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What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ y/o F with PMHx of HTN, HLD, DM, GERD, recent colonoscopy
with polyp removal, who presented with BRBPR concerning for
post-polypectomy bleeding.
# GI BLEEDING: In the setting of recent polypectomy. The patient
underwent colonoscopy with epinephrine injected into EMR site
and clipping of polypectomy sites. She was monitored overnight.
H/H remained stable with no further bleeding episodes reported.
The was discharged home the following morning.
# HTN: Antihypertensive agents held in the setting of bleeding.
BP's moderately elevated currently. Restarted home meds prior to
discharge.
# GERD: On PPI
# HLD: On statin.
# DM: Oral agents held. On HISS while here with FSBS largely
well-controlled. Will continue to hold metformin x 72 hours
following contrast study. Continued glipizide at discharge.
TRANSITIONAL ISSUES:
- Needs repeat colonoscopy in 6 months.
***. | COMPLICATIONS OF TREATMENT 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 hx of CAD, HTN, HLD, Asthma and recent dx of extensive
disease small cell lung cancer on ___ (___) and
recent admission for post-obstructive PNA who presents from
clinic with ongoing fevers. Fevers and leukocytosis improved
with IV abx. Comleted C2 of ___ ___, and patient was
scheduled for Neulasta on ___. Transitioned to IV ertapenem with
~4 week course with OPAT follow-up.
# Post-obstructive pneumonia - maintained on Vanc/Ceftaz/Flagyl
during prior admission and transitioned to PO cefpodox and
metronidazole days prior to discharge but with continued ongoing
fevers in outpatient setting. CT chest with contrast on this
admission with R hilar mass causing obstruction of RUL brochus
and pulm artery, with progressive cavitation, ischemic necrosis
of RUL. Patient was started on vanc/zosyn, and quickly
defervesced and remained stable hemodynamically thoughout
hospitalization. Blood and urine cultures were negative, sputum
culture with respiratory flora, and MRSA swab was negative (and
vancomycin was discontinued on ___ when resulted).
Interventional pulmonary was consulted, who noted that no
interventions were possible given the narrow caliber of his
bronchus. ID was consulted, who recommended transitioning
patient to ertapenem prior to discharge with plan for 4 week
course for presumed lung abscess. He had a PICC placed on ___
for prolonged antibiotic course. Patient was arranged with
weekly monitoring labs for ertapenem and will be arranged for
OPAT follow-up.
# Extensive Stage Small Cell Lung Cancer: Known brain mets. SP
C1D1 carboplatin/etoposide on ___, completed C2 during
hospitalization (___). Patient arranged for Neulasta given
concurrent infection, and was arranged with outpatient oncologic
followup.
#Blurry Vision - no neuro deficits detected on exam and patient
with known brain mets. Given history of brain metastases, CT
head was ordered, which did not show any evidence of progressive
CNS disease. Symptoms resolved spontaneously during admission.
CHRONIC ISSUES:
# Hypertension: continued home HCTZ/Losartan
# CAD s/p MI: Continued home metoprolol, ASA
# Hyperlipidemia: continued home statin
TRANSITIONAL ISSUES:
======================
- Neulasta scheduled ___ at 10:30 at ___
- Ertapenem 1g IV daily with tentative end date of ___
- OPAT monitoring labs:
WEEKLY: CBC with differential, BUN, Cr, AST, ALT, Total Bili,
ALK
PHOS
ATTN: ___ CLINIC - FAX: ___
- ID OPAT will arrange outpatient follow-up.
-Patient to have follow up with Dr. ___ on ___, C2 due to start
___
CODE: Full
***. | RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ male with history significant for cardiomyopathy s/p
ICD, CHF EF 15%, CAD s/p multiple PCI, HTN, DM2, HLD, OSA,
admitted after syncopal episode related to ventricular
fibrilllation, ICD fired appropirately.
.
ACTIVE ISSUES
=============
# Syncope: Presentation not consistent with orthostasis or
vasovagal syncope. He was not orthostatic. Electrophysiology
interogated his ICD and found that he had entered vetntricular
fibrillation, the ICD fired he was cardioverted and returned to
sinus rhythm. He was started on amiodarone 200mg TID with a plan
to change to 200mg Daily in one month. He was discharged with a
plan for follow up with Dr. ___ in electrophysiology and
Dr. ___.
.
# Congestive heart failure: with systolic and diastolic
dysfunction LVEF 15% in ___. He reported 5kg increase in weight
and had mild fluid overload on exam. Chroinc congestive heart
failure was believed to have contributed to development of
ventricular fibrillation. He has depressed EF with ventricular
dysynchrony and NYHA class II-III he was previously evaluated
for BiV pacer placement and found to be an appropirate
candidate. He will follow up with Dr. ___ BiV
placement. His digoxin level was elevated and the dose was
decreased. Lisinopril dose was decreased to 20mg daily. He was
continued on furosemide 120mg BID.
.
# Coronary: s/p multiple interventions to LAD, most recently in
___ when he had instent restenosis and had a DES to distal
LAD. He was ruled out for myocardial infarction. Continued
Aspirin, prasugrel, carvedilol, rosuvastatin and imdur.
.
INACTIVE ISSUES
===============
# Diabetes mellitus: Continued home regimen.
.
# Hypertension: Continue home meds, carvedilol decreased
lisinopril as above)
.
# HLD: Continue home meds, Rosuvastatin as above.
.
# Gout: he had previously been on Allopurinol for gout
prophylaxis, he had not been taking this and it was restarted.
***. | 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.
***. Depression. Patient denying suicidal intent upon transfer to
D4, although he continued to describe: "going back and forth"
between killing himself by taking Tylenol overdose and "getting
clean." Effexor was initiated at 75mg daily, as he reported
doing well previously at 225mg QD. He also indicated that he
had done well with effexor/wellbutrin combination, but
wellbutrin was deferred ___ elevated seizure risk following
detox. He is to initiate psychiatric care in ___, and
uptitration of effexor can be discussed with his provider.
Wellbutrin may also be considered after the risk window for
benzodiazepine withdrawal seizure has passed. At the time of
___, the patient expressly denied suicidality although he was
disappointed that he did not have appointments in psychotherapy
and psychopharm sooner than ___. He is making plans to go
home and feed his cats.
2. s/p opiate detox. Patient had narcan while in the ICU, and
he indicated that he did not want to use any further opiates for
detox. He complained of muscle aches and cramps but was able to
tolerate symptoms with bentyl, robaxin, and motrin. At the time
of discharge he initially expressed interest in restarting
methadone maintenance, but his ___ clinic is unwilling to
restart methadone in him. He is ___ with a 2-week supply of
bentyl and robaxin, and at the time of ___ he reports only mild
withdrawal symptoms.
3. s/p benzodiazepine detox. Patient did not experience any
benzodiazepine withdrawal symptoms during this admission.
Depakote continued at 750mg BID for seizure prophylaxis, and he
is to discuss tapering this with his PCP or psychiatrist after
his next appointment.
4. UTI. Patient found to have a UTI growing coagulase negative
staphylococcus. Cipro was initiated prior to D4 transfer and is
to be continued through ___.
***. | DEPRESSIVE NEUROSES |
What is the most likely Medicare Severity Diagnosis Related Group (MS-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 a ___ with hx of undercontrolled HTN, HLD,
T2DM, CAD (s/p CABG ___ w/ LIMA to the LAD, SV to OM and PDA),
CHF (EF 25% in ___, and CKD, who presented with worsening
dyspnea and managed for HFrEF exacerbation.
Patient with known ischemic cardiomyopathy. Patient was noted to
have an elevated kappa lambda ratio without monoclonal spike on
SPEP, and UPEP without proteins. TTE did not suggest cardiac
amyloid. She is also noted to have moderate aortic stenosis.
Dobutamine stress echo was ultimately deferred to evaluate
whether this is truly low flow low gradient AS versus pseudo-AS.
CT scan demonstrated age-related ILD findings.
The patient was diuresed and increased to lisinopril 5 mg daily
and transitioned from metoprolol tartrate to metoprolol
succinate 12.5 mg daily. She received 4 days of IV iron for iron
deficiency anemia. Her home Plavix was stopped given that her
NSTEMI was in ___. She was discharged on a diuretic regimen of
torsemide 20 mg daily.
The patient's discharge plan was complicated by the fact that
she was refusing rehab despite ___ recommendations. There were
significant concerns from providers about the patient's home
mobility and safety, but she had capacity to refuse rehab.
Ultimately, she was discharged home but will need close
follow-up.
TRANSITIONAL ISSUES:
====================
#MEDICATION CHANGES:
[]New medications: Torsemide 20mg daily
[]Changed medications: Lisinopril increased to 5mg daily.
Metoprolol tartrate changed to metoprolol succinate 12.5mg
daily. Rosuvastatin increased to 20mg daily.
[]Stopped medications: Clopidogrel
#AT DISCHARGE:
[]Weight: 53.84 kg (118.69 lb)
[]Cr: 1.7
#PCP:
[]Diabetes: Will need continued titration of insulin regimen as
an outpatient.
[]Continue to monitor weights, BPs, electrolytes on current
cardiac medications as below
#CARDIOLOGY
[]Will need repeat labs (lytes, Cr) within 1 week of discharge
and titration of cardiac medications
[]Could consider initiation of spironolactone 12.5 as outpatient
pending pressures, electrolytes
[]Consider decrease torsemide to 20mg every other day based on
weights and labs
[]Consider dobutamine stress echo in the outpatient setting to
evaluate for true low flow low gradient AS vs pseudo AS
[]Would try to transfer patient's care to ___
cardiology if possible to make it easier for patient to receive
cardiology care
#PULMONOLOGY:
[]Found to have peripheral reticular opacities throughout the
upper and lower lobes bilaterally, likely reflecting mild age
related interstitial lung disease/fibrosis.
#CODE STATUS: Full (presumed)
#CONTACT: ___ ___
ACTIVE ISSUES:
==============
#Dyspnea,
#Acute on Chronic HFrEF exacerbation:
On admission, patient was volume overloaded on exam with BNP 27k
and CXR showing pulmonary edema and small L pleural effusion.
Underlying etiology due to ischemic cardiomyopathy, given recent
___ TTE and nuclear stress test at ___ showing new
HFrEF and likely missed infarct, in the setting of variable
medication non-compliance/contraindication. TTE this
hospitalization showed mixed global and regional systolic
dysfunction with EF ___. There was some concern for cardiac
amyloidosis, given elevated free kappa light chains at 55 and
kappa/lambda ratio of 3.3, but ___ showed no monoclonal spike,
and in-house TTE was not suggestive of an amyloidotic pattern.
Patient was diuresed with furosemide. She was also started on
captopril, spironolactone, and metoprolol. However, given
uptrending Cr, captopril and spironolactone were held. She was
eventually restarted and uptitrated to lisinopril 5mg daily and
metoprolol succinate 12.5mg daily.
#Ischemic Cardiomyopathy
#CAD:
Patient is s/p CABG ___ w/ ___ to the LAD, SV to OM and PDA.
Recent TTE and nuclear stress test during a hospitalization at
___ were suggestive of a prior missed MI and worsening
ischemic cardiomyopathy. This may have occurred due to patient's
poorly controlled diabetes and variable medication
compliance/tolerance (rosuvastatin, ___, all in the
setting of being lost to cardiology follow-up since ___. On
admission, patient's had no anginal symptoms. ECG showed a known
LBBB but with no new ischemic changes and negative trops.
Patient has been continuing to take dual antiplatelet therapy
___ + clopidogrel) since her NSTEMI in ___, in the setting of
not seeing her cardiologist consistently since. Plavix was,
therefore, discontinued. Patient's home ___ 81 mg was continued,
and home rosuvastatin was increased in dose from 10mg to 20mg.
Patient's home beta-blocker was transitioned to metoprolol
succinate XL 12.5 mg PO daily.
___ on CKD:
Patient with CKD Stage II/III. On admission, patient's Cr was
1.3, which is her baseline. Cr trended upwards in setting of
diuresis with possible contribution from low-dose ACEi.
Patient's ACEi, spironolactone, and diuresis were held as a
result. Once Cr downtrended to baseline, ACEi was restarted.
#Low-Gradient Aortic Stenosis:
TTE this hospitalization showed moderate aortic stenosis (AV
area of 1.2 cm2) with a low transvalvular gradient. This was
suspected to be pseudo-aortic stenosis in the setting of
patient's low EF and poor systolic function, causing poor
forward flow. Dobutamine stress echo was deferred, but could be
considered in the outpatient setting to further clarify true vs.
pseudo moderate AS.
#Anemia:
Patient's lab showed Fe 35, ferritin 109, Tsat <20%. This is
likely iron deficiency anemia with possible anemia of chronic
inflammation (given normal ferritin levels). Patient was given 4
doses of ferric gluconate 250mg IV.
#IDDM2: Patient with poorly controlled sugars per her PCP ___.
On admission, patient's glucose was 203. Given uncertainty
regarding her insulin regimen, patient was managed on Humalog
low-dose sliding scale with 4U glargine at dinner. Patient's
home glipizide was held while in house.
#Nausea/Vomiting
Patient had an episode of non-bloody, non-bilious emesis this
hospitalization with difficulty in eating and concerns of
aspiration. Per Speech and Swallow, she had no suspicion of
suspected oropharyngeal dysphagia or significant overt signs and
symptoms of aspiration.
CHRONIC ISSUES:
==============
#Depression:
Patient was continued on home citalopram 20mg PO daily and
bupropion 150mg Po daily.
***. | 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.
***
___ is a ___ y/o woman with a PMH of colitis who presented
with increased diarrhea and BRBPR as well as fevers in the
setting of tapering her steroid dose after an admission for
acute Crohn's flare.
#CMV Colitis: The patient was initially started on IV
methylprednisolone for what was thought to be a Crohn's flare.
She had a flexible sigmoidoscopy on her second hospital stay
that showed pitting and ulceration concerning for CMV colitis.
Biopsies were taken. The steroids were continued and the patient
did not show any signs of improvement thus a plan was made to
start infliximab. There was low suspicion for CMV given negative
IgG 2 weeks prior. She had received a partial dose of Infliximab
when the biopsy results came back positive for CMV. Infliximab
was discontinued mid-infusion and the patient was started on IV
Ganciclovir. She was transitioned to PO Prednisone at this
point. ID consulted and recommended a 21 day course of
ganciclovir with transition to PO Valganciclovir when the
patient was discharged. Given recently negative IgG and negative
CMV viral load, this was thought to be reactivation CMV with
local infection. She will follow up with Dr. ___ taper of
her steroids. She was discharged with instructions to continue
her Lialda but discontinue the Azathioprine at this point. Stool
studies were negative as was C.diff.
#Crohn's disease: The patient developed the CMV colitis in the
setting of tapering steroids after an acute Crohn's flare. She
was continued on her home Lia___ while inpatient although
azathioprine was held. Discharged on 40mg prednisone daily and
will followup with her GI specialist to restart azathioprine.
#Tachycardia: The patient presented with tachycardia to the 120s
at rest and to 150s on exertion. She reported having tachycardia
since a recent pyelonephritis. Her tachycardia persisted
although it was somewhat ameliorated by intermittent fluid
boluses. Her HR normalized before discharge.
Transitional issues:
-Azathioprine was stopped during inpatient course. GI specialist
should evaluate need to restart this med.
-The patient has stool viral cultures pending at discharge
-___ will need GI and PCP follow up
***. | VIRAL ILLNESS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient is an ___ y.o. F with osteoporosis, h/o GI bleed on
NSAIDs, MAC with bronchiectasis c/b pseudomnonas who presented
with L upper back pain and side pain s/p fall during which she
lost her balance now with new 7th rib fracture along with new
hypoxia.
.
# L 7th rib fracture/Pain: Pt was admitted with severe L lateral
rib pain. She did have some relief with percocet at home but it
had caused her nausea and vomitng. On admission, pt was started
on Tylenol around the clock, Toradol (converted to ibuprofen the
following morning, around the clock), zofran around the clock,
morphine ___ 15 mg every 8 hrs as needed and neurontin 300 mg x1
(pt normally takes 100 mg at night). Four hrs after receiving
morphine and neurontin, pt complained of visual hallucinations,
dry mouth, dizziness, and. fatigue. This was attributed mostly
to the neurontin, which was then stopped. The chronic pain
service was consulted and agreed with above plan. Nerve blocks
were discussed, however these provide only ___ hrs of pain
relief so this was not pursued. On the evening of the first day
of admission the patient again vomited after receiving morphine.
Her morphine was changed to dilaudid 2 mg-4mg oral every 4 hrs
as needed, which did provide her with some pain relief and no
nausea. Plan would be to continue dilaudid as needed, zofran
around the clock, tylenol around the clock, and ibuprofen around
the clock (but only for 4 more days of ibuprofen due to history
of GI bleeds on NSAIDS in the past).
.
# Hypoxia: Pt was satting 88% RA on arrival to ED, sats came up
to mid ___, and then would drift back down to low ___. She did
intermittently required 2 L NC. Probably secondary to underlying
lung disease- bronchiectasis and MAC in the setting fo severe
pleuritic rib pain and splinting secondary to the rib fracture.
She was given oxygen as needed and incentive spirometry was
encouraged. She should not use her pulmonary vest until her rib
fracture has healed. Mobilization and incentive spirometry
should be encouraged as the pt is at high risk for developing
pneumonia.
.
# Bronchiectasis: Continued on salmeterol (on foradil at home).
Also given nebs. No vest at this time due to rib fracture.
.
# Distended Abdomen: Per pts son-in-law, the pt has always had
an enlarged abdomen. Pt herself states her abdomen has increased
in girth. She had 2 bowel movements while here and initially was
placed on an aggressive bowel regimen with lactulose and
bisacodyl suppositories. Abdominal xray showed no dilated loops
of bowel or evidence of obstruction. Her abdomen is benign on
exam and soft. Would continue current bowel regimen.
.
# Osteoporosis: continued fosamax, calcium, and vitamin D
.
# history of GI bleed: Increased PPI to BID and limited NSAID
use to 6 days.
.
# Spinal stenosis: Neurontin is being held in the setting of a
reaction to receiving a higher dose (300 mg) as per above and in
the setting of receiving narcotics and complaining of fatigue.
Can resume neurontin 100 mg at night once pt is off opiates. Can
continue quinine for leg cramps.
.
# SVT: s/p ablation maintained on toprol. Continued toprol 12.5
mg bid.
.
# Failure to thrive/increased abdominal girth/anorexia/Early
Satiety and weight loss: Pt has had a normal colonoscopy in the
past year, and mammogram this past year was BIRADS-1 negative.
Discussed with son. Needs outpatient follow up. Albumin is 3.4
with normal LFTs. Consider repeat outpt EGD given history of
duodenal adenoma as well as screening CT.
***. | OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient was admitted to the General Surgical Service for
evaluation and treatment.
___:
On ___, the patient underwent ERCP, which was unsuccessful
due to inability to cannulate the ampulla (reader referred to
the Operative Note for details).
___:
The patient underwent another ERCP attempt, which was
unsuccessful due to inability to cannulate the ampulla (reader
referred to the Operative Note for details).
___:
The patient underwent a PTC catheter placement. The ampulla
again was unable to be cannulated; therefore, the patient
received an external biliary drain.
___: Patent underwent successful PTC placement where high
grade stricture of lower CBD was balloon dilated and a ___ F
internal/external locking PTBD was placed to bag drainage.
___: Two days following PTC placement Tbilli was decreasing,
patient was tolerating regular diet, ambulating at liberty and
felt remarkable improved. Patient was dischaged home with
instruction to follow up with Dr. ___ regarding
future surgery.
***. | DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ h/o hemorrhoids who presents with recent GI bleeding and
symptomatic anemia.
1. Acute blood loss anemia due to hemorrhoidal bleeding
-Patient with known history of hemorrhoids s/p banding declining
hemorrhoidectomy in the past and also noncompliant with iron and
bowel regimen opting to achieve this through diet. He notes
regular bleeding with bowel movements that has been increased
this past week. He is straining to have bowel movements and has
been sitting on the toilet for prolonged periods of time waiting
for the bleeding to stop. Due to symptomatic anemia he received
2Units PRBC with improvement of his hemoglobin from 5.6 to 7.4.
He had one bowel movement during the admission, which was
positive for blood, but he finished quickly and the bleeding
stopped as soon as he completed his BM. GI recommended
colonoscopy, which patient deferred to outpatient setting. They
also recommended hemorroidectomy (with Dr. ___, which
patient has refused in the past. I stressed the importance of
iron, fiber, and bowel regimen, which patient understands. With
elimination in symptoms, improved bleeding, and improved
hemoglobin patient requests to go home. I explained the more
conservative approach of monitoring overnight and repeating
hemoglobin in the morning with subsequent hemoglobin if needed,
which patient understood, but opted for discharge tonight with
close outpatient follow up.
>30 minutes spent on discharge 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 PMHx of diverticulitis s/p resection in ___ who
initially presented with diffuse abdominal pain, fever and
leukocytosis. She was managed conservatively for presumed viral
enteritis and improved prior to discharge. However, she
developed recurrent abdominal pain within 48hrs and returned to
the ED, where repeat imaging showed persistent jejunitis. Pt
was admitted on IV antibiotics with plan for bowel rest and
further work up. She underwent a EGD on ___ which showed
duodenitis and ulceration. Biopsies showed active inflammation
but did not reveal any evidence of malignancy or granulomas.
Gastrin level was normal and TTG was still pending at the time
of discharge. Pt was very slowly advanced a diet and treated
with IV PPI BID. Her leukocytosis trended down and was ___ on
the day of discharge. Pt was feeling better, tolerating a
regular diet and pain was controlled with po oxycodone. GI
consult agreed to continue a course of Cipro/Flagyl and pt will
be seen by her new PCP ___ on ___ to
ensure resolution of symptoms and to follow up on the mild
persistent leukocytosis.
.
There were stool studies and a TTG pending at the time of
discharge that will likely be available for review by ___
when she is seen by her PCP at ___. Pt is scheduled for GI
follow up on ___ and can also review the final results
at that time.
***. | 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.
***
___ y/o F s/p restrained MVC with bilateral first rib fractures
and grade IV liver laceration transferred to ___ for trauma
evaluation. The patient was hemodynamically stable. She was
admitted for serial abdominal exams, serial hematocrits, and
pain control.
Hematocrit and vital signs remained stable and there was no sign
on bleeding. The patient worked with Physical Therapy, who
cleared her for discharge home with home ___. Pain was initially
poorly controlled but with medication adjustments it was well
managed by HD4.
Diet was advanced as tolerated to a regular diet with good
tolerability. The patient voided without problem. During this
hospitalization, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirometry, and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
***. | MAJOR CHEST TRAUMA WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with h/o CAD, afib/aflutter and dCHF presents with
exhaustion and bradycardia after uptitrating his Lasix dose 4
days ago for worsening peripheral edema.
#Bradycardia/confusion: Improving after holding atenolol. Renal
function improved with gentle diuresis. Likely due to decreased
GFR from diuresis causing increased serum levels of atenolol.
Lasix and beta blocker were held
-d/c atenolol
-restart lasix
#dCHF: h/o dCHF (last EF >55% in ___, with worsening
peripheral edema. Lasix recently increased as outpatient
(detailed above). Pt does not have crackles on exam and CXR in
ED showed no signs of volume overload, but patient has mild
ankle edema. proBNP 829, down from 1375 on ___. Pt was able to
tolerate gentle IVF which improved his Cr and ___
-hold atenolol
-restart lasix
#Afib: pt currently in afib and bradycardic. INR 2.1
-holding atenolol
-Coumadin
#HoTN: SBPs ___, likely from decreased CO ___ bradycardia
-holding atenolol
-hold lisinopril ___ ___
___: Recent increase in Lasix (see above). Cr now 1.7 from 2
after 500cc, baseline unclear however was 1.5 on ___ and 1.1 in
___. Pre-renal azotemia from overdiuresis vs. cardiorenal.
-hold ___
-given lack of crackles on exam and normal CXR, gentle IVF 500cc
NS
Chronic Issues
#Restless legs syndrome: stable
-Will decrease gabapentin dose due to renal function
-cont. benzos to prevent withdrawl since patient is on high dose
-cont. Pramipexole
TRANSITIONAL ISSUES
[ ] consider restarting ___ resolved
[ ] assess need to restart atenolol
***. | 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.
***
1. LEGAL & SAFETY:
On admission, Mr. ___ signed a conditional voluntary
agreement (Section 10 & 11) and that legal status remained in
place throughout admission. Mr. ___ was also placed on 5
minute checks status on admission and was switched to 15 minute
checks on ___ and remained on that level of observation
throughout while being unit restricted.
2. PSYCHIATRIC:
#) PERSONALITY DISORDER
On initial evaluation, he endorsed suicidal ideation and
medication non-adherence in the setting of chronic pain and
limited mobility as well as financial distress. His initial exam
was notable for poor grooming, dysthymic but reactive affect and
linear thought process. His risk factors were notable for a
prior attempt over one decade ago, completed suicide by hanging
by his father, chronic disease, and limited social supports.
During his hospitalization, he restarted dialysis and requested
evaluation for additional pain management interventions. He
remained highly future-oriented with interest in trying to
ambulate with a walker and return home to his wife.
Throughout current hospitalization, patient remained
persistently irritable with labile mood and reactive affect. His
thought process was often recursive to the topic of his chronic
pain, and he occasionally required redirection to the previous
question asked. His thought content was notable frequent
discussion about pain and possible discontinuation of dialysis
due to his pain. As such, treatment team consulted the pain
management service, who evaluated the patient and provided
treatment recommendations (see below re: Chronic bilateral
shoulder pain and myofascial pain").
Patient inconsistently endorsed symptoms of depression (poor
sleep, low energy, anhedonia), but consistently stated that
symptoms of depression were due to his pain. He did not endorse
experiencing any perceptual disturbances, and he did not
appeared internally preoccupied. His judgment and insight were
limited.
Initially, the differential for patient's presentation consisted
of both adjustment disorder with depressive features or
depressive disorder due to another medical condition, with mixed
features. However, over the course of the current
hospitalization, patient's presentation appeared most consistent
with a decompensated personality disorder with prominent
deficits in coping abilities, such as poor distress intolerance
and emotional reactivity.
At time of discharge, patients mental status at time of
discharge was notable for mood congruent euthymic and stable
affect. Thought content was linear without loosening. Thought
content absent for current thoughts or urges to harm self or
commit suicide; he verbalized future oriented thought content
(e.g. optimism about working with ___ physical therapist,
___, on ___, and he expressed willingness to
continue with dialysis treatment.
3. SUBSTANCE USE DISORDERS:
Mr. ___ does not have any substance use disorders, and
therefore did not require any counseling or treatment in this
regard.
4. MEDICAL
Mr. ___ was medically cleared in the ED; no acute medical
issues prevented admission to Deac 4. Mr. ___ has CKD and
was followed by nephrology while in the unit. He received
dialysis on ___, and ___ during admission.
Additionally, he has chronic joint pain and was evaluated by the
pain service during admission for medication adjustment.
Additionally, physical therapy was consulted to review his
mobility status.
