of infection, including no
fluctuance or purulent drainage. Erythema did not expand. Rash
improving with application of topical triamcinolone acetonide
0.1% cream.
.
# Delirium: Patient had waxing and waning mental status during
her hospital course. She was sometimes AAOx2 (forgot date), but
was sometimes AAOx3 and normally conversant. Her confusion was
likely multifactorial in the setting of acute infection, volume
depletion, electrolyte abnormalities, pain, and ongoing diarrhea
(which is chronic). She did not require any sedating
medications. Mental status was improving at time of discharge.
.
INACTIVE ISSUES:
.
# Hypertension: Upon admission, there was concern for relative
hypotension in the setting of sepsis as the pt is normally has
SBP 150-160s. Her SBP's trended in the 140's, and her home
regimen of oral antihypertensives was resumed.
.
# Depression/Anxiety: As per recommendations of her cognitive
neurologist ___, her home meds were continued with
the following changes: aripiprazole was discontinued, and
paroxetine was decreased to 20mg daily, and then decreased 3
days later to 10mg daily.
.
# History of seizure disorder: ___ have psychogenic component to
disorder as per neuropsychiatry. Home medications were
continued.
.
# GERD: Omeprazole was continued.
.
TRANSITIONS OF CARE:
- Blood Cx ___ pending
- Urine Cx ___ pending
-Patient's code status was DNR/DNI this admission
***. | 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.
***
MENINGITIS/CEREBRITIS/BRAIN ABSCESSES: brain abscesses were not
in locations which were amenable to biopsy per neurology. No
organism was found as the cause for the patient's
meningitis/cerebritis but a dental source was suspected. The
patient was treated empirically initially with
vanc/ceftriaxone/acyclovir/bactrim/flagyl. Acyclovir was
discontinued when HSV PCR returned negative. Subsequently
bactirm and vancomycin were discontinued and the patient was
treated with PO flagyl and IV ceftriaxone (2g q12 hours) and did
not show any evidence of worsening infection. Toxo antibodies
were negative, as were lyme serologies. TB PCR was pending at
the time of discharge. HTLV I/II were negative. CSF ___ and
culture were negative. EBV PCR returned positive, this was of
unclear significance. Given the possibility of CNS lymphoma a
repeat LP was performed, fluid was sent for cytology and flow
cytometry and extra fluid was saved in the lab. The patient's
fever, leukocytosis, and headache markedly improved. He was
discharged on a ___ and follow up appointments were
recommended to the patient and he said he will call and make
these appointments for within 2 weeks with Dr. ___
from ID and with a new PCP at ___. He was told not to drink
ETOH with flagyl. The patient was told that there are some
studies still pending and that he will need to follow these up
with his PCP when this is established and with Dr. ___.
Given the likely dental source the patient was seen by a dentist
inpatient who recommended outpatient tooth extraction. The
patient stated that he has a dentist outpatient and has already
been planning on this tooth extraction. He is HIV negative. He
was discharged on 6 weeks of antibiotics and will follow up with
ID, he will likely require repeat MRI imaging of his brain prior
to cessation of antibiotic therapy.
***. | NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ female with CVID (on monthly IVIG) and a initially
3B follicular lymphoma originally treated for 3b FL in ___ with
6 cycles of R-CHOP, relapsed in ___ with DLBCL.
autologous transplant ___, relapse ___, got 2 cycles
R-GemOx with significant cytopenias and persistence of
circulating lymphoma cells, changed to lenalidomide-rituximab.
She has been on lenalidomide and now admitted for allogeneic
stem cell transplant w/brother as donor, MRD AlloSCT w/RIC (day
0 = ___. Had mucositis which improved before discharge, was
briefly on TPN for nutritional requirements, had vaginal rash
resolving with nystatin. No complications or evidence of acute
GVHD. Had chronic cough, CT-sinus showing chronic sinusitis,
started on nasal steroid and afrin.
# DLBCL w/ relapse x 2 here for MRD RIC alloSCT. Her brother is
her donor. She was cleared by ID with VATS shows non-necrotizing
granulomas and no evidence of active infection. Counts slowly
recovered while inpatient. Cyclosporine dose adjusted to 75mg PO
QAM, 50mg PO QPM prior to discharge.
#Diarrhea-started ___ with new increased frequency of BMs
loose, mushy consistency, relatively small volume, w/ nausea,
may represent acute gvhd of gut; over weekend patient has been
able to tolerate soup, rice w/ no more loose stools. C.dif
negative.
___: Had Cr bump to 1.2 I/s/o decreased PO intake when TPN
stopped, resolved with fluids and encouraged PO intake.
#Cough: Pt reports minor cough with dripping down back of her
throat. CT sinus w/ chronic sinusitis. Tx w/ Afrin & nasonex.
# Rash on mons pubis: Diffuse papular itchy rash improving w/
Nystatin cream bid as per Derm.
# H/o recurrent C diff: c/w po vancomycin 125 mg bid
# CVID: IVIg monthly or as indicated clinically/based on levels
throughout her transplant course. (___) IgG = 531. No need to
replete at this time.