#)CKD with Dialysis:
Mr. ___ was followed closely by nephrology during his stay.
He received hemodialysis ___, and ___. His diet
was adjusted to a low K/low Na/low Phos diet with water
restriction to 1.5 L/day. He was started on EPO 6000U 3x/week.
Last dose was ___. The patients AV fistula was assessed by
ultrasound and demonstrated "Low volume flow noted throughout
the patent arterial venous fistula with increased velocity at
the anastomosis suggesting hemodynamically significant
stenosis." Fistulogram and balloon angioplasty was preformed by
interventional radiology and reslts were: "Improvement in
baseline palpable pulse of the immature right upper arm fistula
status post balloon angioplasty." However, this fistula
re-thrombosed the next day and was unusable for dialysis
thereafter.
- Continue ___ dialysis as outpatient
#)Chronic bilateral shoulder pain and myofascial pain
Mr. ___ stated mood was often fluctuated with the
severity of his osteoarthritis and myofascial pain. On his
intake interview, and throughout his hospitalization, patient
often rated his pain as 9 or ___. His outpatient medication
regimen consisted of largely controlling his chronic pain with
oxycodone to poor effect. Due to ESRD, he was not a candidate
for NSAIDs/COX-2 inhibitors. Patient was evaluated by Chronic
Pain Service who assessed patient's symptoms as "very diffuse
and mostly upper body, differnetial likely multifactorial with
myofascial pain syndrome or fibromyalgia, facet arthropathy,
cervical spondylosis, and rotator cuff OA contributing to his
pain. Pain service recommended optimizing non-opioid pain
modalities; they did not recommend a procedural intervention
(e.g. injection).
Treatment team recommended a trial of Duloxetine (an SNRI
indicated for depression and chronic, neuropathic pain) 60 mg
daily, which was uptitrated to 120 mg daily. His gabapentin
dosage was adjusted to 300 mg daily with an additional 300mg
dose on dialysis days. Also started tizanidine for muscle
spasms. His home oxycodone regimen was continued, but he
objectively appeared to be in less pain on this new regimen. His
behavior was also notable for fewer spasms of pain and increased
mobility in his wheelchair.
Additionally, he was evaluated by physical therapy, and it was
recommended that he be referred to a ___ rehab for
intensive physical therapy following discharge for improved
mobility (and decreased pain), such that he may be able to go
down stairs in ___. However, patient and his wife declined
referrals to all but two ___ rehab facilities (of note,
neither of those facilities accepted the patient for treatment).
Thus, patient stated that he would prefer to return home and
resume ___ physical therapy with his established provider,
___.
Prior to discharge, discussed with patient the option of
___ for opiate replacement and pain management. However,
patient was not interested in this medication or a referral for
this treatment at this time.
- Gabapentin 300 mg daily (additional 300 mg dose on dialysis
days)
- Duloxetine 120 mg daily
- Tizanidine 2mg QHS
#)Hypertension
His systolic blood pressure remained in the 100s-110s throughout
his hospitalization, so metoprolol was held.
- Consider restarting Metoprolol as outpatient depending BP at
home
5. SURGICAL
#)AVF MANAGEMENT
Mr. ___ received dialysis through a right tunneled line due
to decreased patency over his right arteriovenous fistula. The
transplant service evaluated his AVF to determine his candidacy
for recanalization. An ultrasound of his AVF demonstrated
decreased patency with limited flow, so it was thought to be
salvageable and he went for fistulogram with balloon angioplasty
on ___. Following this procedure, the fistula was patent.
However, the next day it re-thrombosed. It's worth noting that
review of the literature indicates that post-op re-thrombosis
occurs in about 30% of ESRD patients. Defer to outpatient
nephrology for further management preferences.
6. PSYCHOSOCIAL
#) GROUPS/MILIEU:
Mr. ___ was encouraged to participate in the various groups
and milieu therapy opportunities offered by the unit. The
occupational therapy and social work groups that focus on
teaching patients various coping skills. Mr. ___ rarely
attended these groups. While on the milieu, Mr. ___ was
visible on the milieu and appropriately interacted with staff
and peers.
#) COLLATERAL CONTACTS & FAMILY INVOLVEMENT:
Mr. ___ gave verbal and written permission for the team to
contact his outpatient psychiatrist, Dr. ___ outpatient
therapist, ___. Both were provided with a summary of
Mr. ___ presentation to the ___ ED/Deac 4 and an update
of his progress since admission on Deac 4, and they provided
collateral information and treatment recommendations.
Mr. ___ gave verbal and written permission for the team to
contact his family members, ___ (cousin), and ___
___ (wife), who was also given an update on Mr. ___
progress while admitted and discharge plan. A family meeting was
held on ___, where discharge planning and Mr. ___ progress
on the unit was discussed. On day of discharge, patient's wife
was available via speaker phone to review the patient's
discharge plan along with the patient (see Risk Assessment
below)
#)Transitional Issues:
___ services were offered, and patient declined. He was assessed
for Mass Health and determined to be eligible, but he declined
application for Mass Health benefits due to a pending lawsuit.
Informed patient that Mass Health may be able to assist with
transportation if he were to enroll in the future. Medicare only
covers transportation for emergencies or dialysis. However, PCP
confirmed that patient has been able to access transportation to
and from medical appointments. An application for ___ benefits
and services was submitted. He was referred to ___
___ for them to assess eligibility for ___ services. In
addition, a referral was made to ___
for ___ therapy services. For the time being, patient will
continue to receive ___ weekly therapy with ___
(confirmed that she would be willing to accept the patient back
into treatment), and patient's primary care provider ___
continue medication management until patient can arrange
transportation to psychiatrist, or an ___ visiting
prescribing ___ or nurse practitioner can be identified.
7. INFORMED CONSENT:
Medication: Cymbalta (duloxetine)
---Benefits: Treatment of depression, treatment of pain
---Adverse effects: Decreased appetite, nausea, diarrhea,
constipation, dry mouth, insomnia, tremors, headache, dizziness,
sexual dysfunction (decreased sexual desire, anorgasmia),
sweating, hyponatremia/SIADH (rare, in older patients),
bruising, seizures (rare), weight gain (unusual), sedation
(unusual), activation of suicidal ideation (rare)
Mr. ___ was informed of alternative treatments, the
consequences of no treatment, and the expected duration of
treatment. He appeared to appreciate the information conveyed in
the consent process by asking appropriate questions, which were
answered by the treatment team, and expressing understanding of
the potential risks and benefits (see above). Prior to starting
treatment, the team also 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. Mr. ___
understood the above and consented to begin the medication.
8. RISK ASSESSMENT
On presentation, Mr. ___ was evaluated and felt to be at an
increased risk of harm to himself. Mr. ___ static risk
factors noted at that time include male gender, age, prior
suicide attempts, active SI with plans, financial stressors,
chronic mental illness, limited social supports, family history
of suicide, chronic medical illness, and chronic pain. The
modifiable risk factors identified were as such: medical
non-compliance, lack of outpatient treaters, acutely stressful
events, sense of isolation. These modifiable risk factors were
addressed with acute stabilization in a safe environment on a
locked inpatient unit, psychopharmacologic adjustments,
psychotherapeutic interventions (OT groups, SW groups,
individual therapy meetings with psychiatrists), and presence on
a social milieu environment. Mr. ___ is being discharged
with many protective factors, including married status, no
chronic substance use, no access to lethal weapons. On day of
discharge, patient's wife was available via speaker phone to
review the patient's discharge plan along with the patient.
Although patient's wife did not report any safety concerns with
her husband returning home on ___, team engaged in
discussion about safety planning in the event that patient's
symptoms acutely worsen or if he were to express suicidal
ideation independent of dialysis and his chronic pain; wife
expressed her willingness to seek additional medical or mental
health support. Additionally, during this conversation,
patient's wife agreed to dispose of old medications (depakote,
etc.) that patient previously stated he would use if he were to
overdose as a means of suicide.
It's worth noting that patient's expressed suicidal ideation
(not only prior to the current admission, but also in the months
preceding this admission) has been closely linked to his chronic
pain, deteriorating health, and waning ability to care for
himself. Although patient remains at acutely elevated risk for
self-harm given both his history of prior suicide attempts,
family history of completed suicide, limited resources available
to address worsening medical/pain needs, he does not exhibit
symptoms consistent with an acute affective disorder that would
impair his ability to express an informed opinion about goals of
care and future treatment. Although patient's diminished
distress tolerance has limited the options available and
recommended to him for additional treatment, he does not exhibit
an impairment in his ability to express a preference regarding
his treatment goals (e.g. improved quality of life vis-à-vis
improved pain management or less pain overall), and he is aware
of the risks and possible negative outcomes should he refuse
recommended treatment following discharge. His capacity to
render these decisions, albeit inconsistent at time, is not
impaired by depressive or other acute psychiatric symptoms. Of
note, case discussed with Dr. ___, Vice-Chair of
Psychiatry, who offered consultation and agreed with disposition
plan and assessment of risk. Case also discussed daily in
multidisciplinary team rounds.
Overall, based on the totality of our assessment at this time,
Mr. ___ is not at an acutely elevated risk of harm to self
nor danger to others.
***. | O.R. PROCEDURE WITH PRINCIPAL DIAGNOSES OF MENTAL ILLNESS |
What is the most likely Medicare Severity Diagnosis Related Group (MS-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, pmh of Cerebral Palsy and Epilepsy, was admitted to
Epilepsy for breakthrough seizures. She had 3 drop seizures < 1
min and maybe 1 partial complex events on cvEEG. Her labs were
notable for nonanion gap metabolic acidosis, with pH on VBG
ranging from 7.37 to 7.31, which is likely secondary to chronic
diamox use. She was also noted to have a hyponatremia. Medicine
was consulted and recommended diamox weaned. Per discussion with
Dr. ___ should be started on vimpat 50 mg BID,
uptitrating as an outpatient with plan to wean off of diamox and
trileptal once patient is on appropriate vimpat dosing. Of note,
during her stay, she was noted to have asymptomatic bigeminy on
telemetry, which can also be followed outpatient. She improved
to discharge home
.
#Tranisitional Issues
- Chem10 in 2 weeks
- Vimpat uptitration as outpatient
START Vimpat 50 mg twice daily x 1 week (___)
Increase Vimpat 100 mg twice daily x 1 week (___)
Increase Vimpat 150 mg twice daily x 1 week ___ - ___
Increase Vimpat 200 mg twice daily indefinitely ___-
indefinitely)
Or as instructed by Dr. ___
- ___ up with Dr ___ may wean patient off of diamox
and trileptal as an outpatient and who will follow up re:
Bigeminy with Cardiology Consult if needed.
***. | 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.
***
Mr. ___ is a ___ male with history of OSA on CPAP who is
presenting here to the ED w/ ~1 wk hx of b/l lower abd pain
affecting the left side more than the right. Started mildly last
weekend and acutely worsened over the past two days. It is dull
moderate localized to the bilateral lower, nothing makes it
better or worse. He reports decreased p.o. intake. Also has had
constipation. No dark or bloody stool. No fever chills nausea
vomiting. Atrius PCP CT scan with "Sigmoid diverticulitis with
perforation of the mid sigmoid with a gas-containing
retroperitoneal abscess measuring 4.6 x 4.7 x 2.5 cm in size."
WBC was 10.5 and was told to present to the ED for further
management, for which we were consulted.
Once on the floor in the hospital on ___, Mr. ___ was
made NPO and given IV fluids. Over the next few days, his diet
was advanced as tolerated as bowel function was monitored. His
pain was controlled with IV medications. Interventional
radiology was consulted and it was determined that diverticular
abscess drainage was not necessary. Surgery was also not
indicated on this admission.
At the time of discharge on ___, the patient was doing well,
afebrile and hemodynamically stable. The patient was tolerating
a diet, ambulating, voiding without assistance, and pain was
well controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
***. | ESOPHAGITIS GASTROENTERISTIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ yo M w/ HTN, hyperlipidemia, recent hospitalization for fall
found to have PNA presents from ___ with acute on
chronic hypoxia with CTA concerning for RLL bronchus
obstruction.
# Acute on Chronic Hypoxia Secondary to Foreign Body Aspiration-
OSH imaging negative for PE, but RLL bronchus showed mucous plug
vs foreign body. On admission, denied fever, no WBC elevation
making infectious process less likely. Ruled out for MI. There
was concern for contribution from CHF given previous echo in
___ citing possible high output failure, so one unit of PRBC
was given on ___ with little improvement. Finally, could be a
component of respiratory muscle weakness (? h/o mylopathy/ALS),
a NIF was considered, but did not occur as this was not felt to
be the inciting factor.
Ultimately, he was taken for bronchoscopy and subsequent rigid
bronch when a pill was discovered as the cause for RLL findings
on CT. His hypoxia improved such that his oxygen saturation was
95% on Room air. He continued to use 2 Liters nasal cannula
oxygen for comfort. He was continued on nebs as he was taking
before hospitalization.
Speech and swallow saw the patient given his aspiration, and
felt that he was not aspirating on a video swallow evaluation.
They ultimately recommended for the patient to crush his pills
with puree, but had no further diet restrictions.
# Weakness/?ALS: Exam notable for profound ___, RUE weakness.
TSH n/l ___. This was not felt to be the cause of his hypoxia
as the pill was found on bronchoscopy. He will follow as an
outpatient with neurology.
# Iron deficiency Anemia - At or near baseline on admit. Patient
received one unit PRBC as above, with appropriate increase in
Hct. B12 and folate were wnl, he was continued on iron
supplementation. Last colonoscopy was in ___. Patient will f/u
as an outpatient.
# Cachexia: Patient seen by nutrition as inpatient, who
recommended TID ensure.
# h/o Hypertension: Home meds have been held since last
admission given hypotension to SBP's in ___. His home imdur
was held throughout admisson and on discharge.
# Chronic Diastolic CHF: Euvolemic on exam. Beta blocker not
started given respiratory distress. No ACEi started since pt in
diastolic failure and because BP would be unlikely to tolerate.
Lasix was held during hospitalization given relative
hypotension, but should be administered as outpatient based on
weight gain > 3 lbs from dry weight or shortness of breath that
cannot be attributed to alternate etiology.
# Code: DNR/OK to intubate confirmed w/ patient, HCP, and chart
# Emergency Contact: Son ___
***. | OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left patella fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction, internal fixation
of the left patella, 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 weight bearing as tolerated in the
left lower extremity in ___ locked in extension and will
be discharged on lovenox for DVT prophylaxis. The patient will
follow up in two weeks per routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course, and all questions were answered prior to
discharge.
***. | LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP FOOT AND FEMUR WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is a ___ yo female with a history of insulin-dependant
diabetes, ESRD on HD, and multiple thrombi on coumadin, who
presents with cardiac tamponade in the setting of
supratherapeutic INR.
.
#. Pericardial effusion: Patient presented to the ED with
abdominal pain. A CT performed in the ED demonstrated a large
pericardial effusion. Patient had a TTE performed at the
bedside which demonstrated tamponade physiology, with a
pericardial pressure in the ___. 700 ccs of bloody fluid was
drained from the pericardium, which was shown to have a Hct of
35, PMNs, and no growth of organisms. Patient was found to have
an INR of 18.2 on admission, and it was thought that this
effusion was a spontaneous pericardial bleed in the setting of a
supratherapeutic INR. The pericardial drain remained in place
for 24 hours and it was pulled after a repeat TTE demonstrated
that there was no reaccumulation of pericardial fluid.
Patient's aspirin and coumadin were both held and her hematocrit
remained stable for the duration of this admission. Patient's
INR had decreased to 2.3 prior to discharge.
.
#. Coagulopathy: Patient has a remote h/o bilateral DVT's and
was found to have bilateral thrombi of her internal jugular
veins during a recent admission. She was not on Coumadin from
___ until discovery of IJ occlusion in ___.
According to ___, patient had INRs of 1.0, 1.22, and
1.87 on the three days prior to admission. She thus received 7
mg, 8 mg, and 8 mg of Coumadin the days prior to admission.
These supratherapeutic levels also occurred in the setting of
recent coumadin reinitiation, antibiotic use, and liver failure.
Patient presented with acute life-threatening bleed and INR was
reversed with Vitamin K, factor IX, and FFP. Patient's coumadin
was held during this admission until her INR decreased to 2.8.
She thus was restarted on 2 mg daily. She should continue to
have her INR checked at ___, and she should be
monitored for signs of bleeding.
.
#. Transaminitis: Patient presented with a complaint of
abdominal pain and RUQ pain on physical exam. Patient had a new
elevation of her transaminases and alk phos. A CT of her
Abdomen showed an enlarged gallbladder and common bile duct. A
HIDA scan was then performed which showed evidence of chronic
cholecystitis. Patient's statin was held, and her transaminases
are now trending down. Hepatitis serologies were all repeated
and are still pending at time of discharge. The use of
simvastatin was discontinued in the setting of her elevated
liver enzymes. Restarting this medication should be addressed
with her PCP.
.
# R. Leg Pain: Pt. developed right lower extremity pain during
this admission. On physical exam, the lateral aspect of her
right quadricept is tense, warm, and she experiences pain with
light palpation. Patient had a CT of her lower extremity
performed which did not show a marked difference from a previous
R lower extremity CT performed in ___. There was no hematoma
or compartment syndrome noted on CT and only slight edema of the
interstitial fat. Given that this appeared to be a chronic
symptom, no further intervention was made and it was felt that
the pain should be followed by her outpatient care providers.
.
#. ESRD: Patient has a history of ESRD and undergoes HD on
___. Patient was admitted with hypocalcemia,
so her Cinacalcet was held on admission. Patient was initially
continued on Sevelamer during this admission, but this was
discontinued in the setting of her lowered phosphorus. She
received HD on ___ and ___. She should follow up with
her Nephrologist in the next ___ weeks.
.
#. Hypotension: Patient has relative hypotension at baseline
with SBP's regularly in 80's-90's. She was continued on her home
dose of Midodrine, and she did not experience any acute events
during this hospital stay.
.
#. Diabetes: Patient has a history of insulin-dependent
Diabetes. She was continued on her home dose of Glargine and
her home insulin sliding scale. She did not have any acute
events during this hospital stay.
.
#) Obstructive Sleep Apnea: Patient has a history of OSA
requiring BIPAP. Patient was continued on her BIPAP during this
hospital stay. She had one episode where she desatted to 60%
overnight. It was found that her BIPAP mask was not tightly
secured on her face. This was adjusted, and the patient's
oxygen saturation increased appropriately.
.
#. Code status: full code.
***. | OTHER CIRCULATORY 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.
***
___ is a ___ male with a h/o HFpEF (75%), DM2 on
insulin, HTN, CKD Stage III, OSA who presented from home with
one week of progressively worsening cough and dyspnea likely
secondary to a viral upper/lower respiratory infection with
concomitant mild exacerbation of acute on chronic diastolic
___ failure.
ACUTE ISSUES
=============
#Acute Hypoxemic Respiratory Distress #Cough
#Dyspnea
Presented with 1 week of progressive cough and dyspnea. Work up
in the ED negative for influenza, no focal consolidation on
chest xray. Initial DDx included viral URI/bronchitis,
decompensated HF, and PE. PE less likely given no recent surgery
or hx of VTE but with obesity as only risk factor. Patient had a
___ leukocytosis but was treated with prednisone burst for
a gout flare that was completed the day prior to admission. Most
likely etiology is viral bronchitis with concomitant acute on
chronic ___ failure with preseserved EF. Patient was given
Benzonatate, guaifenasin, ipratropium/albuterol and albuterol
nebulizer treatments. He was successfully weaned from 3L O2 NC
to room air. It is unclear if he ever had a true O2 requirement,
as he was never documented as being hypoxemic.
#Acute on chronic HFpEF (> 55% ___
___ Class II. Dry weight 389; 392 on admission.
Presented with ___ ~ 250 (although obese) with symptoms of
orthopnea and mild peripheral edema. Likely mild exacerabation
of ___ failure contributing to dyspnea. S/p ___ mg IV
furosemide x2 on admission with improvement in creatinine.
Restarted home bumetaninde. Continued home carvedilol 6.25 QAM,
12.5 QPM. Lisinopril discontinued in ___ in setting of ___
continued to hold.
#UTI
Described mild dysuria X ___ days. No penile discharge, rash. UA
suggestive of UTI with pyuria and moderate bacteria. Urine
culture grew >100k cfu of Klebsiella. Treated with 3 days of
ceftriaxone and transitioned to cefpodoxime to finish a 5 day
course on ___.
#Troponinemia
Elevated to 0.2 on admission, noted to have chronic elevation in
tropnonin in this range. Likely chronic/demand related in the
setting of CKD and hypoxemia. Trended troponin to peak at 0.2.
No ischemic EKG changes.
#Type II diabates, insulin dependent
Held home semaglutide. Gave Humalog 10u before meals plus
sliding scale and Glargine increased from 60 to 70 BID.
#Gout
Patient with first flare of ___ gout earlier this
month. Finished a prednisone taper on ___ just prior to
admission. Still notes some tenderness in right knee. His uric
acid was 13.2. Recommend starting allopurinol as outpatient to
be addressed as a transitional issue.
CHRONIC ISSUES:
===============
#Severe pulmonary hypertension Based of RHC from ___, patient
with severe pulmonary hypertension with mPAP of 57. PCWP of 27
and transpulmonary gradient of 20 indicated likely combined
post- and ___ pulmonary hypertension.
#Normocytic anemia
H/H 10.8/35.3 on admission which is baseline. Iron studies from
___ were not suggestive of iron deficiency anemia. Likely
related to anemia of chronic inflammation/CKD.
#CKD Baseline
Cr ___ 1s to low 2s, likely due to HTN and DM2. Presented
on higher end of baseline. Improved with diuresis to baseline of
1.8 on discharge.
#OSA
CPAP at night
#Insomnia
Continued home Amitriptyline 75 mg PO QHS
#Morbid Obesity
Scheduled for bariatric surgery on ___.
#Chronic back pain: Continues home pain regimen:
Acetaminophen 1000 mg PO Q8H:PRR, tramadol 50 mg PO QHS:PRN,
OxyCODONE (Immediate Release) 5 mg PO TID:PRN, Lidocaine 5%
Patch 1 PTCH TD QPM, Cyclobenzaprine 10 mg PO HS:PRN muscle
spasm, diclofenac sodium 1 % topical BID:PRN.
#CODE: Full(presumed)
#CONTACT: ___ (fiance) ___
TRANSITIONAL ISSUES
===================
Discharge weight: 361.7 Discharge creatinine: 1.8 Discharge
diuretic: bumex 8mg
[ ] On cefpodxime for a UTI through ___
[ ] Patient with recent initial gout flare (crystal proven).
Finished prednisone course ___. Please discuss prophylaxis with
allopurinol (uric acid level of 13) although this was his first
gout flare and was mildly symptomatic on discharge
[ ] Scheduled for bariatric surgery on ___.
[]F/u GC and CT urine tests (pending at time of discharge)
Mr. ___ is clinically stable for discharge today.
The total time spent today on discharge planning, counseling and
coordination of care was greater than 30 minutes.
***. | 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.
***
Ms. ___ was admitted to the neurology service on ___ due
to unsteadiness in the setting of carotid stenosis.
Neuro:
Carotid dopplers showed high-grade/critical right ICA stenosis
(80-99%), which has
increased in comparison to the prior study from ___ (where
it was 60-69%) and left ICA stenosis of 60-69%, which is also
slightly increased in appearance compared to the prior
ultrasound (where it was 40-59%). Vascular surgery was consulted
and recommended CEA. A CTA head and neck was performed which
showed calcifications at the carotid bifurcations bilaterally
and at the origin of the left vertebral artery. Carotids
appeared patent on prelim read; reconstructions pending.***
There was also a 2.2mm aneurysm seen in the proximal anterior
division of the right MCA which appeared unchanged from her
prior scan. There was also an 11-mm round soft tissue density in
the right orbit medial to the optic nerve, possibly arising from
a vessel but indeterminate on this study. **Consider MRI**
CV:
She was maintained on telemetry monitoring. Orthostatic testing
was positive with a fall in SBP from 150's to 130's and an
increase in HR from 60's-70's from lying to standing. She was
started on IV hydration.
Pulm:
Respiratory status remained stable. She was continued on her
home inhalers for COPD.
Prophylaxis:
She was maintained on heparin SQ for DVT proph and a bowel
regimen for GI prophylaxis.
***. | EXTRACRANIAL PROCEDURES WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
*** y/o with systemic Amyloidosis with
cardiac, renal, peripheral nervous, and GI involvement c/b
recurrent gastroparesis with intractable nausea/vomiting.
Course has been complicated by gastroparesis now TPN dependent,
mult DVT and lung empyema for which he was on micafungin and
ertapenem at home.
He is currently on treatment with ___ for his advanced AL
amyloidosis (this is his off week). Patient now admitted with
hypotension, pre-syncope, and poor PO intake due to nausea and
vomiting.
# Systemic Amyloidosis - end stage disease with multi-organ
involvement.
-Currently on ___ follow-up with Dr. ___
week
-___ on ___ showed trace monoclonal ___ lambda
detected by IFE only (too low to quantify), and
protein/creatinine ration in the random urine sample was 7.6.
This is an improvement from ___ when the ___
proteinuria was 200 mg/day and protein/creatinine ratio in the
urine was 11. This suggest an encouraging hematologic response
to ___.
# Orthostatic hypotension: secondary to severe dysautonomia with
systemic amyloidosis, possibly a component of volume depletion
in the setting of poor PO intake and nausea/vomiting
- received gentle hydration with normal saline for less than 24
hrs, blood pressure increased to SBP 90-110 for the remaining
hospitalization
- continue midrodine
# Nausea & vomiting: secondary to long-standing gastroparesis.
Patient had only one more episode of vomiting after admission on
___ am. Otherwise he improved and was able to tolerate all
his meals.
- continue 2mg dex daily for symptom control
- will continue TPN overnight
- continue home Metoclopramide 10 mg PO QIDACHS, intermittent
doses of reglan prn
- continue Diazepam 5 mg PO BID
#Enterococcus UTI: >100,000, symptomatic, on chronic IS, chronic
foley use, hx of VRE
-initiated dapto, f/u with sensititives
-repeat u/a and u culture PND
-to complete 10d course total of dapto, 7d left at home set up
through ___
#Hyponatremia (sodium 128): Improved to 134.
# CHF - Systolic and Diastolic - ECHO was done on ___, with
improved EF. Followed closely by Cardiology, and he is currently
on Lasix 40
mg twice daily and spironolactone 50 mg daily.
# Abdominal pain reported upon admission in the LUQ
- CT ABD without SBO but showed increased size of renal cysts
and
incidental finding of a calcified lesion on right thigh
- urology reviewed images and feel renal cysts stable and to
re-evaluate in one year
- femur of right leg ___ likely myositis ossificans per ortho,
f/u MRI right thigh and f/u outpatient in ___ weeks
#Hypogammaglobulinemia - ___ progressive disease/treatments
- recived IVIG on ___
# Neuropathy: stable
- continuned duloxetine
# Chronic Constipation: see above
- dulcolax PRN
- docusate 100mg BID PRN
- senna 8.6mg BID PRN
- polyethylene glycol 17g BID PRN
# Oral ___ - ___ dexamethasone
-fluconazole started
# Nutrition
- cont TPN as ordered over 10hrs
PAIN: Morphine ___ and SR. Refer to MAR to dosages
BOWEL REGIMEN: See above
DVT PROPHYLAXIS: Hx of RUE DVT
- on therapeutic anticoagulation
- lovenox 60mg SC
ACCESS:
- tunnelled line
CODE STATUS:
- DNR/DNI per discussion with Dr. ___ on ___
DISPO: home
CONTACT INFORMATION:
Name of health care proxy: ___
Relationship: wife
Phone number: ___
Cell phone: ___
***. | CONNECTIVE TISSUE DISORDERS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient was admitted and taken to the operating room by Dr.
___ the patient underwent the above surgical
procedure. The procedure was well tolerated and there were no
complications. Please see the separately dictated operative
report for details regarding the surgery. The patient was
subsequently transferred to the post-anesthesia care unit in
stable condition and transferred to the floor later that day.
Overnight, the patient was placed on a IV and PO medicaions for
pain control. IV antibiotics were continued for 24 hours
postoperatively for prophylaxis.
Aspirin was started for DVT prophylaxis.
The surgical dressing was found to be clean, dry, and intact
without erythema or purulent drainage.
The patient was tolerating regular diet and otherwise feeling
well. Overnight on POD#1 patient was tachycardiac while
normotensive. His clinical picture was most consistent with
alcohol withdrawal. He was treated with PO Valium, IV Fluids,
and electrolye repletion. His tachycardia improved with PO
Valium.
The patient was discharged in stable condition on POD#3 with
written follow up instructions and detailed precautionary
guidance.
***. | MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
This is a ___ year old female with PMH significant for severe
depression, autonomic dysfunction, and DM1 who is brought in by
her husband for an ingestion of 27 tablets of Fioricet
(butalbital 50/APAP 325/caff 40).
.
#. Fiorcet (butalbital 50/APAP 325/caff 40) overdose: If she
has truly ingested 27 tablets of Fioricet, then she would have
taken in 8775 mg of acetaminophen, 1350mg of butalbital, and
1080mg of caffeine in the last 36 hours. This does not seem to
fit her clinical picture as her serum Tylenol level was negative
shortly after admission on ___. Toxicology followed the
patient from admission and recommended discontinuing NAC after
12 hours. She had only a mild transaminitis which resolved
prior to discharge and her coags remained WNLs. Her CK was
checked and normal despite her alleged caffeine overdose. She
was monitored on telemetry. She was initially monitored with a
1:1 sitter. Her husband was contacted and felt that her
overdose was unintentional. The patient also reports that it
was unintentional and she was taking the Fioricet until her
headache resolved. She is followed closely by psychiatry as an
outpatient. An inpatient psychiatry consult was obtained and
felt as though she was safe for discharge home. Of her home
medications, Fioricet was the only medication that was
discontinued on discharge.
.
#. Lethargy: The patient initially presented with lethargy and
quickly resolved. It is likely that her lethargy may have been
related to overdose, but she was also on a lot of sedating
medications at home. An ABG revealed no hypercarbia despite her
low respiratory rate. She did not have any fevers or
leukocytosis. Initially her clonazepam, trazodone, and
gabapentin were held, but they were all reinitiated prior to
discharge.
.
#. Autonomic dysfunction: The patient did not experience any
hypotensive episodes during her admission and her home midodrine
was not administered.
.
#. IDDM: She was maintained on a diabetic diet and her home
regimen of lantus and insulin sliding scale.
.
#. Major Depression: She was continued on her home Effexor XR.
.
#. Hypothyroidism: She was continued on her home Synthroid
dose.
.
#. Urinary incontinence. She was continued on her home
oxybutynin.
.
#. Code: The patient's code status was confirmed as full code
.
#. Communication: Patient and ___ (husband)
___
***. | POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ yo F with h/o COPD, IDDM, HTN, and cirrhosis presented with
progressive exertional chest pain and dyspnea likely due to
anemia from upper GI bleed and iron deficiency.
ACTIVE ISSUES:
# Anemia: The patient presented with anemia, with hemoglobin of
8.2. She was given a blood transfusion with an appropriate
increase in her blood counts. She had evidence on EGD of
esophagitis, gastritis, and duodenitis, likely due to recent
NSAID use in setting of recent shoulder fracture. H. pylori
serum and stool tests pending. Lab work revealed iron deficiency
anemia. She was given IV iron and was transitioned to PO iron at
discharge.
# Exertional chest pain and dyspnea: Likely due to anemia.
Resolved with transfusion. Had negative ultrasound for DVT, and
no tachycardia or hypoxia, thus unlikely PE. Echocardiogram was
within normal limits and troponins were negative. Was given
lasix IV x1 for pulmonary vascular congestion with some
improvement. By discharge she was asymptomatic.
CHRONIC ISSUES:
# Left humeral neck fracture: The patient recently fractured her
left humerus in ___. She was taking NSAIDs to control the
pain, which likely contributed to her gastritis. She was placed
on tylenol and tramadol with good pain control. Occupational
therapy saw the patient in house and recommended exercises for
the patient. She will follow up with her orthopedic surgeon at
discharge.
# HTN: well controlled. Her enalapril was continued. Her HCTZ
was initially held as she was given lasix, but was resumed by
discharge.
# DMT2, insulin dependent: Her home glargine was continued, and
her metformin was held. She was also placed on SSI.
# COPD: currently well controlled with no symptoms of flare. Her
home tiotroprium and albuterol were continued.
# Cirrhosis: Stable. Should have follow up with PCP and GI.
TRANSITIONAL ISSUES:
- Follow up of blood counts at PCP ___ up of iron levels with oral therapy
- Repeat EGD in 8 weeks, GI follow up
- Avoid NSAIDs for pain control
- Follow up H. pylori serum and stool studies
- Follow up upper gastrointestial biopsy
- ___ bearing of L arm until follow up with orthopedics,
can perform exercises as outlined by occupational therapy
***. | RED BLOOD CELL DISORDERS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with systolic and diastolic CHF and paroxysmal afib who
presented with severe acute on chronic systolic CHF. Upon
presentation, the patient's weight was elevated approximately 10
pounds from her dry weight, her BNP was 5800 from 700 in the
past, she had anasarca and malabsorptive diarrhea as a result of
bowel wall edema. She was diuresed with IV lasix until close to
euvolemia with resolution of her abdominal discomfort and
diarrhea. She was then converted to PO torsemide with titration
to achieve and maintain euvolemia. She was discharged on
torsemide 60mg BID with instructions to continue with daily
weights and to call in if her weight fluctuates more than 3
pounds. Home lisinopril was continued.
.
#. Rhythm: The patient has a history of paroxysmal afib for
which she was previously on coumadin, amiodarone and
beta-bloackade. Her beta-blockade was discontinued due to
bradycardia. The patient's heart rate remained in the ___
throughout her hospitalization while off beta-bloackade. She
appeared to be in an ectopic atrial rhythm while in the
hospital. She was discharged on coumadin and amiodarone.
.
#. CAD: The patient has no known history of CAD. Upon initial
presentation, she has two sets of negative enzymes. She was
maintained on aspirin 81mg.
.
# CRI: The patient has a history of baseline creatinine 1.4-1.6.
Her creatinine at discharge was 1.0 after diuresis.
.
On ___, the patient was near euvolemia at her baseline weight
with stable, normal vitals in fairly good condition. She was
released to the care of her son who had arranged 24 hour in-home
care along with ___ and home ___. She was discharged with follow
up scheduled in ___ clinic.
***. | 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.
***
A/P: ___ y/o M with acquired factor VII deficiency, common bile
duct stone, biliary obstruction, failed ERCP, transferred from
___ for ERCP today
# biliary obstruction- s/p successful ERCP ___ with stone
removal and cannulation of biliary duct. percutaneous drain not
removed.
- monitored overnight with no abdominal pain, fevers, change in
clinical status.
- to return to ___ for removal of Percutaneious drain.
# factor VII deficiency- no interventions here.
# degenerative joint disease, chronic- continued oxycodone prn
# ectopy- transient episodes of ectopy by telemetry, with
ventricular bigeminy. no known underlying heart disease
Outpatient follow up.
***. | 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.
***
Ms. ___ was admitted post-operatively following Left foot
triple arthrodesis. Pt tolerated the procedure & anesthesia ___
& without complication. it should be noted that she was admitted
for potential pain-control, respiratory monitoring (given the pt
is obese and general anesthesia was employed). Please refer to
op-note for full detail.
.
Overnight the pt's foley was re-placed b/c she was not making
any urine and her bladder scan revealed +900ccs of urine
retained. Pt states this happens regularly when she's admitted.
___ was consulted to assess if pt can remain NWB to her LLE. She
was maintained on Ancef for a total of 3 doses.
.
POD#2: Pts dressing was taken down & replaced with a clean
dressing. Ortho-tech was consulted and fit the pt with a bivalve
cast. Pt continued to evaluate the pt, case-manager worked on
screening the pt for rehab. Her electrolytes were replenished as
necessary.
.
POD#3: pt was discharged to rehab. Vital signs stable, vascular
status intact. NWB to LLE in bivalve cast with f/u appt
scheduled.
***. | PERIPHERAL CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mrs. ___ was admitted following a laparoscopic ileo
cecectomy and umbilical hernia repair. She tolerated the
procedure well, was extubated and transferred to the PACU. She
was then transferred to the floor, where she continued to
improve. She was able to tolerate a diet of clear fluids
initially, but was not having bowel movements or passing flatus.
However, these symptoms improved by POD2. She was tolerating a
regular diet and ambulating without difficulty. Her pain was
well controlled, post operatively with IV pain medications, and
she was able to transition to PO pain medications on POD 2. She
was doing well and was discharged on POD3. She was tolerating a
diet, ambulating, passing flatus, and having bowel movements. At
the time of discharge she was stable and in good condition
***. | MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
*** severe AS s/p surgical AV replacement w procine valve ___
0.8-0.9cm2) in ___, now s/p TAVR ___ w/ high gradient across
valve concerning for thrombus and now on coumadin, hepatic DLBCL
s/p CHOP in ___, HTN, presents with anemia.
# Anemia - Hgb 7.9 on admission during most recen
hospitalization. Hgb on admission 7.3. Pt asymptomatic on
admission. Guaic negative. Hemolysis labs negative. Iron
studies suggested mixed picture of iron-deficient anemia and
anemia of chronic disease. Pt was started on iron supplement
and received 2 units of RBC transfusion with IV lasix without
signs of volume overload. On discharge, hemoglobin was 10.1.
# Heart Failure with preserved Ejection Fraction. Stable, no
exacerbation this hospitalization. EF 60%. Dry weight 200lbs. Pt
received IV lasix with each unit of RBC transfusion with
appropriate response. She missed a few doses of aspirin and
since she required previous desensitization, she was observed
during reinitiation. She received 40.5mg on the evening of ___
and tolerated this well. Thereafter, she was restarted on 81mg
daily.
# Shoulder pain: Musculoseketal in origin. Chest xray negative
for abnormalities. Lidocaine patch applied.
# ASA was initially held as pt reports history of allergy. Pre
review of record, pt has been desensitized to aspirin
previously. Pt was restarted on 40.5 mg dose of aspirin and
proceeded to 81mg of aspirin without allergic reaction per
allergy rec. pt can safely take 81mg daily asa at home.
# Severe AS - s/p surgical AV replacement w procine valve ___
0.8-0.9cm2) in ___ and s/p ___ TAVR ___ with
subsequent high gradient across valve concerning for thrombus.
Repeat ECHO showed improved gradient across AV (40 to 32) last
hospitalization. Pt was continued on coumadin with therapeutic
INR.
# Hypertension - Stable. Continued Metoprolol Succinate XL 12.5
mg PO DAILY, Lisinopril 2.5 mg PO DAILY
# COPD - Stable. Continued Fluticasone-Salmeterol Diskus
(250/50) 1 INH IH BID, Albuterol Inhaler ___ PUFF IH Q4H:PRN
shortness of breath
# GERD - Stable. Continued Omeprazole 20 mg PO DAILY
# Depression - Stable. Continued Escitalopram Oxalate 10 mg PO
DAILY
# Gout - Stable. Continued Allopurinol ___ mg PO DAILY. colchine
was held initially given possibility of BM suppression
TRANSITIONAL ISSUES:
-monitor hemoglobin, no sign of GI bleed, good response to
transfusion of 2 units PRBCs.
-Monitor warfarin for INR goal 2.0-3.0
***. | RED BLOOD CELL DISORDERS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ yo F with paroxysmal atrial fibrillation, diastolic
dysfunction, obesity, thyroid cancer and hypertension admitted
with abdominal pain and brbpr and found to have a leukocytosis
and colitis of descending colon likely infectious vs ischemic.
.
#Colitis: The patient was admitted to the general medicine
service and had work-up for colitis which was thought to be
infectious vs ischemic. She was started on Cipro and Flagyl and
given gentle IV fluids given history of diastolic dysfunction
and aortic stenosis (per chart and murmur consistent however
___ TTE did not show AS). GI consulted and felt that her pain
was secondary to ischemic colitis. She was kept NPO and given
IV narcotics and anti-emetics. Repeat CT scan on ___ showed
radiographic improvement. Her hospital course was also
complicated by blood streaks with bowel movements, but serial
HCT were stable. GI stated that some bleeding with bowel
movements and abdominal pain were expected in her condition.
They elected to do outpatient colonoscopy as to not risk
perforation while she had this exacerbation. She will be
scheduled for Colonoscopy with MAC anesthesia along with EGD for
dysphagia which has been a chronic problem for her. Her diet
was advanced to regular foods and she did not have significant
pain with eating. After initial diarrhea, she had constipation
for 6 days which resulted in crampy abdominal pain. The day of
discharge, she was given GoLytely 500cc with good bowel movement
and much improvement of her symptoms and bloating. She did not
have any fever after her ABX were discontinued and was afebrile
for at least 72 hours before discharge.
.
#Leukocytosis: initial WBC count of 18.9 was likely acute phase
reactant due to stress from colitis which normalized throughout
her hospital stay. Blood cultures drawn in the ER on ___ fere
finalized as negative on ___.
.
#PAF: She continued flecainide and metoprolol and did not have
any Afib. ASA was held secondary to bleeding; telemetry
monitoring was unremarkable.
.
#HTN: benign
Her in initial lasix and lisinopril were held as she appeared to
have intravascuar volume depletion. I will continue her Lasix
and Lisinopril on discharge for her to have close follow-up with
her PCP. Kidney function is normal and stable.
#HLD:
--cont crestor
.
#Hypothyroidism:
--cont synthroid
.
#Code status: DNR/DNI
.
HCP: ___ (# in OMR)
Email sent to PCP ___
***. | 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.
***
PSYCHIATRIC: Pt is ___ yo man with prior diagnosis of
schizoaffective disoder who
was BIBA with concerns for safety, as he was expressing suicidal
ideation at home to his mother & fiance. Pt was experiencing an
exacerbation of his depression, as evidenced by +NVG symptoms.
He was reporting thoughts of wanting to kill himself/wanting to
be dead, however denied any particular plan. This was in the
context of a number of psychosocial stressors, including
expecting a new child, being unemployed, and having conflict
with his mother, as well as having his birthday pass without any
contact from his father. Pt was initially quite hostile and
angry on unit, but agreed to take a low dose of quetiapine prn
anxiety or agitation and this was increased slightly during his
hospital stay. He stabilized on quetiapine 75 mg TID which was
adjusted for ease of administration to 75 mg qAM and 150 mg qHS.
His SI resolved and he felt ready to return home, however pt's
mother (whom pt lives with) did not feel that pt would be safe
with this plan as she would be out of town and unable to monitor
him. Pt's mother agreed to have pt return home when she returned
from being out of town. Pt has ___ filed for his threatening
comments toward younger sibling who is also in the home.
Pt d/c to f/u at ___ in ___ with ___
___ and expecting to estabilish a psychiatrist there. Also to
attend partial hospital program at ___ beginning ___.
MEDICAL: Pt was admitted with HR range in the ___. During
sleep pt was noted to have a more pronounced bradycardia with a
low HR of 32. Pt had several repeat EKGs which showed sinus
bradycardia and his HR stayed in the ___ to low ___ while awake.
No intervention was made. Spinal xrays done for c/o back pain
which showed no concerning finding.
LEGAL: ___
BEHAVIOR: Despite frequent arguments with staff and frequent
hostility pt was able to maintain behavioral control and stayed
on 15 minute checks.
***. | NEUROSES EXCEPT DEPRESSIVE |
What is the most likely Medicare Severity Diagnosis Related Group (MS-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 chronic systolic and diastolic cardiac
dysfunction (LVEF 40%), HTN, afib on Coumadin, gout, CKD who
presents s/p fall with multiple pelvic fractures.
.
#S/P fall: Fall was mechanical, no pre syncope, no
lightheadedness, no LOC, no palpitations prior to fall. CT from
OSH with multiple hip fractures (left iliac fx, left inferior
pubic rami fx, and left acetabulum fx). Seen by orthopedics who
said fractures are stable and inoperable. Patient's pain was
managed with Tylenol and Oxycodone.
#UTI: Patient with dysuria, leukocytosis (12.6), and U/A
indicative of UTI, urine culture +enterococcus. Patient was
treated with cefpodoxime 400mg q24h x3 days prior to final
results of urine culture. However, cefpodoxime does not cover
enterococcus, thus, patient will need amoxicillin 500mg bid x7
days.
.
#Acute on CKD: Baseline Cr is 1.5-2. Cr 1.9 on admission, ___
up to 2.5. Etiology likely pre renal as patient not taking in a
lot of fluids and ___ resolved with hydration and holding
diuretics. Renal US ruled out obstruction. On discharge, Cr
trended down to 1.6. Torsemide was decreased from 80mg qd to 40
mg qd.
.
#Afib s/p ablation and pacemaker placement ___: On admission,
held Coumadin as INR was supratherapeutic. Continued Coumadin
at home dose once INR became therapeutic.
.
#CHF: Severe systolic and diastolic heart failure with LVEF of
40%. Currently, appears euvolemic, no crackles on lung exam, no
___ edema. Decreased Torsemide from 80mg qd to 40mg qd as patient
had acute on chronic kidney injury and SBPs in the ___. Patient
was diuresing well during the admission. Weight on discharge
was 162 lbs. Can uptitrate Torsemide to home dose based on
patient's volume status. Continued spironolactone, atenolol,
aspirin.
.
#HLD: Continued simvastatin.
.
#Gout: Continued allopurinol, colchicine at home dose.
.
#Hypothyroidism: Continued Levothyroxine at home dose.
.
TRANSITIONAL ISSUES
-DNR/DNI
-amoxicillin 500mg bid x7 days for UTI
-will f/u with orthopedic surgery as outpatient as below
-patient should be weighed daily to assess for fluid overload
***. | FRACTURES OF HIP AND PELVIS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ female with HIV/AIDS on HAART admitted from the ED with
right sided Bell's Palsy and found to have cryptococcal
meninigitis.
1. Cryptococcal Meningitis
Patient was found to have low-titer CSF cryptococcal antigen
(1:16) on day of admission in setting of new onset right facial
droop and intermittant headaches in the two weeks prior to
admission. Head imaging was unremarkable, other than
inflammation along the right facial nerve. ID was consulted and
patient was started on liposomal amphotercin B and flucytosine
on the day of admission. This was considered an atypical
presentation and possibly a false positive given the low titer
and possible confounders that can result in a false positive
cryptococcal antigen assay. An LP was repeated on day 6 of
admission which showed no evidence of cryptococcal antigen and
was otherwise unremarkable. Patient was given a one time dose
of fluconazole 800mg po on day of discharge. ID felt comfotable
given low titer cryptococcal antigen and minimal symptoms to
discontinue liposomal amphotercin and flucytosine and the
patient was discharged on 400mg of fluconazole daily with
outpatient ID follow-up.
Unfortunately because of her insurance, she can only receive 15
days worth of medications per perscription without having to pay
an enormous co-pay. She received 1 perscription for 15 days
during this admission, and the above consideration was
communicated with her ID team, which will follow-up and provide
additional prescriptions.
2. Bell's Palsy
Patient presented to the ED complaining of a right sided facial
droop. Her Bell's palsy is of unclear etiology. She was
initially discharged with a prescription for valacyclovir and
prednisone from the ED, however when her CSF cryptococcal
antigen test returned positive, she was called back, and the
prednisone was discontinued. She was kept on the valacyclovir
for four days and it was then stopped. An MRI showed
inflammation along the right facial nerve and radiology
recommended a dedicated MRI of the IACs with contrast for
further evaluation to rule out the small possibility of
schwannoma. Given her acute kidney injury the risks of an MRI
with contrast at that time was considered to outweigh the very
marginal possible benefit. Further discussion of whether to
perform this study should continue as an outpatient depending on
the resolution of her symptoms. This finding was shared with
her outpatient ID doctor.
3. Acute Kidney Injury
Patient's creatinine on admission was 0.8. It increased to 1.4
on the third day of admission and improved with substantial
fluids. The patient continued to develop worsening ___ each
time we attempted to stop fluids, which resolved with increasing
hydration. The most likely etiology of this injury was thought
to be her liposomal amphotercin B in the context of inadequate
PO hydration. Prior to discharge she was given a large bolus of
fluid and she will follow up with ID and post discharge clinic
where her kidney function should be followed.
4. Exposure Keratitis
On the second day of admission patient developed an
erythematous, swollen and tender right eye. She denied any
changes in her vision. She was seen by ophthalmology that felt
her presentation was most consistent with an exposure keratitis
in the context of her Bell's palsy and recommended eye ointment.
Her symptoms improved during the remainder of her stay in the
hospital.
5. HIV/AIDS
Patient was continued on her home regimen for HAART (Darunavir
600mg PO bid; Maraviroc 150mg PO bid; Raltegravir 400mg PO bid;
Ritonavir 100mg PO bid) and also given SS TMP/Sulfa daily for
PCP ___. Her Infectious Disease doctor was aware of her
admission and the consult team followed her in the hospital.
The patient was ordered for subcutaneous heparin for DVT
prophylaxis but consistently refused this though she did
ambulate. She was full code. She was discharged with follow up
in ___ clinic. She also has a follow up in ___ clinic
to recheck her renal function and discuss/ensure adherence to
her fluconazole regimen.
***. | HIV WITH MAJOR RELATED CONDITION 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:
======================
Mr. ___ is a ___ y/o M with a medical history notable for
locally advanced cholangiocarcinoma with metastases to the liver
s/p chemo/radiation c/b recurrent biliary obstruction and
cholangitis s/p multiple ERCPs w/ stenting and transferred from
___ on ___ for sepsis ___ citrobacter cholangitis and
transferred to the FICU from ___ to ___ for acute respiratory
failure and septic shock s/p failed extubation after ___
cholangiogram w/ PTBD. His hospital course has been c/b VRE
bacteremia, aspiration pneumonia, and acute renal failure
requiring CRRT (___) for worsening metabolic acidosis,
volume overload and electrolyte abnormalities, now with no
indications for ongoing CRRT. Off pressor support with stable
hemodynamics and MAPs. Extubated successfully ___ and remained
somnolent for several days before improvement in his mental
status. His mental and physical status declined and was then
transitioned to CMO. He was discharged to hospice.
# SEPTIC SHOCK
# VRE BACTEREMIA
# HX CITROBACTER BSI ___ ___
Mr. ___ presented to the ICU with hemodynamic instability,
lactic acidosis, leukocytosis, multi-system organ dysfunction,
concerning for septic shock. He was being treated for
Citrobacter and VRE bacteremia from a biliary source with
daptomycin and meropenem. He underwent PTBD on ___ and failed
extubation and was transferred to the ICU for septic shock
requiring pressor support, CRRT, and an A line. ID was consulted
and he completed a course of antibiotics and remained HDS and
afebrile and was transferred to the regular nursing floor.
Completed a course of meropenem, daptomycin, linezold, and one
dose of tobra. He was ultimately discharged to hospice.
# ACUTE RENAL FAILURE, OLIGURIC
# CHRONIC KIDNEY DISEASE STAGE III
# ANION GAP METABOLIC ACIDOSIS
# VOLUME OVERLOAD
Baseline Cr 1.5-1.9. During admission his SCr peaked at 6.1 and
he was on CRRT from ___ and after stopping CRRT he had
good urine output and renal did not think he had indications for
continuing HD at this time. His ___ was likely ___ ATN secondary
to polymicrobial infection and sepsis.
# TRANSAMINITIS
# ASCITES
# CHOLANGIOCARCINOMA
Had transaminitis with septic shock in the setting of
cholangiocarcinoma and recurrent obstruction, recent balloon
sweeping of biliary stents and PTBD placement. His tube feeds
going into the small intestine were coming out of his biliary
drain and per discussion with ___ this is not unusual and with
holding tube feeds his drain only had bilious output.
# ALTERED MENTAL STATUS
After he was extubated on ___ he was still very somnolent, not
following commands,
and not tracking or following with gaze. This was thought to be
due to metabolic encephalopathy in the setting of ongoing renal
dysfunction, liver dysfunction, and acute illness. Non-contrast
CT head was normal. He was noted to have more purposeful
movements on the morning of ___ and by ___ he was alert and
awake and asking appropriate questions. However this continued
to wax and wane.
# THROMBOCYTOPENIA
# MDS
___ thrombocytopenia was as low as 12 before beginning to slowly
uptrend and HIT panel was negative and no evidence of TTP or TMA
on labs. Etiology unclear but likely marrow suppression in the
setting of septic shock, medications (linezolid from ___
and underlying malignancy.
# ACUTE RESPIRATORY FAILURE
He failed extubation after PTBD on ___ and was successfully
extubated ___. CXR obtained ___ with e/o bibasilar
atelectasis, pleural effusions, pulmonary congestion but
significantly improved from prior. After extubation he had AMS
and was coughing/choking and felt to be high aspiration risk and
was kept NPO for several days before undergoing speech/swallow
evaluation which he at times passed, but eventually failed.
# DVT/PE in ___
He was recently started on apixaban 2.5mg BID per primary
oncologist
given PE on OSH imaging and history of DVT but his apixaban was
held for concern for GI bleed and platelets <50k.
# ACUTE HGB DROP
# ACUTE ON CHRONIC ANEMIA
Pt's Hg dropped from 9 to 7 w/ dark stool (was on iron as well).
This is likely an upper GIB as ERCP noted few angioectasias with
stigmata of recent bleeding in antrum thought to be due to
radiation gastritis. Received multiple blood transfusions.
# DECREASED CARDIAC OUTPUT (SELF-RESOLVED)
Pt was enrolled in the esmolol study and noted to have an
increased SV, but decreased CO by NICOM previously. EKG with
possible J point elevations, but no diffuse ST elevations or PR
depressions c/w pericarditis. IF this were acute pericarditis,
would like be iso acute renal failure and uremia, which would be
treated with HD. No abnormalities detected on bedside echo, no
pericardial effusions. Hemodynamically stable. Troponin was
stable.