# hypothyroidism - cont levothyroxine
# CODE: Full
# EMERGENCY CONTACT: Name of health care proxy: ___
Relationship: husband
Phone number: ___
___ Issues
===================
-Pt will f/u in ___ for labs on: ___
-Pt will f/u with Dr ___ ___ clinic on ___
-Started on Flonase and afrin for chronic sinusitis, and afrin
to stop on ___
-Continued on PO Vanc for hx of C Diff
-Has required TPN for issues with nutrition, requiring
intermittent IVF for pre-renal ___, please check electrolytes to
ensure resolving ___ upon hospital follow-up.
- Re-evaluate aspirin at follow-up with platelet
levels/indication
***. | ALLOGENEIC BONE MARROW TRANSPLANT |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with history of anorexia requiring medical admission for
concern for asymptomatic bradycardia and hypoglycemia.
# Anorexia - Patient with ___ year history of eating disorder. Her
electrolytes were normal throughout her stay. Psych, social
work, nutrition, and case management were involved in her care.
She was started on an eating disorder protocol and was adherent
to the protocol in spite of her understandable anxiety.
# Bradycardia - She remained asymptomatic throughout her stay.
She was initially bradycardic to the ___. During her stay
her daytime heart rate improved to the ___. Overnight she
would dip down to the ___. She would be woken up and each time
would be asymptomatic. No medical intervention was needed given
her lack of symptoms.
# Hypoglycemia- She had concern for asymptomatic hypoglycemia
prior to admission. Upon admission her glucose fingersticks were
greater than 50, earlier on she required one glucose tab for
asymptomatic hypoglycemia. She then maintained her glucose
levels in the high ___ throughout her stay with no symptoms.
***. | DISORDERS OF PERSONALITY AND IMPULSE CONTROL |
What is the most likely Medicare Severity Diagnosis Related Group (MS-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 ___ yo M who presents w/ a bullous rash and
biopsy findings c/w pemphigus, who is stable w/ improving rash.
ACTIVE ISSUES:
# Bullous skin rash: Most consistent with pemphigus
vulgaris-like drug related skin rash (pemphigus foliaceous)
given bullous cutaneous rash sparing the mucosa, marked initial
eosinophilia, and pt's ___ heritage. Ddx includes pemphigus
vulgaris and paraneoplastic pemphigus, though these are both
less likely given sparing of mucosa. Steroid responsive but has
recurred in the past when tapered. On admission, all potentially
offending medications (ACE, dilantin, calcium channel blockers)
were held. After holding these medications, his marked
eosinophilia normalized the following day. In consultation with
dermatology, he was started on 40mg po prednisone BID. Over the
next couple of days, his bullous skin rash appeared to improve
both objectively and subjectively. He never had any evidence of
super-infection of his ruptured blisters. No leukocytosis or
recent fever. He will continue on prednisone as well as
prophylactic medications while on prednisone including
omeprazole, atovaquone, calcium, and vitamin D. A PPD was also
placed which was read as 2mm and negative. He will continue to
receive daily dressing changes with xeroform from ___ we have
been doing while in the hospital. He will continue to hold these
home medications pending further improvement in his rash, and he
will be followed closely by dermatology as an outpatient.
# Diabetes Mellitus Type 2: Onglya was stopped on admission
given concern for contribution to his rash. His sugars began to
elevate at times to high 200s and low 300s after starting on
prednisone. He was started on SSI initially and in consultation
with ___ placed on Humalog 75/25. This was titrated up to 28
units before breakfast and 15 units before dinner. He received
diabetes and insulin education before discharge. He will be
followed by ___ as an outpatient for further titration.
# HTN: Suboptimally controlled, especially after starting
prednisone. All of his BP medications were held given concern
for his rash. In consultation with dermatology, labetalol was
felt to be the safest option. He was started on 100mg BID with
improved BP control though still with some SBP readings to the
140s. He will be followed by his PCP for further titration.
# Seizure disorder: His dilantin was held on admission due to
his rash. He reported only remote seizure activity, and the
decision was made to hold off on initiating alternative
anti-epileptic medications for now. The decision regarding
whether to initiate alternative medications can be made by his
PCP as an outpatient, given that he has not had seizure activity
for a very long period of time.
# Normocytic anemia: Hematocrit stable but low around 33-35.
Etiology unclear, initially thought to be due to fluid shifts
from his IV fluids. He may need work-up for underlying anemia,
especially in the setting of pemphigoid rash. While it is not
favored, paraneoplastic pemphigus can occur and may sometimes be
associated with blood cancers. Further work-up per PCP.
CHRONIC ISSUES:
# BPH - No acute issues, cardura held. Further management per
PCP.
TRANSITIONAL ISSUES:
# Pemphigus work-up: Given rare possibility of association with
malignancy (paraneoplastic pemphigus) as well as his anemia,
recommend age-appropriate cancer screening, consider repeat
colonoscopy as well as SPEP, UPEP, and serum free light chains.
# Hypertension: Will likely need further titration of labetalol.
# Diabetes: Will be followed by ___ for further insulin
titration
# Follow-up Strongyloides Antibody: Was initially ordered due to
eosinophilia. Send-out lab and has not yet returned result.
***. | MAJOR SKIN DISORDERS WITHOUT MCC |
Subsets and Splits