# Oral Thrush
Was treated with a course of fluconazole and thrush resolved.
# Metastatic Cholangiocarcinoma
Previously received gemcitabine/cisplatin. Imaging with
progressive disease. Dr. ___ aware of
hospitalization.
# DMII
Held his home home glipizide and HISS.
# GERD
He was on protonix while hospitalized in lieu of his home
ranitidine.
# BPH
Had urinary retention requiring foley placement.
# Chronic Cough
Discharged on cough suppressants.
# Gout
Held home allopurinol in setting of ___ renal failure.
# Hyperlipidemia
Held home rosuvastatin.
# Pressure Ulcer, Stage 3: Found on admission.
Continued wound care.
# BILLING: 55 minutes were spent in preparation of discharge
summary and coordination of care.
***. | 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.
***
Mr. ___ is a ___ year old right handed man with a history
of predominantly bulbar myasthenia ___, DM Type II with
probable polyneuopathy, hypertension, hyperlipidemia, and
chronic foot ulcers with MRSA colonization s/p multiple digital
amputations who presented with fever and found to have ESBL
E.coli/Citrobacter Freundii bacteremia.
1. GNR bacteremia/Fungemia: Initial blood cultures grew both
ESBL resistant E. coli and Citrobacter. Given these organisms,
the gangrenous left heel was the most likely source of
infection, especially since CXR, U/A were negative for
infection. Before the sensitivities were known, broad spectrum
antibiotics including Flagyl, Vancomycin and Ceftazidime were
started. The patient had a spike in fever to 101 while on these
antibiotics. Sensitivities revealed that the E.coli was
resistant to cephalosporins and aztreonam, so meropenem was
initiated on ___. ID was consulted and he it was felt the
patient would require a 4 week course of antibiotics for the
treatment of the ESBL (to be completed with Ertapenem on
discharge due to daily dosing). A PICC Line was placed. On
___, maintenance blood cultures drawn from the PICC were noted
to be positive for yeast ___ PARAPSILOSIS). This PICC was
removed and all subsequent blood cultures were negative. ID
recommended initial treatment in micafungin which was switched
to fluconazole upon discharge. He will need to continue a 2
week course of fluconazole for treatment of his fungemia. At the
time of discharge, the patient was afebrile and hemodynamically
stable; all surveillance blood cultures subsequent to ___ were
negative.
2. Left gangrenous heel: MR. ___ was evaluated by
Podiatry for his left foot ulcer. MRI was without evidence of
osteomyelitis. The wound was debrided on ___. During the
debridement, there was concern for vascular insufficiency and
vascular surgery was consulted to assess the patient's blood
supply to his lower extremities. An angiogram and Balloon
angioplasty of the left anterior/posterior tibial arteries was
performed on ___. This was tolerated well. The patient was
started on Plavix therapy and should continue which should
continue for the next ___ days. He will need to follow-up in the
___ clinic with Dr. ___ next month.
3. Myasthenia ___: Mr. ___ had a history of Myasthenia
___ and Neurology was consulted upon admission. He was
initially on CellCept but his was discontinued upon admission
given his infections. He was, however, continued on Prednisone
15 mg daily. Given the patient's history of myasthenic crisis,
q4 hr neuro checks and q4 hr NIF were in place following his
angioplasty and debridement. On ___, the patient's NIF was
noted to drop from 80 to 40 and complained of right eye and arm
weakness. He was transferred to the ICU for concern of worsening
MG and plasmapheresis was initiated. After a 24h uneventful
observation period, he was felt to be stable and was transferred
to the neurology service. He completed 4 rounds of
plasmapheresis with good improvement of his symptoms and
throughout his remaining hospitalization, the patient had a
stable neurologic exam notable only for right eye ptosis and
esotropia. He was discharged on 10mg prednisone daily and was
scheduled for follow-up in the ___ clinic.
4. Diabetes: The patient was noted to have elevated blood sugars
during this hospitalization which were felt to be due, in part,
to his use of steroids and his infections. He was seen by the
___ consult service and his sugars where monitored throughout
his hospital course. With the decreased prednisone prior to
discharge, the patient's evening Lantus dose was decreased to 65
units per night. He was instructed to continue monitoring his
blood sugars at home and to contact his PCP with any concerns or
noticeable changes in glucose control.
***. | SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE NUTRITIONAL AND METABOLIC 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.
***
Mrs. ___ is a ___ year old woman with history of colitis who
presented with worsening diarrhea and abdominal pain, found to
have mild sigmoid colitis.
ACTIVE DIAGNOSIS:
# Sigmoid Colitis: Mrs. ___ was admitted with severe diarrhea
and associated abdominal pain which has been chronic since the
___. An abdominal CT scan showed sigmoid colitis.
Stool studies were negative for C. diff, campylobacter, ova &
parasites, vibrio, yersinia, E.coli O157:H7, cryptosporidium,
and giardia. Stool cultures, including viral culture, were
negative. CMV antibodies were negative. HIV negative. TTG-IgA
negative. TSH normal at 1.1. Lactate 1.5. CBC, chemistries,
liver function tests, iron studies, and lipase were all within
normal limits, aside from a mild WBC elevation to 11,000 on
admission which quickly normalized with fluids. CRP and ESR were
both elevated at 5.5 and 48, respectively. Cathartic laxative
screen, blood cultures, and yersinia antibodies were pending at
the time of discharge. She was evaluated by the
gastroenterologists who performed a flexible sigmoidoscopy on
___. This showed mild sigmoid colitis and 1 polyp. It is
unusual for a patient of this age to have a polyp. The GI team
planned to do a colonoscopy on ___ to evaluate for other polyps
in the remainder of the colon, however anesthesia was
unavailable to do the case, so this procedure will be deferred
to the outpatient setting. The patient has a follow-up
appointment with ___ GI on ___ at which time scheduling of
the colonoscopy should take place. The patient was instructed to
take Immodium up to 8 times daily to control her symptoms. For
pain control, she received 5mg oxycodone while inpatient but was
instructed to try Tylenol alternating with ibuprofen at home.
The importance of hydration was reinforced. Empiric therapy for
colitis was not initiated given the mild degree of colitis on
flex sig.
CHRONIC, STABLE DIAGNOSIS:
# Anxiety: The patient was continued on PRN Ativan.
TRANSITIONAL ISSUES:
-Pt needs colonoscopy scheduled as outpatient to evaluate for
polyps
-Results pending at discharge:
Send Outs
___ ___ YERSINIA ENTERCOLITICA ANTIBODIES (IGG,IGA)
___ 20:18 CATHARTIC LAXATIVE SCREEN (stool)
Microbiology
___ 08:26 Immunology (CMV) CMV Viral Load
___ 21:14 STOOL VIRAL CULTURE
___ 20:42 BLOOD CULTURE Blood Culture, Routine
___ 07:04 BLOOD CULTURE Blood Culture, Routine
Diagnostic Reports
___ Tissue: LOWER GASTROINTESTINAL BIOPSY
***. | ESOPHAGITIS GASTROENTERISTIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is a ___ year old with a history of colon cancer,
duodenal cancer, breast cancer, DMII with chronic foot ulcers,
HTN, and chronic kidney disease, newly diagnosed with EIN who
underwent robotic-assisted total laparoscopic hysterectomy and
bilateral salpingo-oophorectomy on ___. Please refer to
Dr. ___ note for full details. Her post-operative
course was complicated by symptomatic anemia characterized by
fatigue, with a hematocrit nadir of 24.9 on post-operative day
1. She was transfused 2 units of packed red blood cells with
good effect. Her creatinine was stable at 1.8, her baseline,
and NSAIDs were held. She was seen by podiatry in house, who
she follows with as an outpatient, for chronic foot ulcers.
They recommended an interval foot xray as the lesion on her left
foot probes to the bone, but she declined this as an inpatient.
They made recommendations for home dressing changes and will see
her again as an outpatient weekly at ___.
Her home medications for hypertension and hyperthyroidism were
continued. Her blood glucose was reasonable and her home
insulin regimen was resumed when she was tolerating a regular
diet. By post-operative day 1, she was voiding, tolerating a
regular diet, pain controlled with oral medication, symptomatic
anemia improved, and she was ambulatory with a cane at her
baseline. She was discharged to home in good condition.
***. | UTERINE ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ elderly woman with dementia comes in after a fall found to
have left femoral neck fracture fracture and leukocytosis with
elevated lactate s/p hemiaropathy.
#Femoral neck fracture: as a result of fall. Pateint treated
with left hemiarthropathy on ___ and Enoxaparin Sodium for DVT
prophylaxis. With standing tyelenol and dilaudid for pain.
#Leukocytosis - On admission patient was found to have a
leukocytosis to 20.7 thought to likely be reactive after
fracture. There were no focal signs of infection on exam. CXR
only showed evidence of atelectasis. We were unable to obtain
urine sample secondary to pain related to fracture on admission
so patient was covered for UTI with CTX.
#fall- Patient presented s/p fall next to her bed. This was
presumed mechanical though cannot exclude orthostatic (as it was
early morning) and arrhythmia (no history of arrhythmia but has
audible AS and found to have afib on tele.
#Elevate Cr- Patient was found to have elevated Cr. on admission
likely secondary to dehydration as she had been down for an
hour, and had been NPO for 2 days prior to surgery. She was
treated with fluids. Cr on discharge was 0.7.
#Dementia- recent cognitive decline per daughters history. Has
been agitated and confused. Patient was recently admitted for
psychotropic optimization at ___. She was continued on
OLANZapine 5 mg PO DAILY TraZODone 50 mg PO/NG HS Escitalopram
Oxalate 20 mg PO/NG DAILY
#volume status- looks dry on admission, likely from no PO all
day, though has 2+ pitting edema b/l and CXR shows mild fluid
overload. Furosemide 20 mg PO/NG DAILY held in setting of ___.
- considering restarting furosemide in rehab
#Cardiac meds- hx of MR and AS with audible SEM. Found to have
afib on telemetry. CHADS2 score of 1 Rate controlled on home
meds. Metoprolol Tartrate 12.5 mg PO/NG BID. ASA 81 mg held for
surgery restarted on discharge
#Home meds. Carbamide Peroxide 6.5% 5 DROP AD BID for ear wax
and Multivitamins.
TRANSITIONAL ISSUES:
# Leukocytosis - please recheck in several days to ensure
downtrending (most recent 14.5)
# Acute kidney injury - patient with elevated creatinine on
admission, downtrended to baseline. Home furosemide 20mg was
held. Please restart furosemide 20mg QD and recheck creatinine,
potassium.
# Anemia - patient started on ferrous sulfate at time of
discharge due to iron-deficient anemia.
# Anticoagulation - patient currently on enoxaparin 30mg daily.
INR most recently 2.0. Please recheck INR on ___. If 2.0 or
greater please stop enoxaparin. If less than 2.0, continue
enoxaparin 30mg daily for total 14 day course (started ___
#Code during hospitalization - DNR/DNI
#Contact: Dtr ___ ___ HCP 1
son ___ ___ HCP 2
dtr ___
***. | 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.
***
___ is a ___ with a history of a R frontal AVM
coiled in ___, R frontal ischemic stroke in ___ and focal
motor seizures of the left leg>arm who was admitted for
continuous EEG monitoring while his phenytoin was weaned. During
days 1 and 2, his phenytoin dose was unchanged and he was
monitored on EEG to establish a baseline - there was no seizure
activity.
.
His lamotragine dose was increased from 250mg BID to ___ BID
because his pre-admission lamotragine level was subtherapeutic.
On day 3 his phenytoin dose was decreased to 200mg, on day 4 it
was decreased to 100mg, on day 5 it was decreased to 50mg and on
day 6 it was discontinued. While there were no patient had some
generalized spikes on EEG but was asymptomatic. For this reason,
his trileptal dose was slightly increased to 200mg BID from
150mg/200mg.
.
He didn't experience any motor or other clear seizure events. On
hospital day 3, he did experience an episode of strange
sensation in his left arm that he described as a feeling he gets
before a seizure, as well as a similar feeling in his leg that
was more mild and much more brief on day 7 of hospitalization.
.
TRANSITIONAL ISSUE
-No longer taking phenytoin
-Lamotragine dose increased to 300mg BID
-Trileptal increased to 200mg BID
-Follow up with you epilepsy doctor on ___ at 09:00AM
-Your epilepsy doctor should follow up on the results of your
Lamotragine level that was drawn on ___
***. | 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.
***
For much of her initial two weeks on the unit, the patient was
near catatonic: in bed, under the covers, avoiding all
interactions and barely moving. She ate very little and only
left her e=bed to use the bathroom. We used high dose Ativan, up
to 2 mg PO q4hours, to treat the catatonia, along with the
antipsychotic medication Risperdal. Over time and with many
attempts, we learned from the patient that she was mourning the
death of her boyfriend, who had expired in front of her in the
near past.
Eventually we were able to lower the Ativan as the patient
showed more initiation of movement. She became much more social,
avoiding groups but sitting with peers all day in the dayroom.
She began to eat full meals and stopped napping. Near the end of
her stay she expressed strong desire to return to her group
house. She saw it as her home and wanted to reunite with her
friends there. Her mood was brighter and she denied any suicidal
thights or feelings.
***. | 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.
***
___ F with nine day ___ course notable for findings
of PNA and PE, presenting with worsening hypoxia.
.
# Hypoxia - Patient with progressively worsening hypoxia, with
known PNA and pulmonary emboli on OSH imaging. It was felt that
the patient likely had an underlying infectious process driving
the gradual worsening of her medical condition, especially given
limited community acquired pneumonia treatment at outside
hospital. The pulmonary emboli was felt to possibly be
worsening, precipitating her decline although this was not able
to be confirmed given she was far too ill to travel for a CTA;
this was felt to be less likely in the setting of her
supratherapeutic INR, recent Lovenox administration, and her IVC
filter placement. The patient's ABG showed significant A-A
gradient, her PaO2/FiO2 was suggestive of ARDS as were her CXRs
on admission (bilateral fluffy infiltrates). The patient
developed worsening respiratory distress upon arrival (hypoxia,
shortness of breath, tachypnea) and was intubated/sedated
shortly after presentation. Her antibiotics were broadened to
Vancomycin and Meropenem and cultures drawn (blood, urine,
sputum). There was no growth to date by the time the patient
expired. She was maintained on ARDsnet Protocol but required
paralysis with cisatracurium for high plateau pressures,
dysyncrony with the vent, and high tidal volumes prior to
paralysis.
.
# Sepsis/multiorgan failure - The patient continued to
decompensate with rising lactate, LFTs, INR, creatinine. Her
blood pressures dipped into the systolic ___ and was gradually
broadened to Vasopressin, Levophed and Neosynephrine for
pressors. She was aggressively volume resuscitated and her
pressures were fluid responsive. She was also started on stress
dose steroids. Despite aggressive resuscitation measures,
however, her lactate, LFTs, INR and creatinine continued to
climb. In discussions with the family, she was made DNR/DNI and
ultimately comfort measures only. Pressor support was
discontinued and the patient passed away shortly thereafter,
with her husband, children and extended family at the bedside.
Because of her rapid decompensation, the family requested
autopsy to be performed.
.
# Tachycardia - The patient presented with tachycardia, HR110s
and initially in sinus rhythm. Thus, it was felt that she was
most likely septic and hypovolemic with low urine output and dry
mucus membranes. At the time, her creatinine was normal. The
patient received aggressive IVF rehydration (6 liters overnight)
but continued to be persistently tachycardic and eventually
transitioned in atrial fibrillation/flutter. The patient
received one bolus of amiodarone without improvement in her
heart rate, requiring uptitration of her neosynephrine, so
further amiodarone was discontinued.
.
# Supratherapeutic INR - INR >4 on admission, likely in setting
of poor coumadin processing in septic physiology, with
antibiotics. The patient was treated with Vitamin K. She
continued to develop worsening INR (up to 6) with worsening
liver function during this hospitalization.
.
# Elevated Troponin - Reportedly elevated troponin at OSH and
here as well. Initially troponing here was 0.16 with flat MB, no
chest pain, TWI on V1-3 on EKG. Gradually CK bumped but not the
MB or MBI. It was felt that the patient likely had some demand
ischemia. Her ECHO showed depressed ejection fraction of 30% but
without focal wall motion abnormality.
***. | SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ was transferred from ___ on ___ following
cardiac cath that revealed severe left main and three-vessel
coronary artery disease. Patient arrived at ___ with an IABP
and was placed in the CVICU for close monitoring while
undergoing surgical work-up. On ___ he was taken to the
operating room where he underwent a coronary artery bypass graft
x 5. Please see operative note for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. He was given 1 unit RBC post op night for
post op anemia and IABP was kept overnight. He was extubated and
breathing comfortably on POD 1 and weaned from all vasoactive
medications. IABP was removed POD 1 without complication.
The patient was neurologically intact and hemodynamically
stable. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. Beta blocker was
increased for better blood pressure and heart rate control.
The patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the Physical Therapy
service for assistance with strength and mobility. By the time
of discharge on POD 4 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged home with visiting nurse services in
good condition with appropriate follow up instructions. All
follow up appointments were arranged.
***. | CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr ___ was admitted postoperatively after his ileostomy
reversal to the transplant surgery service. Please see operative
note for full details. He received product in the operating room
and perioperatively for anemia and thrombocytopenia with
improvement in his labs. He initially did well postoperatively
but then had a complicated course. His course is summarized
below, by systems. Multiple consult services followed him during
his stay.
Neuro: Depending on his mental status and NPO status, he was
given either IV or PO pain medications to treat his pain. He did
have encephalopathy, as well and his mental status waxed and
waned. Postoperatively he had a soft palate laceration that ENT
followed him for.
Cardiovascular: He was initially stable but then went into afib
RVR. He was treated with multiple medications for this and was
mostly rate-controlled. He also required pressors that were
weaned and started as necessary.
Pulm: He was initially extubated postoperatively but with
increasing pulmonary edema and respiratory distress, he required
re-intubation. He then failed a trial of extubation and required
re-intubation. For treatment of ARDS, he was paralyzed. He also
had first a thoracentesis and later a chest tube placed for
treatment of pleural effusion.
GI: He had his NGT removed postop and was initially advanced,
gradually, to a diet, then required a Dobhoff for tube feedings.
He had cholecystitis, so his gallbladder was aspirated and then
he underwent perc chole tube placement. He received lactulose to
treat his encephalopathy. He had a VAC to his abdominal incision
that was changed approximately every three days. He also had
some incisional erythema, for which antibiotics were started and
a few staples were d/c'd. He required a paracentesis for volume,
as well, and required octreotide for a period of time.
ID: He was covered with broad spectrum antibiotics for empiric
PNA and cholecystitis treatment when his clinical picture
worsened and eventually was treated with daptomycin, cefepime,
flagyl, vancomycin, and fluconazole. His cultures grew
Bacteroides, VRE, and ___.
Renal: He was aggressively diuresed with lasix,to which he
initially responded and then stopped responding to. He was given
albumin as needed for intravascular volume depletion. His
electrolytes were monitored and treated as necessary.
Endocrine: His fingerstick blood glucose levels were followed
and treated as needed. He was given hydrocortisone for
refractory sepsis.
Heme: He was resuscicated and given mtuliple products throughout
his stay to manage his anemia, coagulopathy, and
thrombocytopenia. He was given vitamin K.
On ___, he had continued hypotension with high doses of
three pressors. His urine output dropped to minimal amounts. He
was in ARDS and acidotic. His health care proxy and son,
___, as well as his long-time friend, ___, were
notified and informed of his worsening clinical status. They,
along with other members of his family, came to the hospital and
a family meeting was held. They brought up him likely wanting to
be 'comfort measures only' and after a discussion with them and
the ICU attending and a verbal discussion with the surgical
attending as well, it was decided to make him CMO, as that is
what his family said he would have wanted at this point. He was
made CMO, though the ETT left in place due to him likely gasping
if that were removed, and he died shortly thereafter, within
approximately 15 minutes. He was pronounced dead at ___. His
family declined an autopsy and the medical examiner declined the
case.
***. | MINOR 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.
***
This is a ___ year-old female with a CAD s/p DES to middle RCA
and angioplasty of distal RCA, history of hypertension,
hyperlipidemia, DM type 2, diastolic heart failure, PVD s/p
bilateral L-AKA/R-BKA, COPD on 2L home 02, who presents with HA
and developed chest pain after he headache resolved.
.
#Chest Pain: Patient with known h/o of CAD, having CP that was
non exertional and sounded atypical. However as she has
significant risks including DM and previous MI ___ with
enzymes. On previous admission, it was noted that despite having
stents, the patient was not on Plavix ___ GI bleed this ___
and ongoing GAVE. EKG unchanged. Would have considered stress
test but positive stress in ___ without intentions for further
intervention so held off. Continued aspirin, ACE, BB, Statin,
monitored on tele.
.
# COPD exacerbation: Patient with severe obstructive disease on
most recent PFTs. Bicarb elevated chronically ___ C02 retention.
On home O2 2L, had increased it to 3L for subjective feeling of
dysnea. Some concern for COPD flare. Afebrile, cough not
productive of sputum, no leukocytosis. Short steroid burst 60mg
PO qday for 5 days, continued albuterol, advair and tiotropium
inhalers. Started albuterol/atrovent nebs and titrated 02 sat
>95%.
.
#. Chronic Diastolic Heart Failure: Patient with multiple recent
admission for chronic diastolic heart failure. EF 60%. No signs
of volume overload. Continued home dose of lasix, continued
cardiac meds.
.
# Diabetes Type 2, controlled with complication: last HGBA1C 6.5
on ___, insulin dependent, diabetes managed by daughter,
continued home ___, started HISS, continued asa, statin,
aceI and diabetic diet.
.
#Anemia: Hct 27, baseline 30, hemodynamically stable, no active
signs of bleeding, likely ___ to GAVE, continued home PPI,
continued home iron, trended hct
.
# GAVE: Treated in past with argon plasma coagulation (APC).
Hematocrit down slightly. Continued home BID PPI, trended hct,
should f/u as outpatient.
.
# Obstructive Sleep Apnea: She was continued on her home CPAP
machine.
.
# General Care: given 1L NS, repleted lytes prn, diabetic diet,
PPX: PPI, heparin SQ, bowel regimen, ACCESS: PIV, CODE: Full,
CONTACT: daughter ___ ___, ___ when clinically
stable.
***. | 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.
***
___ male with a history of celiac disease, a remote
diagnosis of peptic ulcer disease at age of ___ years which was
thought to be secondary to nonsteroidal anti-inflammatory drug
use, and alcohol induced pancreatitis (remote) who presented to
___ with hematemesis.
During the patient's hospitalization at ___, he was made NPO
and started on a proton pump inhibitor drip. His hematocrit was
trended. During his hospitalization he had no pain, no nausea,
and no vomiting. GI was consult and they recommended upper G.I.
endoscopy. The patient tolerated the procedure well, and during
the procedure there was a non-bleeding ulcer, which was found
but not interveined upon.
GI found and recommended:
Impression:
Blood in the stomach body
Ulcer in the anterior bulb
Congestion and erythema in the duodenal bulb compatible with
duodenitis
Erythema in the antrum and stomach body (biopsy)
Otherwise normal EGD to third part of the duodenum."
Recommendations:
Await pathology results
Treat H. pylori if positive
Omeprazole 40mg BID
The ulcer in the duodenum is the source of his GI bleeding.
Given its endoscopic appearance it is overall a low risk to
re-bleed and should be treated medically.
No NSAIDs
Repeat EGD in 8 weeks to asses healing given family history of
GI cancer and prior ulcer disease. If H. pylori negative will
need work-up for recurring ulcerations.
F/u can be with outpatient GI MD or with Dr. ___
(___).
Following the procedure, the patient return to the floor and his
repeat hematocrit was stable. In addition his vital signs were
stable. He had no pain or hematemesis. His diet was advanced to
regular (celiac free) and he was started on an oral proton pump
inhibitor. He was subsequently discharged.
***. | G.I. HEMORRHAGE WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is an ___ c/ PMHx of stroke, A. fib, CAD S/P CABG,
HTN, prostate cancer, newly diagnosed pancreatic cancer S/P ERCP
+ stent who presented to ___ with presyncope, found to have a
GIB at the site of his sphincterotomy; now S/P ERCP with
epinephrine injection.
ACTIVE ISSUES
# GIB: patient presented with pre syncopal episode. His symptoms
were secondary to hypovolemia due to GI bleed, thought to be due
to post-sphincterotomy bleed. Lovenox was held, the patient
received 2 u pRBC to and the ERCP team consulted. At that time,
they recommended close monitoring of H/H and if worsened, would
require endoscopic intervention (at this time HCT was 26). After
receiving the 2 units of pRBCs, his HCT continued to trend down
to a nadir of 20.3 and he had two large melanotic BMs, at which
point the ERCP team brought him for endoscopy, where the source
of bleeding at the sphincterotomy was identified and hemostasis
achieved.
After ERCP, he was given 1 additional unit of blood and has
since remained hemodynamically stable, no longer had any
melanotic stools, without any physical or laboratory signs of
blood loss.
# Anemia: see above
# Hypercoagulabilty: Lovenox was stopped upon arrival due to
GIB. The patient is at high risk for clots, given intermittent
A. fib and pancreatic cancer, however, with recent GIB, he is
also high risk for bleeding. Lovenox was held during the
hospitalization, but the patient is discharged with instructions
to resume Lovenox anticoagulation at home, 5 days post-ERCP.
# Pancreatic cancer: S/P ERCP with metal stent placement.
Cytology brushing came back as atypical. Sent for CT chest with
contrast for staging purposes that revealed a thorax without any
evidence of metastases. Will meet with ___ oncology/surgery team
on ___.
# Sinus bradycardia: the patient has been in NSR or sinus
bradycardia during this hospitalization. His HR had fallen to
the high 30's (sinus bradycardia) overnight but he remained
asymptomatic.
CHRONIC ISSUES
#Hypertension: holding beta-blockers due to bradycardia
#Chronic lipoma: stable
#Anxiety associated with depression: not currently on medication
#Prostate cancer: noted
#Hyperlipidemia: not currently on medication due to liver damage
#Gout: stable
#CAD--silent MI s/p CABG ___
TRANSITIONAL ISSUES
[ ] Multidisciplinary pancreatic cancer meeting on ___
[ ] Restart beta-blocker if HR permits
***. | COMPLICATIONS OF TREATMENT WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ y.o woman with h.o MS, asthma, chronic pain who presents with
SOB/cough/ fever s/p fall.
.
# Atypical vs CAP: She presented with dyspnea on ___. CT and
CXR of lung showed opacification of the left lung (effusion
vs.collapse), and right lung with patchy airspace opacity. CT
findings of ground glass opacities in both lungs suggested
atypical pneumonia. On ___, she was started on
Methylprednisolone 60 Q 8 and given lasix 20 IV x 1. Pt
continued to have worsening dyspnea and was intubated on ___
until ___. Pt's abx was broadened to Zosyn for 5 days and
after extubation, she was placed on Levaquin again by ICU to
finish a 7 day course of abx. ON floor, pt continued to have
productive cough but oxygen requirement is stable at 0 liters
and has remained afebrile. Pt finished levaquin on ___. For
ongoing cough, pt is on frequent nebs, guaifenisen, prn
suctioning and also ordered for chest ___.
.
# S/P Fall: She had a fall with no available history for
pre/post symptoms to suggest syncope from vasovagal,
orthostatic, or cardiac cause. Pt remembers the fall and she
denies pre-syncopal/syncopal sx. She thinks she tripped. She has
an L eyelid superficial lac which was steri-stripped in ICU. CT
head and C spine are negative.
# Altered Mental Status: Pt appeared delerious upon admission.
It was believe that the pt was AOx3 at baseline, however had
been noted to be suffering from hallicinations/paranoia prior to
admission. DDx included infection, narcotic intake (although tox
negative), toxic metabolic. Pt is s/p fall but CT head/neck
negative for acute process. Following extubation on ___, the
patient's mental status cleared and she was subsequently AOx3 on
the morning of ___ and has continued to remain oriented and
calm on floor.
.
# advanced MS ___ sclerosis). Neurology was consulted for
help on medical management, they recommended continuing all her
MS meds but they were inaccurately dosed in ICU. Home meds
reconciled with husband on ___ and except for soma, pt is on
all of her MS meds again as of ___.
# Chronic Pain: Per husband, pt is on oxycontin 40mg bID. Pt
continued on Oxycontin 20mg BID here with prn oxycodone and
appeared to be doing well.
# Diarrhea - in ICU. Stool studies sent when came to floor.
Cdiff X 1 neg. Cdiff X 2 pending. Stool cx ordered. She was
started on flagyl for 14 days for high clinical suspecion.
.
.
.
total discharge time 36 minutes.
***. | RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
# Rhythm: Patient has history of paroxysmal atrial fibrillation
and flutter, s/p ablation in ___. She has been on Flecanide
for 9 months with continuing episodes of AFib/Flutter. She's
also on a low dose BB at home as patient can become bradycardic
with higher doses. Given the continued a-fib/flutter on
flecainide, the patient was switched dofetilide on ___. She
was monitored for 6 doses and did well here. There was no QRS
prolongation. She was continued on her home coumadin dose.
Upon discharge, she was hemodynamically stable and asymptomatic.
She was discharged on dofetilide 500mg PO BID.
# Coronaries: No history of CAD. In ___ had nuclear stress
with no perfusion defects. She was continued on aspirin 81mg
daily and denied any chest-pain while in the hospital.
# Pump: ECHO in ___ showed preserved systolic function. On
admission, patient found to be dry on exam. BP lower than
baseline. Metoprolol was initially held and patient was given
1L NS bolus with good response in BP. Once BP was normalized,
home metoprolol was resumed. Patient remained hemodynamically
stable throughout the rest of her hospitalization.
# HTN: Continued patient on home metoprolol
# Depression: Continued on home fluoxetene
# DM II: Held metformin and placed patient on HISS. Sugars
well-controlled. Metformin was resumed on discharge.
# FEN: Cardiac/DM diet
# PROPHYLAXIS:
-DVT ppx with Coumadin
***. | CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient presented to ___ on ___ and underwent
minimally-invasive esophagectomy performed by Dr. ___
Dr. ___. The patient tolerated the procedure well and
was subsequently extubated and brought to the SICU for
postoperative management, admitted under the ___ General
Surgery Service. He was transferred to the floor on POD1.
Neuro: Postoperatively, pain was well-controlled with IV
morphine PCA.
CV: Vital signs were routinely monitored and the patient
remained hemodynamically stable.
Pulm: Postoperatively, the patient initially reported chest
discomfort with deep inspiration. He was instructed on PCA use
as well as incentive spirometry, and comfort with respiration
improved by POD1-2. Chest tube, placed intraoperatively, was put
to water seal on POD2, with the thoracic team in agreement and
removed prior to discharge.
GI: NG tube was placed perioperatively and pt was initailly NPO.
Electrolytes were monitored and repleted as necessary. The
patient was seen by the Nutrition team and tube feedings were
started on POD2 via the J-tube. A regular PO diet was resumed by
discharge and patient will go home Isosource TFs at goal 60
ml/hr from 20:00 - 08:00. His PO intake will be assessed on
follow-up appointment.
GU: Foley catheter was placed perioperatively. It was removed on
POD2 and patient subsequently voiding spontaneously.
ID: The patient received two doses of Ancef perioperatively.
Endo: Blood sugars were satisfactorily controlled with sliding
scale insulin.
PPX: The patient received subq heparin and wore SCDs.
***. | STOMACH ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with PMH of diverticulosis, HTN, diabetes, hyperlipidemia,
and arthritis presenting with LLQ pain, found to have acute
diverticulitis.
1. Acute diverticulitis: Patient was initially treated with IV
Ciprofloxacin 500mg BID and IV Flagyl 500mg q8 hours. Her pain
and nausea resolved, and the following day she was able to
tolerate a clear liquid diet, which was advanced to full liquids
that evening. Given her prior severe nausea and vomiting with
oral Cipro and Flagyl she was transitioned to oral Augmentin on
the evening of ___ for an anticipated 7 day course. Given
the findings on her CT scan this admission it was recommended by
radiology that she have a repeat abdominal CT once her acute
symptoms have resolved to ensure no mass is present.
2. Diabetes II, controlled, without complications: Patient's
oral medications were held during this admission and re-started
at discharge. She received contrast on ___, and so was
instructed to re-start her Metformin on ___.
3. Hypertension: Patient was continued on her home regimen of
Norvasc and Cozaar.
***. | ESOPHAGITIS GASTROENTERISTIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year old woman with severe sarcoidosis on home O2 (___),
DVT/PE (not anticoagulated), COPD, here with dyspnea and chest
pain.
#Dyspnea:
##Pulmonary HTN
##Sarcoidosis
##Pulmonary edema
A right heart cath was performed after TTE revealed elevated PA
pressures. Right heart pressures were elevated with severe
pulmonary hypertension demonstrated, likely secondary to
pulmonary sarcoidosis, but also with elevated wedge pressures.
Sildenafil and diuretics were initiated with good improvement in
dyspnea. Also s/p 7 day levofloxacin course. Started on
Colchicine for chest pain of possible pericardial source.
Rheumatology was consulted who recommended stopping
methotrexate. She will need concurrent treatment of latent hep
B with lamivudine if starting Embrel. She will follow up with
Dr. ___ ongoing management. Dr. ___
prior authorization for sildenafil, which she will continue to
take as an outpatient.
TRANSITIONAL ISSUES:
- QWK MTX held in house, per Rheum recs. F/U with Dr. ___
___: ? anti-TNF therapy
- Consider hepatology f/u if pursuing anti-TNF therapy for HBV
treatment
***. | INTERSTITIAL LUNG DISEASE WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ was transferred to the inpatient colorectal surgery
service after a brief stay in the PACU. On ___ he restarted
home trazodone, melatonin, and Seroquel. An NGT was in place and
he was NPO and hydrated intravenously. On ___ NGT removed
at bedside, and he was advanced to sips of liquids and he then
tolerated clears. ___ he had bowel function and was
tolerating a regular diet, pain medications by mouth. He was
having loose stool. We continued to observe him given his
history of dementia. ___ He continued to do well and
tolerated a regular diet. He was requiring narcotics for pain
and this was not compatible with his home facility so
rehabilitation stay was needed. On ___ we removed the JP
drain. We continued to monitor how many bowel movements he was
having daily given his cognition. On ___ he was having a
reasonable number of bowel movements and he was meeting
discharge criteria and discharged to rehab. I attempted to reach
his HCP who is his brother however, I could not reach him on the
phone. The case manager had contacted him earlier in the day.
***. | 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.
***
Patient admitted with intermittent abdominal pain, chills. Ct
scan and ultrasound done. Positive blood cultures, antibiotics
started. Patient underwent ERCP with successful extraction of 2
stones. He feels well today, tolerating a regular diet. We will
discharge to home with oral cipro for 2 weeks with instructions
to return immediately for fever, abd. pain and any other
concerning symptoms. We have obtained blood cultures today to
confirm resolution of his bacteremia and he will follow up with
Dr. ___ in 2 weeks.
***. | 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.
***
Mr. ___ presented as a transfer from ___ to
___ on ___ after a routine EGD showed an obstructing
pyloric ulcer. Patient denied having any symptoms related to
these findings aside from weight loss and occasional nausea and
vomiting after eat. He was initially kept NPO. KUB was obtained
on ___ that showed no evidence of obstruction. Diet was
advanced as tolerated to regular which patient tolerated well.
GI was consulted and recommended continued Protonix twice daily
and follow-up EGD in ___ weeks.
The outside hospital was contacted and it was found out that
pathology from EGD biopsy should result on ___. Patient will
follow up in clinic with Dr. ___ to discuss surgical planning
after he has obtained pathology results.
He was discharged home on ___. At the time of discharge he
was ambulating independently, tolerating a regular diet, and
voiding spontaneously.
***. | COMPLICATED PEPTIC ULCER 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 a hx of HTN, HLD, PAD, GERD, asthma, and kidney
stones who presents from OSH with STEMI s/p PCI to RCA.
#STEMI
Pt presented to OSH with STEMI with TroponinI initially at 0.02.
He was transferred to ___ for intervention. Cardiac
catheritization was performed on ___ with ___ 1 deployed
to RCA. Troponins remained negative after the procedure with
improvement of STE s/p cath on his serial EKGs. The thought for
the negative troponins was that the thrombus was transiently
occluding the vessel, leading to transmural infarction and STE.
TTE on ___ demonstrated preserved EF of 60% with no wall
motion abnormalities noted. Pt remained chest pain free s/p
revascularization. He will be started on ASA and Plavix,
uptitrtated to atorvastatin 80, and started on Coreg 6.25 BID.
#HTN
Pt with a hx of HTN. Pt presented to floor with SBPs in
140-160s. We started him on Coreg 3.125 BID to control his BP
and for his CAD and uptitrated to 6.25 BID in addition to his
home doses of amlodipine and lisinopril. Pt's BP improved to
SBPs 120-140s. We decided to d/c his HCTZ in favor of
uptitrating Coreg as tolerated for cardioprotection.
#GERD
Pt with a hx of GERD. Given the potential CYP interaction
between omeprazole and Plavix, we changed his omeprazole to
pantoprazole.
Transitional Issues:
- will need an obstructive sleep apnea study since he
desaturated to the ___ while asleep inpatient
- consider uptitration of carvedilol for better blood pressure
and heart rate control
***. | 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.
***
Mr. ___ was admitted to the inpatient colorectal surgery
service after laparoscopic colectomy. On ___ sips advanced
to clears. The Foley catheter was removed and the patient
voided. His hematocrit was noted to drop from 41 to 28. On
___ hematocrit was 25.7 he was monitored closely. He passed
flatus and was advanced to a reg diet in the afternoon. He was
discharged home with follow-up on ___.
***. | 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.
***
*Rehab stay anticipated to be less than 30 days.*
.
#Urinary tract infection: The patient's urinary tract infection
can be classified as complicated given that the patient is male
with urethral stricture. Given the patient's history of MRSA
and E. coli UTIs, he was initiated on broad spectrum antibiotics
with vancomycin and ceftriaxone. Patient's urine culture grew
out E. coli sensitive to cefazolin. His antibiotic coverage was
narrowed to oral cephalexin 500mg every 6 hours, which he will
be continued until ___.
.
#Urethral strictures: Patient underwent flex cystoscopy with
urethral dialtion and catheter dilation in the emergency
department by urology. Received ancef during the procedure.
Urology recommendations were followed through the admission. The
patient is to keep his current catheter in place until ___.
Per urology, the patient is to report to the operativing room on
___ for his previously scheduled procedure with Dr. ___.
.
#Left Hip Pain: On presentation to the medicine floor, the
patient complained of left hip pain. He sustained a fall, unsure
where. His exam was notable for ecchymoses on his buttocks, and
he had full ROM in the hip joint. His pain was managed with
acetaminophen.
.
#Type 2 Diabetes Mellitus: Patient had a HgbA1c drawn in ___,
which was 6.7. Per OMR, the patient was not on any home meds for
diabetes. He was placed on an insulin sliding scale, and
fingerstick glucoses were monitored through the admission. The
patient's blood glucose ranged was within normal limits during
his hospitalization. His home aspirin dose of 81mg was continued
through the admission.
.
#Hypertension: No record of home medications in chart. Blood
pressure was monitored through the admission; his highest
systolic blood pressure was 130.
.
#Depression: The patient's home Sertraline was continued through
the admission.
.
#Glaucoma: Patient with a known history of open angle glaucoma.
His home eye-drops were continued through the admission.
.
#Transition of care:
-Continuation of antibiotic until ___.
-Follow-up of pending blood cultures.
-Follow-up with primary care physician regarding diabetes and
hypertension.
-Continuation of bladder catheter until ___ per Urology
recommendations. On ___, the patient's catheter will need to
be taken out. If there are any problems or concerns, the
facility should call the Urology at ___ (___)
-Patient to return to ___ on ___
having eating nothing after midnight (except for pills with
water) for his previously scheduled Urological procedure with
Dr. ___.
***. | KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ was transferred from the PACU to the VICU in stable
condition following her LLE bypass operation. She tolerated the
procedure well. For details, please see operative report.
Following her procedure, she remained on bedrest until the next
day. She started a regular diet on POD #1, and her pain was
well controlled. Her home medications were restarted. It was
noted that her blood pressure was running low (systolic ___ to
___, and she was given fluid and her blood pressure medications
were all discontinued. On POD#2, it was noted that her HCT was
low and she was transfused 2 units of blood, and her follow up
hematocrit was stable. Her foley was discontinued and she
voided without difficulty. She worked with ___, and was able to
get out of bed to chair. She was started on coumadin 8mg. The
next day, Ms. ___ was able to ambulate with her prosthesis on
her RLE. She was very eager to go home, although with an INR of
1.3 we notified her that she was not yet therapeutic (desired
range is ___. We desired to keep her on her Heparin gtt, and
explained to her that coming off the Heparin before her INR was
therapeutic would increase her risk for bypass failure.
Furthermore, we explained to her at length that in her case,
bypass failure could result in loss of limb. We, the Vascular
Surgery team reiterated this to her multiple times, and she
stated that she was in clear understanding, but desired to be
discharged immediately nonetheless because she wanted to go home
and felt fine. She stated clearly that she would follow up with
Dr. ___ to manage her INR as an outpatient. A follow-up
appointment was arranged for her with Dr. ___ on ___ at
1:15pm and she agreed to attend.
***. | OTHER VASCULAR PROCEDURES WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ yo female with PMHx of nonischemic dilated cardiomyopathy (EF
40%) s/p ICD, hx of AF, HTN, hx TIA vs atypical seizure, hx of
DVT on Coumadin, depression, who was at ___ for
depression, transferred to ___ on ___ for
unresponsive/blank stare found to have possible low output
aortic
stenosis, transferred to ___ for consideration of AVR.
ACUTE ISSUES:
============
# Aortic Stenosis
Concern for symptomatic, low-output aortic stenosis contributing
to her repeated episodes of unresponsiveness, blank stares. TTE
was performed at ___, which showed a valve area of 0.7
cm2 but a mean gradient of 21 mmHg and peak velocity of 3.02
m/s.
Patient transferred from ___ to initiate AVR workup.
Reassuringly, she
has not had any other symptoms of aortic stenosis (no exertional
dyspnea or angina). Dobutamine stress echo was done on ___,
concerning for severe
AS, with increase in gradient w/ progressive dobutamine dose and
blunted HR response. She ultimately had a cardiac
catheterization on ___, which revealed no significant CAD, and
she subsequently underwent continued AVR workup. The cardiac
surgery team felt that she was low-intermediate risk or surgical
AVR, and both the patient and her daughter expressed a desire to
pursue this surgery. Surgery took place on ___, ####
# ?Syncope vs presyncope, repeated episodes of unresponsiveness
Very possible that her episodes may be related to seizures or
pre-syncope as opposed to her AS, given her lack of classic AS
sxs, and the fact that her episodes predate her AS by several
years (reportedly occurring as early as ___. Patient is
followed by neurology as an outpatient. Had EEG in ___
which
was normal. Had CTA head/neck w/o significant atherosclerotic
disease and carotid U/S in ___ with less than 19% stenosis
of ICA. Has never had MRI before, patient and family unsure if
ICD is MRI-compatible. Neurology was consulted, and felt that
there was no role for an EEG inpatient; they specifically felt
TIAs and seizures were unlikely. RPR was negative. The patient
should have neurocognitive testing as outpatient, as well as
continued neurology follow-up. At some point, she should likely
get an MRI as well, as her symptoms and overall decline seem
most consistent with vascular dementia.
# Suspected neurocognitive disorder
# Depression
# Recent SI
Pt presented to ___ on ___ with suicidal ideations, due
to feeling
overwhelmed with her sister's visit and strong personality, as
well as feeling severely depressed regarding her progressive
dementia.
She was transferred to ___, and was
inpatient there
from ___, discharged when she re-presented to ___
after a blank stare/unresponsive episode. Psychiatry saw patient
on ___, felt that
she has not exhibited any unsafe behaviors, and does not meet
section 12a criteria. She was continued on venlafaxine 37.5mg,
which had been started at ___. Her home gabapentin 600mg
BID was also continued. Per ___, she was formally
discharged from facility, and did not need to return there on
discharge. She has outpatient geriatric Psych follow-up through
___, arranged by her daughter, ___.
# Agitation
# Delirium
Patient was agitated and delirious overnight on ___, after
receiving
midazolam and Fentanyl during her cardiac catheterization. This
ultimately resolved after getting 5mg Haldol. Agitation did not
recur in the absence of inciting medications.
CHRONIC ISSUES:
==============
# Chronic systolic heart failure
Per records, the patient has non-ischemic dilated
cardiomyopathy. Appeared
euvolemic on exam throughout admission. Her home medications
(Lasix, metoprolol, losartan) were continued. She has an ICD in
place for primary prevention/history of VT.
# Afib
CHADS-Vasc of 4 vs 6 (dependent on TIA hx). Warfarin held for
possible cardiac cath (if needed for AS workup), last dose ___.
Patient was given 1.25mg vitamin K on ___ at ___, and
then transitioned to Lovenox for anticoagulation at ___. Her
home metoprolol was continued for rate control.
# HTN
On losartan 25mg at home, was lowered to 12.5mg given soft BP at
___ continued at reduced dose of 12.5mg.
# HLD
-continued home simvastatin 40mg
# Restless Leg Syndrome
-continued ropinirole
TRANSITIONAL ISSUES:
==================
[ ] Will need ongoing outpatient psychiatric follow-up;
currently arranged at ___ Adult Day Health
[ ] Dose of losartan was decreased from 25 to 12.5mg over course
of hospitalization
[ ] Should have follow-up with cardiology/electrophysiology
regarding need to change ICD batteries
#CODE: Full Presumed
#CONTACT:Name of health care proxy: ___
Relationship: daughter
Phone number: ___
Cell phone: ___
Cardiac Surgery Post-op Course
The patient was brought to the Operating Room on ___ where
she underwent tissue AVR. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring.
POD 1 found the patient extubated,and breathing comfortably.
The patient was neurologically intact but confused. She had low
cardiac output and required milrinone and pressor therapy. The
milrinone was weaned off over 72hrs, she continued to required
neo gtt for post-op hypotension. She was in chronic afib and was
started on coumadin. Beta blocker low dose was initiated once
stabilized off pressors POD5. She was diuresed aggressively
initially toward the preoperative weight, diureses was adjusted
as she developed mild ___ that has since resolved. Patient
remained in the unit for several more days due to delirium and
agitation. Patient has an know history to dementia and pre-op
was at ___ for significant depression and suicide
ideation. The Geriatric service was consulted to help assist
with her dementia and delirium flair-ups. She was eventually
transitioned to Seroquel from trazadone at hs and was resumed on
her preop dose of venlafaxine and requip low dose for restless
leg history. Her gabapentin was discontinued. As her
delirium/agitated state improved , patient transferred to the
telemetry floor for further recovery on POD10. Chest tubes and
pacing wires were discontinued without complication. The
patient was evaluated by the Physical Therapy service for
assistance with strength and mobility. In light of patient
psychiatric and dementia history she had a prolonged stepdown
stay due to difficulty finding appropriate rehab facility. She
was switched from Coumadin due to neuro status and concern
regarding ability to take consistently to DOAC. After one dose
of Xarelto with INR 2.8, INR had increased to 10.6. Patient was
placed on bedrest, given Vitamin K and Xarelto was held until
INR ~2. Xarelto was resumed at this time for atrial
fibrillation. By the time of discharge on POD 23 the patient was
ambulating with assist, her wound was healing and pain was
controlled with Tylenol. She will need to follow up in the
___ clinic and her outpatient psychiatrist, in order to be
followed closely to assist with her recovery at rehab and post
rehab plan.
On POD 23, she was discharged to ___ and Rehab
in good condition with appropriate follow up instructions.
***. | CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with a remote hx of breast cancer s/p lobectomy and chronic
weight loss now admitted for dyspnea and hypoxia s/p intubation
with difficulty weaning from the ventilator.
.
# Respiratory Failure: Multifactorial, in the setting of mucus
plugging, left lower lobe pneumonia, and muscle weakness
(nutritional and neurologic). The patient completed a course of
vancomycin/zosyn for healthcare associated pneumonia, and
remains afebrile without leukocytosis. She was extubated on
___, but was reintubated on ___ for respiratory distress
and was unable to be re-extubated after that. Her negative
inspiratory forces have been very low, suggesting respiratory
muscle weakness. A CT and MRI of the ___ were both done,
which revealed degenerative changes, but did not reveal any
evidence of fracture, misalignment, or nerve impingement.
Neurology was consulted and an EMG was suggestive of a
polyradiculopathy, demyelinating disorder, or paraneoplastic
syndrome. Numerous laboratory tests were sent to test for this
(GM1, ASAILO-GM-1, GD1B, GQ1B IgG Ab), which are still pending.
She underwent a tracheostomy and peg tube placement on ___.
She has occasional brief episodes of desaturation which improve
with suctioning and are believed to be secondary to mucus
plugging. She has been receiving albuterol and ipratropium nebs
prn. Current ventilator settings are: CMV with a TV 320, RR 12,
PEEP 10, FiO2 50%. She should be seen in the ___
clinic at ___ on the ___ ___ Building, ___ floor)
on ___ at 9:00am. Should there be any difficulty
in getting the patient to this appointment, please call Dr
___ office at ___.
.
# Cachexia/Weight loss: Per the daughter, and in reviewing the
patient's recent primary care notes, the patient's weight loss
has been an ongoing issue for at least the past six months, and
is believed to be related to her depression. No other organic
cause has been found. TSH was mildly elevated, but Free T4 was
normal. Cortisol is also normal. Her albumin is low and
pre-albumin is pending. We started her on tube feeds via an NG
tube and then continued them via the PEG. We also started
fluoxetine for her depression.
.
# LUE DVT: Ultrasound revealed an occlusive thrombus of the left
cephalic vein, with a non-occlusive thrombus of the left
subclavian and left basilic veins, associated with the PICC. The
PICC was pulled and the patient was continued on prophylactic
subcutaneous heparin.
.
# UTI: The patient was found to have a Citrobacter UTI which was
treated with a course of ceftriaxone. Repeat urine culture was
negative.
.
# Anemia: HCT stable in the upper ___ to low ___. Normocytic.
Stool guiac negative and no active bleeding.
.
# Osteoporosis: Could restart her home vitamin D and consider
starting calcium supplementation.
.
# Depression: Per the family, patient very depressed prior to
admission, which has likely contributed to her poor ___ intake
and weight loss. Currently on fluoxetine 10mg ___ (started
___. Will need to reassess after ___ weeks and consider
increasing dose to 20mg ___.
.
# Breast Cancer: Not currently active.
.
# Sacral Decub stage 2: Continue wound care; barrier creams.
Pain control with morphine sulfate 15mg q4h prn.
.
# Code Status: Full Code. Confirmed with the patient and her
daughter ___.
.
# Contacts: ___ (daughter): ___ (h),
___ (c), ___ (w).
***. | TRACHEOSTOMY WITH MV >96 HOURS OR PDX EXCEPT FACE MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURE |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Pt is a ___ w/pmhx significant for asthma exacerbation who
presented for shortness of breath, coughing and wheezing.
#ASTHMA:
On arrival to the ED, Ms. ___ was in moderate respiratory
distress where she received nebulizers and PO steroids. She
arrived to the inpatient service stable and remained clinically
stable. She continued to receive oral steroids and used
scheduled and as needed nebulizer treatments liberally at first,
but tapered use after the first night. Over the next two nights
she improved greatly and was back to her baseline. Ms. ___ was
subsequently discharged on a new medication, Singulair 10mg once
daily as well as a total 14d course of prednisone. She had
persistent upper abd pain believed to be musculoskeletal pain
related to her coughing spells, she was treated with benzonatate
and tylenol.
#GERD
Ms. ___ experienced significant reflux starting the second day
of her admission. While on her home meds 20mg omeprazole bid and
ranitidine 300mg daily she still experienced painful reflux on
multiple occasions which required PRN Maalox w/Lidocaine swish
and swallow. The analgesic effect was appropriate, however she
still had complaints regarding upper abd pain believed to be
related to MSK pain given significant worsening with coughing
spells and pain with ambulation. She was treated as above for
this.
#HYPERTENSION
It was noted on admission as well as throughout Ms. ___ time
on the wards that she was persistently 150 SBP with SBP max of
170. While on steroids during the admission she may, as an
outpatient, meet criteria for hypertension. Consider serial BPs
as outpatient.
TRANSITIONAL ISSUES:
1. Asthma Control-
Discharged on prednisone taper. Has close PCP ___ and ___
need discussion about compliance and taper effect. D/c on
singulair and prednisone taper ___: 40mg daily ___
20mg daily ___ 10mg daily)
2. GERD-
Significant reflux on admission despite dual therapy. Consider
re-education on proper medication regimen as she was not taking
PPI/H2 blkr at least 30min to 1 hr prior to mealtimes.
Re-education on positional aspects of mealtime and before
bedtime. She required maalox and lidocaine during her admission
for persistent GERD sx's in the face of H2 and PPI tx. Pt was
discharged with maalox given her persistent symptoms on ppi and
H2 blocker.
3. Hypertension-
It was noted on admission as well as throughout Ms. ___ time
on the wards that she was persistently 150 SBP with SBP max of
170. While on steroids during the admission she may, as an
outpatient, meet criteria for hypertension. We did not want to
use beta blockers while inpatient for asthma exacerbation. At no
point did she experience a hypertensive emergency. Consider
serial BPs as outpatient.
-Steroid taper ___: 40mg daily ___ 20mg daily
___ 10mg daily)
-Peak flow on discharge 240
-Patient started on singulair during this hospitalization
-Consider stress test
***. | CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
# NEURO: ___ was transferred from ___ with
symptoms of worsening dysarthria and a new pontine stroke
demonstrated on MRI. His symptoms were at first attributed to
hypoperfusion due to hypotension in the setting of known basilar
artery thrombus, but upon review of records from his
hospitalization prior to transfer there was no recorded
hypotension. Despite maintaining permissive hypertension during
the current admission he had the subsequent expansion of his
infarct, demonstrated on repeat MRI. He was thus started on
heparin gtt as bridge to coumadin. He will need to remain on
coumadin until his outpatient Vascular Neurology followup. His
risk factors were again measured and his LDL was 25 and A1c was
5.7%. He failed his swallow study due to severe dysphagia so a
PEG tube was placed. He was evaluated by ___ and OT who
recommended acute rehab to address his right sided weakness and
ataxia as well as his severe dysarthria. On ___ he started
Coumadin, but will be discharged to rehab on heparin drip (goal
PTT 50-70, no boluses) until INR therapeutic. His home Aspirin
325mg daily was stopped in hospital due to alternate use of
anticoagulation; will consider restarting at outpatient
neurology follow-up.
# CARDIOVASC: Permissive hypertension was maintained for
majority of hospitalization, then home meds (lisinopril and
atenolol) were restarted. On discharge he was still
intermittently hypertensive to SBP 150s-180s. Thus, increased
atenolol from 25mg daily to 50mg daily (home dose) on day of
discharge. Will need BP monitoring at rehab to aim for final
goal SBP 130-140.
# PSYCH: Patient was intermittently tearful and depressed during
hospitalization, with a pseudobulbar affect at time. This may
have been some degree of post-stroke depression but also suspect
symptoms are pseudobulbar secondary to involvement of mibrain
and pons in stroke. Started fluoxetine 10mg daily during
hospitalization.
# RHEUM: He developed swelling over his left elbow concerning
for olecranon bursitis. He was evaluated by rheumatology who
performed a joint aspiration which confirmed bursitis. This was
managed with supportive care.
-----------------
TRANSITIONS OF CARE:
- Needs daily INR monitoring while uptitrating Coumadin
- Goal SBP 130-140, may need antihypertensives uptitrated,
increased Lisinopril from 20mg daily to 30mg daily on discharge
(___)
====================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented (required for all patients)? (x) Yes (LDL =
25) - () No
5. Intensive statin therapy administered? () Yes - (x) No [if
LDL >= 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - (x) No [if no,
reason: (x) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (x) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? () Yes [Type: ()
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - () 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.
***
The patient was admitted for EP study and VT mapping following a
recent event in which his device fired and he was admitted to
___ in ___ for acute on chronic heart failure.
He also had recurrent runs of asymptomatic VT. During the
mapping portion of the procedure he experienced spontaneous VT
of two different morphologies. He acutely desaturated and
responded to recruitment maneuvers. His blood pressure fell and
he required four pressures during the procedure (dopamine,
phenylephrine, norephinephrine, epinephrine). The area of VT
was mapped and an ablation performed. The patient again
desaturated to the high 70's and recruitment maneuvers were
performed. LAP measured at 60 and he was given 120 mg IV Lasix
and required DCCV for VT. He had good UOP to diuresis and his
pressors were eventually weaned. Diuresis continued and his
home medications were gradually resumed, including his
Spirinolactone on the day of discharge, and his ___ dose of
Lasix. His creatinine rose to 1.7 and gradually improved to 1.4
on the day of discharge. His weight on the day of discharge was
81 kg, down from 84 kg on ___.
***. | PERCUTANEOUS INTRACARDIAC PROCEDURES W MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is a ___ female with recent diagnosis of
presumed Crohn's disease who was admitted on ___ with acute
worsening of hematochezia, with ___ day history of ___ frankly
bloody stools per day and found to have acute worsening
of her chronic anemia concerning for active Crohn's versus UC
flare.
#Inflammatory bowel disease-Suspected Crohn's disease versus
Ulcerative Colitis with
active flare.
Patient was followed by GI in consult. She was initiated on
solumedrol 20mg TID. Her symptoms improved and on ___ she was
switched to 40 mg PO prednisone once daily. Mesalamine and
budesonide were held.
She had flex sigmoidoscopy done on ___ showing:
"Diffuse continuous abnormal mucosa with contact bleeding was
noted. Endoscope was advanced to 45cm. Mucosa throughout sigmoid
colon and rectum was notable for circumferential absence of
vascular pattern, friable mucosa with oozing on contact, and
congested mucosal appearance. Mucosal exudates were noted, and
washed off, with no frank underlying ulcers noted."
The biopsies showed "Focal chronic, moderately active colitis.
Note: The differential includes inflammatory bowel disease,
diverticularassociated colitis, a drug reaction or chronic
infection. Further clinical correlation is needed to distinguish
amongst these etiologies. No granulomata or dysplasia are
identified."
She was ruled out for infection with negative stool cultures,
negative c diff.
Because of possible need for anti-TNF agents, she had evaluation
with HBV surface antibody positive and HBV core antibody was
positive with HBV viral load undetectable, suggesting the
patient had naturally cleared a past infection.
Quantiferon TB gold was negative.
Ultimately she received a 10 mg/kg dose of infliximab on
___. She had improvement with symptoms with only 1 to 2 BM
per day with almost no blood. She had no abdominal pain. She was
therefore discharged home on ___ with GI follow up the week
after. She may likely have repeat Remicade dosing in 2 weeks.
#Hematochezia
#Acute blood loss anemia
After initiation of steroids, blood loss was improved
significantly with each bowel movement. She had 2 u PRBC for hgb
7 and it improved to 10.
Ferritin was 7.9 and very low. She has iron deficiency anemia
related to blood loss. This will require repletion and recheck
of ferritin as outpatient. Iron supplementation was initiated
upon discharge.
Ms. ___ is clinically stable for discharge today. The total
time spent today on discharge planning, counseling and
coordination of care today was 35 minutes.
***. | INFLAMMATORY BOWEL DISEASE WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
========
SUMMARY
========
Ms. ___ is an ___ year old woman w/ ___ DVT w/ IVC filter,
paroxysmal atrial fibrillation, Grave's disease s/p radioactive
iodine ablation, hypothyroidism, C diff colitis who presented as
a transfer from ___ after a fall and fever. Initially
there was concern for meningitis given fever and neck pain,
however, patient without meningeal signs and refused LP. CTA
chest was done which showed multiple subsegmental PEs in setting
of being off anticoagulation since ___ and s/p IVC
filter. Patient remained hemodynamically stable and started on
Apixaban for anticoagulation.
#FALL:
Has had frequent falls at rehab. All appear to be mechanical. No
history of loss of consciousness but patient may not be a good
historian. Has small pulmonary emboli which could have caused
syncope but they are reportedly smaller PEs which make it less
likely. She did not appear hypovolemic or to have had a seizure
based on history. Trop were negative making cardiac ischemia
unlikely. Held off on TTE as there was no evidence of murmur on
exam.
#SUBSEGMENTAL, SUBMASSIVE PULMONARY EMBOLISM: History of right
lower extremity DVT s/p IVC filter. Discontinued Eliquis in the
___ due to concern for bleeding in setting of multiple
falls. Off anticoagulation, presented w/ multiple subsegmental
PEs. Trop negative and BNP only mildly elevated. LENIs without
evidence of DVTs. Vascular medicine consulted regarding
anticoagulation management and felt that benefit of
anticoagulation in prevention of further PE greatly outweighs
risk of ICH from falls. Unclear why IVC filter was placed on
___ but could certainly be propagating clots. Recommend
removal of IVC filter in ___ months post discharge
#FEVER: No signs of pneumonia, UTI. Has neck pain but no signs
of
meningitis on exam and she refused LP. Pain felt likely due to
neck strain. She reportedly has evidence of diverticulosis on CT
at OSH and was briefly treated with cipro/flagyl. Flu swab was
negative and blood cultures so far showing no growth. Patient
remained afebrile while hostpitalized. Suspect fever may have
been due to PE. Discharged off antibiotics.
#WEIGHT LOSS: History of significant weight loss per patient
over ___ year
period due to eating less. No early satiety, nausea, but has had
decreased appetite. Patient appears otherwise AAOX3 and
independent, which makes malignancy or systemic illness as cause
of anorexia more concerning.
#NECK PAIN: most likely muscle strain but as above could be due
to meningitis in setting of fever. LP refused. Symptoms improved
with pain management as below. Treated symptoms with lidocaine
patch, ibuprofen, Tylenol, and cyclobenzaprine with improvement
in neck pain.
#ATRIAL FIBRILLATION: Continued propafenone. Apixaban was
stopped in ___ due to multiple falls at home and risk of
ICH. Consulted vascular medicine while hospitalized who felt
benefit of preventing future PE and embolic stroke far
outweighed risks of ICH from falls stating "Her CHADS-Vasc score
is 3 (female, age) and her HASBLED score is 1 (Age).
Furthermore, it is estimated in 1 model that a patient would
have to fall 295 times in a year to average 1 ICH, the most
dangerous risk of A/C in patients who fall ___ M,
___ G, ___ A, Laupacis A. Choosing antithrombotic therapy for
elderly patients with atrial fibrillation who are at risk for
falls. Arch Intern Med. ___ This risk is
likely even lower with DoACs whose rate of ICH was lower than
warfarin in trials. Therefore we would advocate continuing dose
reduced Eliquis for Ms. ___ and interventions per the
primary team for lifestyle and behavioral modifications to
reduce falls." Patient was restarted on low dose apixaban.
#ANEMIA: normocytic anemia, stable from baseline
#HHYPOTHYROIDISM:
continued levothyroxine 88 mcg
#DEPRESSION: continue escitalopram 20 mg daily
#ARTHRITIS: ibuprofen and tylenol as needed
===================
Medication Changes
===================
- Started Apixaban 2.5mg BID
- Started Cyclobenzaprine TID:PRN neck pain (Please discontinue
once neck pain improved)
- Started lidocaine patch QAM:PRN neck pain (Please discontinue
once neck pain improved)
- Started multivitamin w/ minerals daily
===================
Transitional Issues
===================
[ ] History of multiple PE s/p IVC filter and on apixaban:
Patient started on low dose apixaban during admission for a fib
and history of PE. Unclear why IVC filter was placed and should
be removed in 1 to 2 months post discharge.
[ ] Weight loss: Patient endorsed significant weight loss per
patient over ___ year period due to eating less. Concern for
malignancy as patient is otherwise functional. Please consider
age appropriate cancer screening as outpatient if within
patient's goals of care
[ ] History of falls: Likely mechanical falls based on history.
Patient will be discharged to rehab but should have outpatient
evaluation of lifestyle and behavioral modifications to reduce
falls at nursing facility.
[ ] Anemia: Patient presented with anemia with normocytic anemia
without evidence of acute bleeding. Given weight loss as
described above, please consider further workup for GI
malignancy if within patient's goals of care
# CODE: DNR/DNI per patient
# CONTACT: ___
Relationship: SON
Phone: ___
***. | 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.
***
Patient summary: ___ M with history of Prader-___ syndrome
s/p gastric bypass, pancreatitis, LGIB from external hemorrhoid,
HTN/HLD, and CHF who presented to the ED with dyspnea and BRPBR,
who then developed left-sided hemianesthesia while being
evaluated in the ED. Now ruled out for stroke or cord pathology.
ACUTE ISSUES:
#Hemianesthesia: On admission, the patient had marked LUE and
LLE weakness and sensory loss, as well as sensory loss of the
left side of the face. He was initially evaluated by neurology
and underwent both CT and MRI of the brain, as well as MRI of
the lumbar spine given some lower extremity leg pain with
straight leg raise. The MRI of lumbar spine revealed moderate to
severe stenosis, but otherwise all imaging was negative for
acute stroke or for cord pathology. TSH, HbA1c, and lipid panel
all normal. UTox and serum Tox pan negative. EEG was negative
for seizure activity or other findings that would explain
symptoms. Carotid US was normal with no plaques or stenosis. By
discharge, L upper extremity weakness (4+/5) and L lower
extremity weakness (4+/5) were much improved without any
neurologic intervetion. He continued to have some mild
tenderness along his lateral L shin but no calf pain, no LLE
swelling, low suspicion for DVT. Etiologies could include small
thalamic stroke not visualized on imaging or functional
neurologic syndrome. At this point, functional appears most
likely given marked improvement with no neuro interventions and
may have been precipitated by the stress of acute CHF
exacerbation. The neurology team signed off.
#Dypsnea on exertion: On admission, it was thought that this
dyspnea was most likely an exacerbation of CHF, and it slowly
improved with diuresis. CXR on ___ showed pulmonary vascular
congestion, though his exam was somewhat equivocal on volume
status (no ___ edema, JVP possibly slightly up, no crackles). He
had given a recent history of subjective weight gain, orthopnea,
and reported a history of newly diagnosed CHF. However, an ECHO
was done to evaluate for CHF and was normal without diastolic or
systolic dysfunction. Initially diuresed with 80mg IV Lasix,
then transitioned to PO torsemide. Discharged on 10mg PO
torsemide. Therefore, since his symptoms did improve with
diuresis, and his creatinine on presentation was elevated from
baseline (4.1 from 2.5) but slowly improved throughout the
admission (on discharge, 3.4), the pulmonary vascular congestion
was thought to be secondary to volume overload in the setting of
acute on chronic kidney disease. Symptomatic anemia may have
been contributing, but Hgb was stable (9.0-9.4) throughout the
admission so less likely. Weight on discharge 102kg.
#Hemorrhoids
#Lower GI bleeding
#Anemia:
Hgb remained stable since his admission (9.0-9.4). He has only
had BRBPR in association with bowel movements. Per patient's
mother, bright red bleeding is a very common occurrence at home
for him, often seen on the toilet seat or near toilet in
bathroom. He is s/p laser ablation of external hemorrhoids and
his most recent colonoscopy was ___ at ___. Lower GI
bleeding is most likely recurrence of his chronic external
hemorrhoids, possibly exacerbated by straining in the setting of
constipation, with anemia resulting from this chronic bleeding.
Ferritin was borderline but normal, so iron deficiency could be
contributing. He also may have some component of suppressed Hgb
production given his acute on chronic kidney disease. Discharged
on PO iron.
#AoCKD: Cr peaked at 4.0. OSH renal records obtained ___ show
most recent baseline Cr 2.5. The Cr did down-trend slowly with
diuresis but did not return to baseline(3.4 on discharge). Both
Cr and BUN improved slightly with diuresis, which initially
suggested this may be due to cardiorenal with renal congestion.
Once CHF was ruled out with ECHO, though, this was less
definitive. Other possible etiologies include pre-renal ___ from
acute blood loss (GI bleed) or infection s/p prostatic surgical
procedure 9 days ago. Lower suspicion for ATN given no granular
casts seen on urine microscopy. As OSH records indicated he was
undergoing work-up for proteinuria and possibly diabetic
nephropathy.
#Transaminitis: Mild, likely due to congestive hepatopathy vs
drug toxicity (had been on course amox-clav after prostate
procedure). A viral etiology was considered but hepatitis
serologies negative and LFTs improved without intervention, so
CMV, EBV, HIV were not thought likely and were not checked.
Chart review shows history of mild transaminitis with
spontaneous resolution on a prior admission for pancreatitis.
Per patient's mother, there is a family history of
hemochromatosis but ferritin was within normal limits, so very
unlikely in this patient.
#Abdominal pain/bloating: Per patient, abdominal pain has been
chronic for several months. CT abdomen/pelvis showed
peripancreatic inflammation c/f pancreatitis vs duodenitis
pending clinical correlation. IgG4 negative (IgG4 associated
with autoimmune pancreatitis). On exam, he remains tender to
palpation but is afebrile and hemodynamically stable so
infection or pancreatitis unlikely. CT also showed R-sided
abdominal hernia, which could contribute to his postprandial
bloating and discomfort but too large to be concerning for
incarceration.
#Hyponatremia: Resolved (140) on discharge, likely due to fluid
retention in the setting of acute on chronic kidney disease with
some contribution of SIADH. Urine lytes show indetermine Na and
high OSM, which could represent SIADH in the setting of
oxcarbazepine 900 mg.
#Thrombocytopenia: Stable compared to baseline 80-120 per past
OMR records, unclear etiology. Not worked up further.
CHRONIC ISSUES:
#Gout: continued allopurinol ___ PO daily
#HTN: Held metoprolol tartrate 50mg PO QAM, 25mg PO QPM for
bradycardia, was not continued on discharge. Restarted home
amlodipine 10mg PO daily once ruled out for acute GI bleed.
#BPH: Held home tamsulosin 0.4mg PO QHS due to c/f
bleeding/hypotension. Continued home finasteride 5mg PO daily.
#Pain: Continued gabapentin 300mg QAM 600 QHS
#Insomnia: Continued home trazodone 100mg PO QHS PRN
#Depression: Previous discharge summary lists patient as taking
oxcarbazepine for depression, confirmed with outpatient
psychiatrist RN that he is currently prescribed this med by her.
Other OSH records list history of Bipolar Disorder Type 1.
#Constipation: Continued bowel regimen of senna and Colace.
#Anxiety: Continued home Ativan 0.5mg PRN.
#HL: Continued home atorvastatin 20mg PO daily.
TRANSITIONAL ISSUES:
[]Medication changes:
- started 10mg PO torsemide
- discontinued metoprolol
- started PO iron 325mg daily
- started calcium carbonate 500mg TID
[]***Renal cyst on CT abd/pelv with attenuation not consistent
with simple cyst. Please repeat imaging and follow-up as needed.
[] Monitor weight and Cr, consider adjusting torsemide dose PRN
[] Creatinine improving but not returning to baseline (on
discharge, 3.4). Please continue evaluation at ___.
[] Discharged on PO iron. Recheck iron studies in ___ months.
[] Consider further evaluation by either GI or by his gastric
bypass surgeons if chronic abdominal pain does not improve.
[] consider starting ACE inhibitor for renal protection and
blood pressure if still elevated
[] As Prader-Willi syndrome can be associated with pituitary
dysfunction, hypocalcemia, and low Vit D resulting in
osteoporosis. Discharged on oral Ca supplement, recommend
re-checking Ca and possibly vit D levels and consider DEXA scan.
[] Thrombocytopenia: Chronic and stable. Consider further
work-up
***. | 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.
***
ASSESSMENT AND PLAN: ___ year old man with A-fib, AAA s/p EVAR
(___), PAD s/p bypass/angioplasties, HTN, HLD, RA on chronic
steroids, prostate cancer s/p XRT, multilevel lumbar stenosis
and compression fractures s/p L1-2 discectomy and L2 ___
presenting with one day of abdominal pain, now improved, and
several days of ___ soft stools per day.
#Lumbar Radiculopathy in setting of L3 Compression Fracture:
Recent imaging confirmed significant L spine disease (MRI),
including new L3 compression fracture, bilateral pedicle
fractures, with retropulsion as well as spinal cord narrowing.
He had hip x rays which showed no fracture and lumbar AP/LAT
flexion/extension XR to assess for dynamic instability which
showed multiple abnormalities similar to recent CT including
compression fractures at multiple levels of the lumbar spine,
sequela of vertebroplasty, and sacral fracture. He was seen by
ortho spine (Dr. ___ who recommended outpatient evaluation
with Dr. ___ possible ___, ___, and wearing TLSO
brace with activity. He continued on his home pain regimen.
#C diff: He had one day of abdominal pain and ___ loose stools
per day prior to admission. C diff returned positive, and he was
started on a 14 day course of PO vanco for recurrent c. diff.
Course to be conclude on ___.
# Pyuria: He had WBC in his UA. Pyuria is expect in the setting
of chronic indwelling foley. He was not started on antibiotics
for his positive UA, and culture grew mixed flora. Foley was
changed per outpatient urologist.
CHRONIC ISSUES:
#URINARY RETENTION: h/o prostate cancer s/p XRT, c/b radiation
cystitis, and multiple episodes of hematuria. During prior
admissions following urethral manipulation as above, he had
failed multiple voiding trials and has a chronically indwelling
foley which was left in during this admission. He was continued
on home finasteride and tamsulosin, foley was changed ,and he
was set up to see urology as an outpatient.
#Paroxysmal Atrial fibrillation: Not on anticoagulation due to
thrombocytopenia and hx of bleeds requiring transfusion.
Continued metop, digoxin.
#CAD: The patient had a recent NSTEMI in ___, managed
medically and a known history of CAD. He continued on aspirin,
metoprolol, atorvastatin, and lisinopril.
#PAD: H/o ___ PAD, AAA, chronic osteomyelitis of his left ___
toe. Amputation had been recommended, but he has been resistant.
He was seen by wound care who made recommendations regarding his
dressings.
#THROMBOCYTOPENIA: Per OMR, this has been attributed to ITP vs
myelodysplastic syndrome. Platelets were in the ___ on admission
and improved to 120s prior to discharge (at his baseline).
#RHEUMATOID ARTHRITIS: continued methylprednisone.
#HYPERTENSION: continued home lisinopril and metoprolol.
#Diastolic CHF: continued Lasix 80 mg PO daily.
TRANSITIONAL ISSUES:
[ ] Continue to follow up with pain, spine as an outpatient.
[ ] He had ongoing anemia which has been a chronic issue for
him. Consider further workup as outpatient. Platelets were also
below his recent baseline. Could consider heme/onc evaluation as
an outpatient.
[ ] Patient has superficial ulcers in both feet for which he
follows with podiatrist Dr. ___. Patient requires dressing
changes by ___ and outpatient podiatry follow-up.
[ ] Recurrent c. diff infection: He was started on PO vancomycin
on ___ which he should continue for a total 14 day course
(up to and including ___. Could consider giving a longer
vanco course with a taper given recurrence.
[ ] KUB showed small dense material consistency of dental
amalgam in colon. He likely swallowed part of a tooth. If he
were to develop acute abdominal pain, please keep this in mind -
however it will likely pass on its own.
[ ] Patient was on small dose of torsemide (2.5 mg daily) prior
to admission. This was held and patient was euvolemic on home
does Lasix alone. Patient was discharged off of Torsemide. This
was discussed with patient's primary care physician who was in
agreement with this. Recommend future titration of diuretics as
clinically indicated as per patient's primary care physician
(Dr. ___).
[ ] patient with chronic indwelling foley. Was changed during
his admission per his urologist. Further foley management per
his outpatient urologist ___ MD, phone
___.
[ ] please do NOT prescribe gabapentin to Mr. ___ going
forward. This medication causes him diarrhea, and has not been
effective for controlling his pain when previously prescribed.
Additionally, there is some concern that it put him at increased
risk for falls as he had two falls when he was previously on
this.
***. | MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient was admitted to the orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Otherwise, pain was initially controlled with a PCA followed by
a transition to oral pain medications on POD#1. The patient
received lovenox for DVT prophylaxis starting on the morning of
POD#1. The foley was removed on POD#2 and the patient was
voiding independently thereafter. The patient was seen daily by
physical therapy.
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 pain was adequately controlled on
an oral regimen. The operative extremity was neurovascularly
intact. The patient is partial weight bearing as tolerated.
Ms. ___ is discharged home with services in stable condition
with prescriptions for hydromorphone.
She had post op anemia with hct of 24 after multiple checks.
Lowest hct was 22.
She was asymptomatic and we discussed the situation and decided
not to transfuse.
***. | 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.
***
Mrs. ___ is a ___ year old female with history of Hep B,
HTN, and Hypercholesterolemia that presented to ED with nausea x
2 days with intermittent left sided chest pain and weakness.
She had recently stopped taking vicodin and flexeril (for her
sciatica) because of it causing constipation. Patient denies
vomiting, but states she has lost her appetite and was very
nauseaus. She denies any fever or chills. Her left sided chest
pain does not radiate to her jaw or shoulder.
1. Nausea. Ddx: Ischemia vs GI. Patient has had episodes of
chest pain similar to those this morning for months at home. The
pain did not not radiate, and her chest hurt more on direct
palpation. She has a history of recent musculoskeletal issues
treated with muscle relaxers and pain killers. Cardiac enzymes x
2 were negative. Ultimately, we felt that that the nausea was
secondary to GI. She was given an extensive bowel regimen, and
gained significant relief once her bowels cleared.
2. Elevated Tranaminases. ALT: 86 to 55, AST: 65 to 33. (trended
down during hospital course)Possible etiologies included
Acetaminophen use (was taking percocet and vicodin) vs.
Hepatitis (diagnosed in ___ with hepatitis B). Patient
acetaminophen levels were negative upon review. HBsAg was
negative; HBsAb was positive; HBcAb was positive; HAV Ab was
positive. Patient scheduled for follow up with PCP.
3. Stage 3 Chronic Renal Failure - Cr level of 1.3 currently at
baseline. Patient given IVF and team continued to monitor Cr
levels.
4. Hypercalcemia. IVFs given; albumin levels normal.
***. | ESOPHAGITIS GASTROENTERISTIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ went urgently to the OR on ___ for graft
cutdown, thrombectomy, and angioplasty of the left anterior
tibial artery - for further details please refer to operative
note. Immediately postop while still in OR she underwent a
cardiac arrest, w/ ROSC after one round of CPR with one dose of
epinephrine given. She was taken to the CVICU for further
management. A TTE was obtained showing LVEF > 55%. CXR was also
noted to show a L pleural effusion. Despite holding sedation her
mental status initially did not improve. Neurology was
consulted, and a CT head was unremarkable. EEG showed cortical
irritability and lacosamide was started. Over the next several
days, she gradually became more alert while continuing to hold
sedation and continuing HD. A repeat NCHCT on ___ was also
-ve. She was subsequently extubated on ___. She required
HFNC and weaned to NC by ___. On ___, after discussion
w/ family, her DNR/DNI status was reinstated. A DHT was also
placed and she was transferred to the floor ___ for the
further management. She was given 2mg Coumadin on ___. Her
INR was supratherapeutic by ___, and her Coumadin was
subsequently held and heparin drip was stopped. On ___
geriatrics recommended starting Seroquel and ramelton, she also
started rehab screening. She was stable on the floor receiving
HD and showing signs of slowly improving mental status ___
through ___. On ___ she was noted to have high potassium and
so her She worked with speech and swallow but was deemed unsafe
to start feeding on her own so a PEG was recommended. She was
initially bridged and therapeutic on Coumadin but was bridged
back on heparin in anticipation of a PEG. On ___ tube feeds
and heparin were held and she underwent a PEG placement for
feeding. She had her tube feeds restarted ___. She had a
bump in her white count post-operatively to 18.5, but it had
trended down to 10 by the time of discharge. She had no
abdominal complaints and was tolerating tube feeds.
Additionally, she was transitioned to Coumadin with a heparin
drip. She was accepted at ___ on a heparin drip. Dr.
___ agreed to help with the transition to Coumadin with goal
___. Follow-up appointments have been arranged.
***. | OTHER MAJOR CARDIOVASCULAR PROCEDURES W MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-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 gentleman with history of HTN and HLD presenting as
transfer from ___ after anterior STEMI s/p PCI to ___
LAD, course c/b cardiogenic shock.
# CORONARIES: ___ LAD occ s/p DES, 90% focal mid LCx lesion
# PUMP: EF 45%
# RHYTHM: Sinus rhythm and intermittent AIVR.
#CAD
#STEMI s/p DES to ___ LAD at OSH.
Patent DES on repeat cath on ___ on arrival to ___. Has 90%
LCx lesion that was not intervened upon (not the culprit
lesion). S/p ticagrelor load. Initially planned to defer
intervening on LCx lesion during this admission with plan for
outpatient stress test but patient had some exertional chest
pain so plan was made to proceed with treated LCx lesion. PCI
was performed at the mid LCx with single DES. TIMI III flow, but
unexpanded region in stent that could not be crossed. Will need
to be readdressed in the outpatient setting. Continued
ticagrelor 90mg BID, ASA 81 daily, atorvastatin 80 daily,
metoprolol succinate XL 100mg daily, lisinopril 15mg daily. Will
defer spironolactone for outpatient given EF >40%.
# Cardiogenic shock, resolved
# Acute heart failure with preserved EF.
Initially with wedge elevated to 28. Low CI and high SVR. Likely
___ new HFrEF 45% as well as beta blockade possibly started too
early. Briefly requiring levophed, but weaned off. Tolerated
beta blockade afterwards.
- PRELOAD: held diuresis as patient was euvolemic
- AFTERLOAD: continued lisinopril 15mg daily (titrated down from
20mg due to soft pressures)
- CONTRACTILITY: Did not require inotropy, weaned off pressors
- MECHANICAL SUPPORT: none required
- NHB: continued metoprol 25mgTID and transitioned to metoprolol
succinate XL 100mg daily
# VT/VF
Likely in setting of acute ischemia. No longer having any
episodes since reperfusion. Was started on amiodarone gtt at OSH
and discontinued upon admission. EF >40% so will not need
lifevest.
# Anterior wall akinesis: present on TTE in setting of LAD
infarct but EF 45% so no need for heparin gtt or long term
anticoagulation.
# Hypertension: continued lisinopril 15mg daily and metoprolol
succinate XL 100mg daily on discharge
TRANSITIONAL ISSUES
====================
DISCHARGE WEIGHT: 98.4kg
New Medications:
metoprolol succinate XL 100mg daily
ticagrelor 90mg BID
aspirin 81mg daily
atorvastatin 80mg daily
lisinopril 15mg daily
Stopped Medications:
amlodipine 5mg daily
[] follow up with primary care doctor; will need Cr and K check
at that time given initiation of Lisinopril in-house
[] follow up with cardiology for continued management of
coronary artery disease and HFrEF
[] needs to continue aspirin daily indefinitely, and clopidogrel
for DAPT therapy for at least a year
[] Consider repeat TTE in ___ weeks to look for improvements in
EF
[] Please check A1C as outpatient. Glucose mildly elevated while
in-house.
# CODE: full, confirmed
# CONTACT/HCP: ___ ___
***. | PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ VESSELS OR STENTS |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is a ___ woman with no significant PMH who
presented with sudden onset dysarthria, R facial droop, and R
sided sensory changes. NCHCT no evident of hemorrhage, given tPA
on ___ 3hrs after symptom onset. Symptoms improved almost
immediately. Transferred to ___ for further workup, developed
pins and needles pain in R side of face. Tongue felt large and
clumsy, sounded much better but not back to baseline. MRI head
showed showed punctate infarct in L lateral precentral gyrus
without hemorrhagic concersion. Admitted to ICU for post tPA
care, did well overnight. Exam now shows no deficits. Possible
etiologies include plaque rupture vs cardioembolic/paradoxical
embolus. Never been on OCPs, no recent surgical history, no
recent travel, smokes ___ for decades. Smokes MJ, uses other
patients' percocets but recently quit and enrolled in ___
clinic with plan in place to wean off entirely.
Stroke workup:
- Labs: HgbA1c 5.4, LDL pending, TSH 0.9
- Hypercoag: Antiphospholipid, Anticardiolipin, Antilupus, B2
glyco
- TTE: EF 67%, patent foramen ovale. Normal biventricular cavity
sizes with preserved regional and global biventricular systolic
function. Mildly dilated ascending aorta
- TEE: pending
- LENNI: no DVT
- MRV pelvis: no DVT
- MRI head and neck: Punctate infarct within the left lateral
precentral gyrus, without evidence of hemorrhagic conversion.
Patent intracranial and neck vasculature without stenosis,
occlusion, or
aneurysm.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? () Yes, confirmed
done - (x) Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 114) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL >100, reason not given: titrate up per PCP]
6. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (X) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
***. | INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Patient presented electively for a endoscopic endonasal
suprasellar mass resection and cyst aspiration in a combined
procedure with neurosurgery and ENT. She was taken to the
operating room, positioned, and the procedure was carried out
without difficulty. She was extubated in the operating room and
was trasnferred to the PACU post-operatively for further
monitoring and care.
On ___ POD 1- the patient remained stable and her post-op MRI
showed expected post-op changes. Urine output was increasing
slowly throughout the day and urine lytes were sent which were
all within normal limits.
On ___, patient remained intact on exam. Urine output was
stable and NA was 142. Patient reported scant drainage from her
nose which was serosanguinous in nature. The lumbar drain had no
output x 2 hrs and drain was flushed distally with improvement
in drainage.
On ___ her cortisol lvel was inacurate and plan was made to
hold ___ steroids in order to obtain a level on ___. Her nasal
packing was removed by ENT and she had no evidence of abnormal
leakage or of CSF rhinorrhea.
On ___ She had no CSF drainagae and plan was made to hold her
___ steroids as it had not ___ the ngiht prior. She remained
stable without evidence of CSF leak.
On ___ again her hydrocortisone was not held so plan was made
to discontinue steroids after her AM dose and obtain an AM
cortisol on ___. Her lumbar drain was removed and a stitch
palced. She also had her foley catheter removed and was
mobilized with plan for discharge likely ___.
On ___ Patient was neurologically stable. Her AM cortisol
level was normal was 16.4. Patient had been ambulating to
bathroom with RN assist but RN felt patient could use ___
consult. Later in evening patient was ambulating indendently
with RN up and down full length of hallway.
On ___ Patient was discharged home in good conditon. Her pain
was well controlled, she was ambulating independently and
tolerating a diet. She was given instructions for follow up.
***. | 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.
***
# Nausea/emesis: The patient's nausea and emesis was likely due
to gastroparesis. The patient vomited bile on presentation. His
diet was maintained on clear liquids until the evening prior to
discharge. He tolerated a normal diet (eggs, cereal at
breakfast and hamburger at lunch) on the day of admission
without nausea or emesis. Supportive care and intravenous
fluids were provided. Antiemetics, ativan, dilaudid, and reglan
were provided for symptom control. The patient was discharged
with a prescription of reglan and encouraged to comply with this
regimen.
.
# Hypertensive urgency: A femoral line was placed in ED for
access; hypertension was easily controlled with IV Labetalol. He
states he was taking his home anti-hypertensive medications, and
this presentation could be attributed to autonomic dysfunction.
He was then transitioned to PO antihypertensives: labetalol 100
TID, Lisinopril 20 daily (his home regimen) in addition to PO
clonidine. He tolerated this regimen well with SBP generally
130s. His clonidine PO was switched to a clonidine patch prior
to discharge. BP is also controlled with volume removal at HD.
.
# Possible Aortic Valve Endocarditis/Staph coag negative
Bacteremia: Staph coag negative GPC grew from ___ Blood and
Catheter TIP. Recent ECHO showed possible evidence of aortic
endocarditis. Subsequent blood cultures to ___ have been
negative; repeat blood cultures on this admission showed no
growth to date (at discharge). Patient was maintained on
Vancomycin with HD to complete ___. Vancomycin trough
levels were maintained at a goal of ___.
.
# DM: Continued outpatient regimen Lantus 5 and additionally
provided HISS.
.
# ESRD: Continued hemodialysis on ___
schedule. Continued
Lanthanum TID with meals. Patient will resume his outpatient
dialysis spot and schedule (T, Th, Sa) with ___
upon discharge.
.
# CAD: ECG unchanged, denies chest pain. Trop elevated to 0.39
which is at baseline. Continued ASA, Plavix, Statin, BB.
.
# FEN: Diabetic/cardiac diet as tolerated, no IVF/managed with
HD.
.
PPX: SC Heparin, PPI, bowel regimen PRN was provided.
.
Access: Femoral Line placed ___ in ED, discontinued on
___
.
FULL CODE
.
***. | RENAL FAILURE WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Given the maroon stools on admission, there was concern for a
lower GI bleeding source. His Hct was monitored every 8 hours
and he required 2 units of pRBC transfusion for 10 point Hct
drop. He was prepped with golytely for colonoscopy and
underwent both upper and lower endoscopy on ___. The EGD
showed a 2-4cm submucosal mass in stomach and there was a large
ulcerated mass on colonoscopy which was partially obstructing
the lumen at the splenic flexure. Patient was notified of the
results of endoscopy. He underwent CT scanning which revealed
aarge heterogeneously enhancing lesion within the left upper
quadrant, with extension into the stomach and colon. A surgery
consult was obtained, but given the extent of the findings on
CT, no immediate surgical plan was undertaken.
At the time of discharge, the path appeared to indicate that the
mass was neoplastic tissue of renal cell origin, but final
pathology was pending several additional stains.
The patient had stable hematocrit following colonoscopy and EGD,
and no large bowel obstructive symptoms. The patient was felt
stable for discharge home with oncology follow-up. He reported
that he felt well with no abdominal pain. He was educated about
warning signs and symptoms and when to return to the hospital.
He will follow-up in HCA in one week after discharge.
***. | DIGESTIVE MALIGNANCY WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is an ___ year old female with PMH significant for
dementia (A&O x1-2 at baseline, dependent on majority of ADLs
including dressing and cooking), mild persistent asthma, dCHF
(last Echo , afib CHADS2 6 on warfarin, recent CVA ___, and
recent hospitalization requiring FICU admission for asthma
exacerbation ___ RSV infection c/b exacerbation of dCHF
(responded well to 80IV lasix boluses) and ___ who presents with
generalized weakness and productive cough, related to persisent
asthma exacerbation related to RSV infection.
.
# ASTHMA - Evidence of acute asthma exacerbation in the setting
of HCAP. Responded to frequent nebulizers and was pulse dosed
with steroids (prednisone 60 mg PO daily) for planned long
prednisone taper. We also continued monteleukast. She will
require slow taper, and increase in steroid taper if her
symptoms flare with the taper.
# PNEUMONIA - Presented with worsening respiratory symptoms and
significant diffuse pulmonary findings on exam, leukocytosis.
Respiratory viral screen negative. Received Vancomycin, Cefepime
and Azithromycin for HCAP treatment with atypical coverage,
urine legionella negative. She weaned quickly to 2L nasal
cannula and with nebulizers, in addition to antibiotics. She was
transferred to the medical floor on ___, where she continued to
improve. Repeat CXR on ___ showed likely atelectasis and not
pneumonia, so antibiotics were narrowed to short course of
levofloxacin, which she completed on ___
# SEPSIS - Evidence of systemic hypoperfusion with lactate of
4.5 on admission which improved with normal saline - she did not
require vasopressor support. Blood, urine cultures negative
to-date. Treated with antibiotics. Improved rapidly.
# PYURIA - Positive urinalysis, with leukesterase and negative
nitrites. Antibiotics covering, as above. Urine culture showed
GPC, likely lactobacilli.
# ___ - Admission creatinine up to 1.4. Baseline 0.8-1.0.
Improved with gentle hydration. Likely pre-renal.
# Diastolic CHF - Without any clear evidence of acute
exacerbation, however difficult to assess presence of pulmonary
edema vs. ongoing pulmonary infectious process. BNP returned
1361, previous 1592 ___, beginning of last admission).
Held torsemide initially, then restarted daily dose. Dry weight
is 145 pounds, weight at discharge was 145. She will resume
home standard diuretic dose at discharge, but if weight loss is
significant, regimen should be changed.
# Paroxysmal atrial fibrillation - PO diltiazem to maintain rate
control and warfarin were continued. Regarding anticoagulation -
recent CVA related to atrial fibrillation is concerning, but per
pcp and neurologist, they do not believe that she is safe to be
anticoagulated if she is at home. I discussed this with her
daughter, who is concerned about stopping anticoagulation. I
will continue coumadin for now, with anticipated discharge to
rehab, and then recommended further discussion between ___ and
Drs. ___.
# Hyperglycemia, related to frequent steroid dosing. She was
maintained on sliding scale insulin. HgbA1c in ___ was 6.2.
Blood sugars, particularly in the afternoon, rose to 350s, but
morning sugars were controlled.
CHRONIC ISSUES
# DMII: Well controlled, most recent HgbA1C 6.2% (___).
Continue on ISS.
# HLD: Stable. Continue atorvastatin.
# Depression/Psychosis: Stable. Continue fluoxetine,
olanzapine. We held ativan and rivastigmine.
# GERD: Stable. Continue omeprazole.
# Asthma: Continue montelukast, duonebs, advair. Hold
loratadine
# Hypothyroidism: Stable. Continue levothyroxine.
# Dementia: Stable. Continue rivastigmine.
Transitional issues:
Being discharged on slow steroid taper, please change based on
her clinical course.
Repeat INR ___
Repeat BMP ___
***. | SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ was admitted to the Neurosurgical ICU with a
subarachnoid hemorrhage for frequent neurochecks and systolic
blood pressure control less than 140. He was started on keppra
500BID for seizure ppx and Nimodipine and Provastatin for
vasospasm prophylaxis.
On ___ he underwent a diagnostic cerebral angiogram which did
not identify an aneurysm. Manual pressure was held at the groin
site. Postangio he was transferred to the ICU for Q1 hour
neurochecks and strict blood pressure control. He remained
neurologically intact.
On ___, Mr. ___ continued to recover in stable condition.
TCDs were completed and no vasospasm was observed. The patient
was continued on normal saline with the goal of euvolemia to
prevent vasospasm. Nimodipine was continued as well. Later
during the day, the patient stated that he feel while trying to
get up on his own from chair to bed. He had no head strike. He
was instructed to call for help before trying to ambulate.
The following day, ___, Mr. ___ was neurologically stable.
He underwent a MRI of the head and neck to further assess for a
vascular anomole. Those exams showed no AVM or aneurysm. He
was kept euvolemic. TCDs showed no vasospasm.
On ___, Mr. ___ was feeling nauseated and vomited
occasionally. His pain was minimally relieved with narcotic and
non-narcotic analgesics. TCDs showed mild right MCA spasm, but
was not concerning to Dr. ___. The patient remained in the
ICU for continued neurologic monitoring. Because the patient
had a slow decline in his sodium levels, they were checked twice
daily. Normal saline was continued with the goal of euvolemia.
On ___, Mr. ___ remained neurologically and hemodynamically
intact. His sodium levels continued to trend downward to 131.
Sodium tablets 2 gram bid were started, and 3% sodium gtt
started at 40ml/hr. He is on the schedule for a diagnostic
angiogram tomorrow. His Sodium levels are checked Q6hrs for a
goal of >135. His TCDs were obtained and showed improved minimal
vasospasm.
On ___, the patient remained on 3% NA gtt, his sodium levels are
trending upward. He remains neurologically and hemodynamically
intact. He was brought for a Diagnostic angiogram which was
negative for aneurysm or vascular abnormality. His TCDs were
obtained and showed no vasospasm.
On ___ Patient was weaned off 3% NS. Patient was transferred
from the ICU to the floor. Patient's Na decreased to 128 from
131, increase NA tab to 3g PO TID.
On ___ 3% NS was discontinued. Na 129 x2 then 131. No free
water. Phenobarb tapered to off.
On ___ Overnight, c/o severe head pressure ("like before my
head popped"). Neuro exam is stable. Repeat AM Na was found to
be 138. Patient will continue on free water restriction and Q6
hour Na checks. CT ordered which revealed no acute hemorrhages.
On ___, the patient remained neurologically stable. Last night
the patient had a fever of 101.3 x1. When rechecked his temp was
99.6, the paitent denies chills. The patient was discharged home
in stable conditions. On discharge his temp was 98.8.
***. | 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.
***
Mr. ___ is a ___ man with history of tachycardia-induced
cardiomyopathy ___ CTI-dependent atrial flutter s/p
radiofrequency ablation (___) with subsequent recovered
LVEF, paroxysmal atrial fibrillation on apixaban, HTN, HLD, BPH,
and prostate cancer who was directly admitted from clinic for
recurrent atrial flutter now s/p ablation as well as mild volume
overload and now s/p diuresis.
# CORONARIES: non-obstructive CAD
# PUMP: LVEF 53% (___)
# RHYTHM: NSR
ACTIVE ISSUES:
==============
# Acute on chronic heart failure with reduced ejection fraction
Thought to be likely tachycardia-mediated in the setting of his
atrial flutter, as per above. Per patient, dry weight is 214-215
lb however during his last hospitalization this was estimated to
be closer to 220lbs. Appeared mildly overloaded on exam at 214
lbs. He was diuresed with lasix boluses of 40mg IV BID and then
got 80mg IV the night before and the morning of discharge -
after which he appeared near euvolemic. He will be discharged on
60mg PO lasix for three days and then return to 40mg daily
subsequently.
- DISCHARGE WEIGHT: 213.4 lbs
- DISCHARGE CREATININE: 1.0
- PRELOAD: 60mg PO lasix for three days and then return to 40mg
daily afterwards
- AFTERLOAD: Continued home losartan 25 mg daily
- NHBK: Per EP, decreased Metoprolol succinate to 100mg daily
(from BID)
# Paroxysmal Atrial Fibrillation / Atrial Flutter
S/p CTI ___ s/p PVI and posterior wall isolation and mitral
isthmus ablation ___. Atypical atrial flutter in ___
requiring cardioversion. Recurrent atypical flutter/atrial
tachycardia requiring DCCV in ___. Recurrent atrial
fibrillation requiring DCCV in ___. Again was noted to be in
atrial flutter on ___, with Dr. ___ repeat
ablation and direct admission. He underwent successful ablation
___ and is now in NSR. EP recommended discontinuing
amiodarone, decreasing Metoprolol succinate to 100mg qd, and
continuing all other cardiac meds. He should follow up in ___
clinic in ___. He was otherwise continued on home apixaban.
Losartan and tizanadine were held for procedure- however his
home losartan was restarted before discharge.
# Chronic back pain
Has history of chronic back pain, on medical marijuana oil which
provides great pain control at home. His chronic pain was
treated here with standing Tylenol and PRN oxycodone. He
continued home Duloxetine 60mg PO BID and home gabapentin 300mg
TID. Tizanidine 2mg daily was held for procedure and was
restarted on discharge.
CHRONIC ISSUES:
==============
# Non-Obstructive Coronary Artery Disease
Per patient report he is no longer on aspirin 81 mg daily but
review of Dr. ___ reveals he intends for the patient
to continue this medication. As such, he was restarted on
Aspirin 81mg daily. He was otherwise continued on his home
Atorvastatin 40mg daily.
# Hypertension
Continued home losartan 25 mg daily
# Dyslipidemia
Continued home atorvastatin 40mg QHS
# Hx prostate cancer
Continued home tamsulosin 0.4 mg PO DAILY
#CODE STATUS: Full Code
#CONTACT:
Name of health care proxy: ___
Relationship: wife
Cell phone: ___
TRANSITIONAL ISSUES:
==================
[] Amiodarone was stopped after ablation performed by EP for
atrial flutter. Continue to reassess for need for
antiarrhythmics.
[] Metoprolol was also decreased to 100mg once daily per EP
recommendations. Monitor HRs and adjust dosing accordingly
[] The patient's dry weight is 213.4 lbs
[] The patient's BPs were lower on days leading up to discharge
despite his tizanidine having been held throughout admission
(Losartan was restarted the day prior to discharge). His home
Tizanadine was restarted at discharge given he was otherwise
asymptomatic.
[] The patient reported that he had been told to discontinue his
aspirin 81mg qd in the setting of taking apixaban. Per review of
outpatient cardiologist notes, the intention had been for him to
continue taking aspirin. The patient was restarted on aspirin
during this hospitalization, and should continue to have
risk-benefits discussions as an outpatient.
***. | PERCUTANEOUS INTRACARDIAC PROCEDURES W MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
HOSPITAL COURSE
This is a ___ F with PMHx known diverticulosis who presented
with BRBPR, 6 point Hct drop, requiring 1 unit pRBCs, then
stabilizing, Hct stable x24hrs, colonoscopy significant for
diverticulosis without clear focus of bleeding, discharged home.
.
ACTIVE
# Diverticulosis c/b Acute Bleed: Patient p/w 2wks BRBPR
associated with constipation/straining; admission Hct was 6pts
below prior baseline and patient was tachycardic to 120s.
Patient received IV fluids and 1 unit pRBCs with stabilization
of vital signs. Abd CT did not demonstrate signs of
diverticulitis or colitis. Patient underwent colonoscopy
significant for diverticulitosis without sign of focal bleeding.
Patient remained hemodynamically stable x 24 hours and was
discharged with Hct 31. Continued home lansoprazole. Patient
counseled on using regular stool softeners.
.
# COPD: Patient w baseline ___ nasal O2 requirement. Patient
was without notable respiratory findings on exam or change from
baseline O2 requirement. Continued home advair, spiriva,
prednisone, albuterol prn. Given her chronic predinisone use,
she was started on PCP prophylaxis with bactrim, as well as
calcium/vitD. She should be evaluated for bisphosphonate
therapy as an outpatient.
.
INACTIVE
#. Psych: Continued prn alprazolam.
.
#. Hypothyroidism: Continued levothyroxine.
.
TRANSITIONAL
1. Code status - Patient remained full code for the duration of
this hospitalization
2. Pending - No labs were pending at time of discharge
3. Transfer of Care - Patient was scheduled for PCP ___
with Dr. ___, who was informed of the details of this
admission via faxing of discharge summary. As discussed above,
given chronic prednisone use, started bactrim prophylaxis,
calcium+vitamin D. Recommend to PCP that bisphosphonate therapy
been considered.
***. | G.I. HEMORRHAGE WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with advanced Alzheimer dementia, CAD s/p remote CABG,
severe AS, CMP (EF 40%), PAF, and DM2 who p/w leg swelling, DOE
& abdominal discomfort found to have HFrEF decompensated by
volume overload.
ACTIVE ISSUES:
==============
#HFrEF c/b volume overload
Likely ___ severe AS and h/o CAD. LVEF 40-45% on TTE from ___,
down to 30% on TTE this admission. Patient's daughter confirms
that patient used to walk stairs without difficulty but over the
past few weeks to months has had diminished exercise
tolerance/dyspnea. After a few days of diuresis with IV Lasix
and PO Torsemide, was able to walk ___ without
dyspnea or hypoxia; thus seems to have regained her baseline
respiratory status. (Day of discharge, patient walked ~60 feet
with 2-person assist with mild/moderate dyspnea but no hypoxia).
However, diuretic regimen was slackened over the course of the
admission because of soft BPs, and by the time of discharge her
standing weight was 61.69kg from 58.79kg on admission. She was
sent home on a maintenance dose of Lasix 40mg PO daily, with
plan to f/u with PCP ___ for reassessment.
#Severe AS
TTE ___ confirming low-flow/low-gradient severe AS, with CI<2
and PCWP>18. Surgical AVR deferred several years ago given
comorbidities; the question of TAVR was pursued by our team
along with the geriatrics and TAVR consult services; ultimately,
it was felt that patient would be better ___ to medical
management given her high periprocedural risk of stroke and
death (mortality risk ~16%) as well as the fact that with gentle
diuresis she appears to be improved to a reasonable functional
status (ambulated 120 feet with ___ without hypoxia or apparent
dyspnea). Confirmed in family meeting that TAVR will not be
pursued
___ on CKD
Patient has had variable renal function but over the past
several
months appears to have average baseline SCr 1.7. 1.3 on
admission, increased to 1.9-2.1 stable at that level for a
period of several days in the setting of aggressive diuresis,
now down to 1.5 after decreasing diuretic regimen. Likely
a combination of cardiorenal syndrome and prerenal azotemia
superimposed on chronic diabetic nephropathy. Should have repeat
electrolyte panel and SCr checked at outpatient f/u.
#PAF
Patient has had this diagnosis for years, on telemetry this
admission has flipped periodically into sinus rhythm HR ___ but
mostly has been 100s-120s in AF. Started anticoagulation with
apixaban 2.5mg BID this admission, given CHADS2VASC score of 6
with low HASBLED score, daughter/guardian on board with this
decision. Reduced metoprolol succinate dose to 12.5mg daily,
given that her BP dropped a few times to ___ (asymptomatic)
with higher doses of nodal blockade. The assumption is that with
her severe AS she may not be able to tolerate more aggressive
rate control.
#Hyperthyroidism
Spoke with ___ endocrinologist Dr. ___ the phone, who
apparently started the patient on 5mg methimazole daily back in
___ pt has been subclinically hyperthyroid since the early
___ and has never had iodine scintigraphy or ultrasound. TSH
elevated at 10 this admission, decreased methimazole to
2.5mg/day
per endocrine consult service recs. anti-TSHR positive,
indicating etiology of Graves disease. Patient should get repeat
TFTs 1 week post-discharge; she has endocrine f/u with Dr. ___
in ___.
#E. coli UTI
Initial abdominal pain on admission, urine growing
cipro-sensitive E. coli. S/p 5-day abx course (2d CTX, 3d cipro)
#Dementia, agitation
Chronically A&Ox1, periodically refusing care/medications.
Received rare low doses of PO Zyprexa or Seroquel for agitation,
largely redirectable.
TRANSITIONAL ISSUES
====================
[] Weigh patient each morning; if weight increases or decreases
by >3 pounds, and/or if patient develops increasing
lightheadedness or dyspnea, contact outpatient cardiologist ___
___ ___ or PCP ___. ___
for titration of Lasix
[] Repeat Chem-10 at ___ PCP ___ & assess symptoms & volume
status, ensure stable renal function & appropriate diuretic
dosing
[] f/u patient's HR/BP; decide whether to increase beta blockade
for AF/RVR
[] Determine whether BP will tolerate the addition of
mortality-reducing HFrEF agents ___, eplerenone)
[] Repeat TFTs at ___ PCP ___ titrate methimazole accordingly
(has endocrine f/u ___ ___
[] Reassess code status with patient's HCP; she is currently
full code but seems incongruous with overall approach of "making
patient comfortable" and avoiding aggressive interventions that
family arrived upon during family meeting this admission
# Code Status: Full Code
# Emergency Contact: Name of health care proxy: ___
Phone number: ___
***. | 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.
***
___ yo M with COPD, aortic dissection, recent spinal cord
infarction, paraplegia, depression, admitted with altered mental
status, somnolence, increased abdominal distension concerning
for colonic pseudo-obstruction. After discussion with family and
wife, a goals of care discussion revealed comfort measures only
was appropriate (as of ___. He was maintained on opioids
for pain control and his colonic distention worsened. The
patient expired on ___.
.
A death certificate was completed, an autopsy was declined by
the family. The attending of record was notified.
***. | G.I. OBSTRUCTION WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
On ___, she underwent Cadaveric kidney transplant using
right kidney
into right iliac fossa. A ureteroneocystostomy was constructed
over a stent. Surgeon was Dr. ___. Induction
immunosuppression was administered (ATG, cellcept and
solumedrol). Urine output was minimal. A renal duplex
demonstrated no evidence of hydronephrosis or perinephric fluid
collection. Resistive indices ranged from 0.63 to 0.76. She
experienced delayed graft function with daily urine outputs of
___ cc/day. Hemodialysis was continued thru the AVG.
Creatinine decreased to 7.2 from 13. The RLQ incision had
staples and had some serous drainage requiring a dry gauze
dressing change a couple times per day.
Immunosuppression was given consisting of ATG. She received a
total of 4 doses of ATG with the 3rd dose split over 2 days for
low platelets of 70-72. Cellcept was well tolerated. Steroids
were tapered. Prograf was started on postop day 1 and adjusted
for low levels. Dose was increased to 8mg bid for a trough of
6.7 on ___.
Diet was advanced and tolerated. She was ambulating
independently.
The plan was to discharge home on ___ to continue on
hemodialysis at her previous clinic on ___.
Coumadin (for the avg)was not to be resumed in the event of
future biopsy.
___ ___ arranged for home.
***. | KIDNEY 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.
***RIEF HOSPITAL COURSE:
Ms. ___ is a ___ year old woman with history of COPD and
ethanol use disorder transferred from ___
___ for fever, bloody diarrhea, and abdominal pain with
evidence on CT of enterocolitis and newly diagnosed cirrhosis.
Her stool studies were negative for C. diff, EHEC, Vibrio,
Yersinia, and Campylobacter and she was started on a course of
cipro/flagyl with improvement. She received screening for portal
vein thrombosis and esophageal varices, neither of which were
found. On hospital day two, she spiked a fever and
pneumonia/parapneumonic effusion found on CXR. Her antibiotics
were expanded for empiric coverage to
cefepime/vancomycin/flagyl/azithromycin and narrowed to
levaquin, completed on ___. Her fever subsided and chest
x-ray showed resolution of pneumonia. Due to concerns for poor
nutritional intake, NGT was placed via EGD and tube feeds
initiated. She was discharged to ___ and will be followed
closely by Dr. ___ in Hepatology for cirrhosis care.
ACTIVE ISSUES
=================
#CIRRHOSIS: CT scan at ___ showed
evidence of cirrhosis, likely from her history of alcohol use.
Workup showed negative hepatitis serologies, AMA -, ___-, and
SMA equivocal, lowering suspicion for viral and autoimmune
hepatitis. RUQUS with Doppler showed no portal vein thrombosis.
Given her progressing ascites, she underwent a therapeutic
paracentesis that removed 1.2L, followed by an EGD that showed
no esophageal varies. She was started on a diuretic regimen of
furosemide 40 mg PO/NG daily and spironolactone 100 mg PO/NG
daily. She received her first doses of Hepatitis A and B
vaccines prior to discharge. She will be followed closely by Dr.
___ in Hepatology.
#NUTRITION: Maximum recorded calorie count was 658.5 kcals, 20 g
protein during her hospital stay. Given concern for sarcopenia
and inability to meet elevated nutritional needs in setting of
new cirrhosis, a post-pyloric NGT was placed via EGD and she
will be discharged on cycling tube feeds. Patient reported
nausea following onset of tubefeeds, so she was placed on Reglan
to improve dysmotility. She should follow a low sodium, high
protein diet, with calorie goal of 2500kcals as per hepatology.
#DIARRHEA: Infectious work up for diarrhea was obtained. Her C.
diff, campylobacter culture and E.coli 0157:H7, Yersinia, and
Vibrio stool studies were negative. She began an antibiotic
course of cipro 500mg PO Q12H/metronidazole 500 mg PO/NG Q8 that
was broadened (see below) in the setting of recurrent fever and
pneumonia. Her diarrhea resolved, but returned with onset of
tubefeeding. She was placed on Psyllium and banana flakes added
to her tube feeds for increased bulking.
#FEVER/PNEUMONIA: On hospital day 2, she spiked a fever to
102.4F and tachycardic to 110s. Negative stool studies and SBP
studies lowered suspicion for persistent enterocolitis and SBP,
respectively. CXR was concerning for left lower lobe pneumonia
and parapneumonic effusion. She began an empiric course of
antibiotics: cipro 500mg PO Q12H (___), cefepime 2 g IV Q12H
(___), vancomycin 1000 mg IV Q 8H (___), metronidazole
500 mg PO/NG Q8H (___) and azithromycin 500 mg PO/NG (___)
that was progressively narrowed to levofloxacin 750mg PO/NG
(___) as her blood and urine cultures, Legionella urinary
antigen, and MRSA screen were negative. Her fever resolved and
repeat CXR showed no evidence of pneumonia or edema.
#COUGH/DYSPNEA: Her cough/dyspnea were thought to be due to her
chronic COPD, worsened by her ascites, pneumonia, and
atelectasis. Her stable O2 saturation and lack of severe work of
breathing make a COPD exacerbation less likely. She was managed
with guifenesin ___ PO/NG Q6H: PRN cough, ipratropium bromide
neb Q6H:PRN dyspnea/wheezing, benzonatate 200mg PO TID, cepacol
lozenges Q4H PRN, and chloraseptic throat spray PO Q4H PRN, and
inspiratory spirometry.
#ALCOHOL USE: Related to her home situation, patient has
increased her drinking for the past ___ years, ___ vodka 3
days/week. Prior to this, she had been sober for ___ years. Last
drink before admission was Christmas Eve. Patient reports home
safety concerns and social work provided safety planning. SW
referred patient to CVPR for further safety planning and trauma
focused addiction treatment resources.
#MACROCYTIC ANEMIA: Her Hb throughout her hospital course ranged
from 8.1-9.6mg/dL, with MCV of 122-126, likely to history of
chronic alcohol use. Recommend checking vitamin B12 and folate.
CHRONIC ISSUES
=================
#RECTAL SQUAMOUS DYSPLASIA: Found on colonoscopy ___.
She should follow up with primary care physician, ___
___, for colonoscopy screening.
# ANTERIOR NECK MASS: Patient reports two right anterior neck
masses known to PCP. She missed her scheduled US due to
admission to ___. She should follow up with primary care
physician, ___ to reschedule US work-up.
#GERD: home omeprazole 20mg PO daily was increased to 40mg PO
daily
#CHRONIC BACK PAIN: continue home OxyCODONE (Immediate Release)
5 mg PO/NG Q8H:PRN severe pain
TRANSITIONAL ISSUES
==================
-MEDICATION CHANGES:
-Omeprazole to 40mg PO daily
-NEW MEDICATIONS:
-Furosemide 40 mg PO/NG DAILY
-Spironolactone 100 mg PO/NG DAILY
-VACCINATIONS:
-Next dose of Hep A vaccine due ___ months
later)
-Second of three doses of Hep B vaccine ___ (one month
later)
-NUTRITION/TUBEFEEDING: She had low PO intake throughout her
hospital stay, thus requiring tube feeds. Jevity 1.5 Full
strength 95 ml/hr. Cycle start: 6PM. Cycle end: 10AM. Flush with
100 ml water before and after each feeding. Add one packet of
banana flakes three times a day. Mix each packet with 120mL
water and stir until dissolved. Administer by syringe through
feeding tube and flush after with ___ water.
#RECTAL SQUAMOUS DYSPLASIA: Found on colonoscopy ___.
She should follow up with primary care physician, ___
___, for colonoscopy screening.
# ANTERIOR NECK MASS: Patient reports two right anterior neck
masses known to PCP. She missed her scheduled US due to
admission to ___. She should follow up with primary care
physician, ___ to reschedule US work-up.
-FOLLOW-UP APPOINTMENTS:
___ on ___
***. | SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Patient is an ___ yo M s/p prior EVAR with type IA endoleak with
sac expansion. The patient presented to ___ on ___ and
underwent extension of his prior EVAR with a ___ cuff.
Procedure uncomplicated, and the patient was extubated
post-operatively and went to the PACU in good condition. After a
brief, uneventful stay in the PACU, the patient was transported
to the floor in good condition for overnight observation.
From the evening of POD 0 into the morning of POD 1, the patient
was noted to be hypertensive to SBP 160s/170s, requiring pushes
of hydralazine 10 IV once and metoprolol tartrate 5 IV x4. His
outpatient cardiologist was contacted on the morning of POD 1
for recommendations on medication changes, but both he and his
NP were out of the office. The patient was given a one time dose
of atenolol 25 mg PO (in addition to his home dose of 75 mg BID)
and close follow up was arranged with his cardiologist on ___
___ for BP check. His home warfarin was also restarted on POD
1 without any bridging. The patient was otherwise doing well,
and deemed ready for discharge from the hospital.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge ___ The patient was discharged on his
home warfarin and ASA 81 daily, and will follow up with Dr.
___ in clinic in the next month.
***. | AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W/O MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-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 inpatient ward under the Acute
Care Surgery service on ___ after she sustained a witnessed
fall. She was taken to ___ for further
evaluation. A head cat scan revealed an acute-on-chronic" right
subdural hematoma and a cat scan of the cervical spine showed a
C1 lateral mass fracture. She was transferred to ___
___ for further evaluation and management.
Mrs. ___ was seen by the neurosurgery team who recommended no
intervention or follow-up regarding the acute on chronic
subdural hematoma. The C1 lateral body fracture was commented on
by neurosurgery as well as ortho spine. The spine team
recommended that a hard ___ collar be worn at all times
(other than for hygiene) for the next ___ to 16 weeks.
While inpatient, Mrs. ___ periods of agitation and
confusion which was expected after discussion with her children.
She was given intermittent doses of haldol. To better care for
her, the Geriatric service was consulted and made
recommendations regarding the management of her delirium and
anti-hypertensive regimen. The social worker provided support to
her family and a family meeting was held to inform the family of
discharge plans.
Mrs. ___ was admitted with a Stage I pressure ulcer to her
coccyx. Although being turned frequently and diligent skin care
via nursing staff, the wound developed into an unstageable skin
ulcer. The patient was seen by the wound care nurse, who made
recommended a skin regimen for its treatment.
Mrs. ___ vital signs have been stable and she has been
afebrile. She has been tolerating a regular diet. Her
electrolytes have normalized and she is voiding without
difficulty. On ___ she was discharged with followup in the
___. Upon discharge, the patient had a foley catheter
placed for urinary retention despite receiving flomax daily.
***. | TRAUMATIC STUPOR AND COMA COMA <1 HOUR WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
================
ASSESSMENT/PLAN:
================
Mr. ___ is a ___ male with pancreatic adenocarcinoma s/p
chemo/xrt with recurrence, s/p pancreaticoduodenectomy, biliary
stent c/b recurrent cholangitis and multi-organism bacteremia,
and recurrent C. Diff, who now presented with fevers, rigors,
and enterococcal bactermia secondary to recurrent cholangitis.
==============
ACTIVE ISSUES:
==============
# Recurrent cholangitis
# Enterococcus Sepsis, with acute blood stream infection
# Biliary obstruction s/p biliary drain placement
Patient presented to his scheduled PCP appointment with fevers
and rigors, and was found to have positive blood cultures for
pan-sensitive Enterococcus Casseliflavus. Because of his history
of VRE, patient was treated with IV daptomycin/meropenem which
was narrowed to IV daptomycin after speciation. Surveillance
blood cultures were negative x 48hours. Source of bacteremia
most likely ___ recurrent cholangitis. Bilirubin and alk phos
were elevated on admission. CT abdomen pelvis as well as MRCP
were significant for severe intrahepatic biliary ductal dilation
likely secondary to biliary stent obstruction. Other infectious
workup including UA, CXR, TTE, doppler U/S for portal vein
thrombosis, and U/S of port for abscess pocket were negative for
alternate infectious etiology. Patient underwent bilateral
percutaneous transhepatic biliary drain placement for source
control without complication on ___. T bili and LFTs
downtrended post-operatively. Of note, during that procedure, a
dense tissue mass was noted at the caudal aspect of his stent
which was very suspicious for tumor ingrowth. Biopsies were of
this mass were sent to pathology. Additionally, a small volume
of ascites was drained for cytology. Cytology and pathology
reports are still pending upon discharge. Plan to continue daily
daptomycin infusions until follow up with infectious disease,
Dr. ___, as an outpatient on ___. Will discuss
discontinuation of infusions vs. lengthening antibiotic course
at that time.
===============
CHRONIC ISSUES:
===============
# Pancreatic Adenocarcinoma:
Patient is s/p pancreaticoduodenectomy ___, chemo ___ with
recurrence ___ s/p cyberknife with course complicated by
hepatico-jejunal stricture requiring multiple PTBDs and multiple
infected bilomas/abscesses, biliary stents, and pancreatic
exocrine insufficiency. Currently followed at ___ by Dr.
___. Recent CT abd/pelvis and MRCP with concern for a
second recurrence with locally invasive pancreatic tail mass
which has increased in size after previous imaging. ___ procedure
as above was additionally notable for dense tissue at the caudal
aspect of the stent very suspicious for tumor ingrowth.
Pathology reports pending. Continue home Creon with meals.
Continue close follow up with oncology and palliative care as an
outpatient.
# Ascites:
Small volume ascites noted on prior admission with initial
concern for underlying malignancy, however, cytology negative at
that time (___). No known history of underlying liver disease.
Etiology of ascites unknown, however differential includes
hypoalbuminemia, direct result from complicated anatomy from
surgical intervention for pancreatic adenocarcinoma, stent
malposition, or unfortunately malignancy recurrence with
suspicious findings on CT and MRCP. Ascitic fluid was again
sampled during ___ procedure and sent for cytology. Cytology
report pending.
# CAD s/p MI, PCI ___:
# Chronic Diastolic CHF LVEF >55% (HFpEF):
Continued home metoprolol during hospitalization at reduced dose
(12.5mg BID) in the setting of bacteremia. Will continue lower
dose on discharge. Patient not on ASA given history of GI bleed.
# Recurrent C. diff:
No current diarrhea with low suspicion of recurrence. Continue
vanc 125 BID while on broad spectrum abx (___).
# Anemia:
HgB close to baseline range (___). Patient was scheduled for
outpatient iron infusion (ferric gluconate) at ___ for
___ which was given during this hospitalization for
convenience.
# DM:
Held home metformin while inpatient. Treated with insulin
sliding scale.
====================
TRANSITIONAL ISSUES:
====================
[ ] Continue Daptomycin IV infusions daily at ___ until
follow up with Dr. ___ end date ___
[ ] Continue PO Vancomycin while on daptomycin infusions to
prevent C. Diff recurrence. Continue until ___.
[ ] Please follow up with infectious disease, Dr. ___, on
___ to discuss duration of antibiotic treatment
[ ] Please follow up with interventional radiology, Dr.
___ 2 weeks of discharge
[ ] Please follow up with PCP ___ 1 week of discharge at
scheduled appointment
[ ] Medications added:
- Daptomycin IV (tentative end date ___
- PO Vancomycin 125mg BID (tentative end date ___ with IV
daptomycin, no taper needed)
[ ] Medications changed:
- Metoprolol tartrate 50mg BID was decreased to metoprolol
tartrate 12.5mg BID
[ ] Medications held:
- Home Metformin
ADVANCED CARE PLANNING;
DNR/DNI
___ ___
***. | SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ was admitted to the hospital and taken to the Operating
Room where he underwent an esophagoscopy, open ___
esophagectomy, buttressing of the anastomosis with omental fat
and injection of pylorus with Botox. He tolerated the procedure
well and returned to the PACU in stable condition. He
maintained stable hemodynamics and his pain was controlled with
an epidural. He remained NPO and was hydrated with IV fluids
and his J tube feedings resumed on post op day #1.
Following transfer to the Surgical floor he was very motivated
in his recovery. His nasogastric tube remained in place for
decompression and his ___ drain and aJP drain were putting out
serosanguinous fluid. He was up and walking frequently and
using his incentive spirometer effectively. His J tube feedings
were resumed as pre op, cycled at 85 cc;s/hr over 18 hrs (
Jevity 1.5). His incisions were healing well.
He underwent an EGD on ___ which showed the esophageal
anastomosis was widely patent and a superficial circumferential
healing ulcer was noted at the anastomotic site. He
subsequently began a liquid diet which he tolerated well and his
drains were removed without difficulty.
He was taking his medications orally without dysphagia and
continued to tolerate liquids. His port sites were healing well
and his J tube was clean and dry. He continues to tolerate his
cycled tube feedings with Jevity. After an uneventful recovery
he was discharged to home on ___ and will follow up with
Dr. ___ in 2 weeks.
***. | STOMACH ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Pt was admitted s/p fall and with some sacral pain and worsened
weakness above baseline weakness in the legs. Her imaging showed
sacral insufficiency fractures for which orthopedics was
consulted. They recommended conservative management,
weight-bearing as tolerated, and follow up in the orthopedics
clinic.
On admission, she had complained of a generalized malaise prior
to her fall, which felt very similar to her experience when she
had a prior lung infection. A Chest Xray was suspicious for
infection and she had a wet cough. We suspected that the
infection may have been the precipitant for her fall, and could
be responsible for a worsening of her underlying demyelinating
disease. Thus she was started on a 2-week course of Levaquin.
There was no evidence for inherent worsening of her underlying
demyelinating disease, and as such, no immmunomodulatory
treatments were considered.
She was evaluated by physical and occupational therapy who felt
she would benefit from a course of rehab. The day following the
initation of steriods, the strength, particularly in her
ileopsoas, was improved. There remained some weakness there on
the order of ___. There was more minor weakness at the hamstring
B/L (___), which was felt to be her baseline. The rest of the
___ strength was full. She did continue to have great spasticity
in her ___ B/L, which is also her baseline.
Her hospital course was otherwise only complicated by a
superficial burn to her L buttock after a hot-pack was left for
too long on ther skin. She has been getting ___ application per
day of hydrocortisone to the affected area, with pain meds
(largely Tylenol) as necessary.
***. | 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.
***
He was admitted to the Acute Care team and underwent CT iamging
of his pelvis showing left perianal abscess with surrounding
stranding measuring 3.8 x
2.9 x 2.0 cm; no supralevator extension or perirectal abscess.
He was given IV Unasyn and taken to the operating room for I & D
of the abscess, a ___ drain was left in place. He received
another dose of IV antibitoics and was then changed to
Augmentin, this will continue for 7 days total. His pain was
controlled with IV Dilauid initially and then he was changed
over to oral Dilaudid.
He was aslso started on an aggressive bowel regimen.
He is being discharged to home with skilled nursing services and
will follow up in Acute Care clinic next week.
***. | ANAL AND STOMAL 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.
***
Psych: Ms. ___ was admitted to psychiatry on ___ after
presenting to the ED with the above complaints. She was
intially started on Fluoxetine 40mg daily, Clonidine 0.1mg PO
TID PRN withdrawal, Mirtazapine 45mg PO QHS, and Seroquel 100mg
PO BID (morning and noon) and 500mg QHS, which were believed to
be her outpatient medications. After confirming with outpatient
providers, pt was also restarted on Methadone 70mg PO daily. Pt
continued to complain of hearing command AH and endorsing
difficulty sleeping; thus her Seroquel was increased to 200mg
QAM, 100mg Qnoon and 600mg QPM. On the second day of her
admission, pt was found to be smoking in the bathroom; it was
believed that her boyfriend had brought her the cigarettes
during her visiting hours, but this was unconfirmed. The
remaining cigarettes and lighter were removed from the patient's
possession by staff. In addition, on the second day of her
admission, the pt got into an altercation with staff. She began
arguing with a staff member, saying that she wasn't doing her
job. When other staff tried to guide the pt back to her room,
she became aggressive and started fighting them, scratching two
different staff members. She was then physically restrained and
brought to the seclusion room, where she voluntarily took Haldol
5mg, Ativan 2mg and Cogentin 1mg PO. She remained in the
seclusion room overnight with constant observation by security.
The following day the pt was unable to reflect on how she
handled the situation, stating that she was "disrespected" and
should have "punched" the staff member who she was fighting
with. Given concern for the pt and the other patients and staff
on the unit, pt remained in the seclusion room for an additional
day, although was allowed to leave the room for 15 minutes to
shower. After 36 hours, the pt was able to state that she would
not be aggressive with other patients or staff, and returned to
the unit on 5 minute safety checks. Pt continued to display
appropriate behavior on the unit and was eventually transitioned
to 15 minute safety checks. While in seclusion, the pt reported
that the voices had improved with the administration of Haldol,
thus the pt was started on Haldol 5mg PO BID, and, throughout
the remainder of her hospitalization, no longer expressed
problems with AH. Pt was offered the option of a Haldol
decanoate shot, but declined, stating that she would prefer to
take the oral medication. Pt was noted to be quite sedated on
the unit following the addition of Haldol; thus her Seroquel
dose was decreased to 600mg PO QHS only, with no additional
Seroquel during the day. She tolerated this change well, and
continued to deny AH.
Medical: The pt was restarted on her medications for HIV
(Combovir 1 tab PO BID, Lopinavir-Ritonavir 2 tabs PO BID) upon
confirmation of doses from her PCP, ___. She also
received a Nicotine patch, 14mg TD daily. Labs were drawn as
above, and pt was noted to have a mildly low WBC count (3.9)
with neutropenia (30% neutrophils) and a mild anemia (RBC 3.45,
Hct 31.4). Given her hx of HIV and anemia and lack of
concerning sx, this was not worked up further.
Legal: ___
Disposition: The ___ House was contacted and stated that
the pt had eloped on ___, but did not arrive at the
___ ED until ___ and had not given them any indication
that she was leaving. Thus, she was discharged from the ___
___ as elopement was against their policy. ___, our
SW, was told that the pt would only be able to return after
completing a dual dx treatment program. A search for an
inpatient dual dx program was initiated, but the pt ultimately
decided she would prefer to go to an outpatient treatment center
and stay with a friend. She was referred to the ___ Partial
Hospital program in ___, beginning the date after discharge. She
was also scheduled for a follow up appointment with Dr. ___
at ___ on ___ at 11am. She was given 2 weeks worth of
prescriptions for the medications that she required.
***. | PSYCHOSES |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is a ___ frail gentleman with known aortic
stenosis previously followed by serial echocardiograms, CAD s/p
PCI, HLD, muscular neuropathy presenting s/p ___ c/b TIA.
# AORTIC STENOSIS s/p ___: The patient underwent successful
___ valve) on the morning of ___. The procedure was
uncomplicated. There was a small post procedural perivalvular
leak. He was tranported to the CCU post op in stable condition,
extubated. He was told to continue on ASA and Plavix.
# TRANSIENT ISCHEMIC ATTACK: Left eye vision altered AM ___.
Neurology was consulted. Head CT was negative. It was thought
that this likely scenario is a small right parieto-occipital
infarct likely in the context of the procedure. His visual
deficits improved over the course of his hospitalization. He was
advised to follow-up with his opthalmologist as an outpatient.
# CAD: Aspirin, plavix and atorvastatin were continued.
# DIASTOLIC CONGESTIVE HEART FAILURE: Stable. Patient was given
a low salt diet.
# NEUROLOGIC MUSCULAR ATROPHY: Seen by ___ who recommended
outpatient physical therapy.
# ADVANCED AGE: seen by Geriatrics consult, who recommended iron
supplementation.
TRANSITIONAL ISSUES:
- patient should not drive until he is evaluated by an
ophthalmologist for vision changes
***. | CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is a ___ year old immunosuppressed woman with
systemic lupus complicated by glomerulonephritis, multiple
recent admissions for sequelae of renal biopsy including
perinephric and retroperitoneal hematomas as well as multiple
urinary tract infections, re-admitted for fevers, worsening
abdominal pain, and acute kidney injury. She was found to have
C.diff infection that was treated with IV 500mg Flagyl with
resolution.
.
# Clostridium difficile infection: She presented with fevers to
102 and tachycardia to 120s which resolved after 4L IVF.
Originally, we suspected urinary source of infection, given
recent multiple UTIs and potential ongoing nidus with known
hematoma. Thus, we pursued an ___ drainage of the
hematoma although the cultures were negative. The drain was
removed after 2 days when cultures were negative and there was
nothing draining out. (Note: even from the beginning, ___ could
not get any hematoma material to drain because it was very thick
and fibrinous. They injected dye and demonstrated that the two
hematoms are communicating.)
She was also having diarrhea and was found to have
positive C. diff. When she was given IV metronidazole her
fevers resolved, WBC trended down, and diarrhea resolved. She
was switched to PO metronidazole and continues to have clinical
improvement, she should continue this 500 mg Q8h until ___.
.
# Acute kidney injury (___): Given decreased PO intake,
diarrhea, and ongoing use of bumetanide at home the most likely
cause of her ___ was dehydration. Her urinary electrolytes were
consistent with a pre-renal azotemia according to FeUrea and her
urine did not have any casts concerning for active nephritis.
The creatinine improved from 2.3 on admission to 0.9 with IV
fluids. Her lisinopril, bumetanide, and gabapentin were
initially held while creatinine was elevated but then these were
restarted. She was continued on prednisone 60 mg daily,
mycophenolate mofetil 1500 mg PO BID, and hydroxychloroquine 200
mg PO BID for modification of lupus nephritis.
.
# Abdominal pain: Felt this was due to ongoing mass effect from
known hematoma and perinephritic capsule stretch. Her oxycontin
was increased to 80 mg BID and dilaudid was continued ___ mg IV
q3h. However, she continued to have incredible pain and so the
surgeric team was called. They did not think that she was a
surgical candidate while acutely infected with C.diff and were
nearly positive that removing the hematomas will not help her
pain. She was discharged on oxycontin 80 mg BID, dilaudid ___
mg q4 hours prn pain, gabapentin 800 mg TID, lidocaine gel 5%
daily, and clonazepam 1 mg q8h.
.
# Hypertension: Blood pressure on admission was 120s/80s which
was actually low for her (likely part of the SIRS syndrome she
had with C.diff infection). After the infection was under
control, her BP increased to 150-160s/100s. We want her BP
controlled less than 140/90 given lupus nephritis. Thus, we
restarted her home lisinopril 30 mg daily and then restarted
bumetanide 2 mg daily with good control of pressures. She then
developed hypotension with SBP 90-100 with three episodes of
sinus tachycardia. We discontinued her bumetanide and increased
her lisinopril to 40 mg daily.
.
# Asthma: No wheezes or shortness of breath, or cough now.
.
TRANSITIONAL ISSUES:
#Abdominal Pain: This was patient's major complaint for the
majority of her stay. Current pain medications have been
adequate for pain control with current abdominal pain of ___.
Patient should follow up with her primary care physcician to
assess quality of pain control.
- Attempt to taper narcotics as retroperitoneal hematoma is
absorbed.
- Consider appointment with pain clinic.
# Acute kidney injury (___) and hypertension: Given patient's
diagnosis of lupus nephritis and the changes that were made to
her antihypertensive medication, patient should be followed up
for assessment of kidney function as well as BP controlled to
<140/90. Currently her BP is in this goal with lisinopril 40 mg
daily and no diuretics. She may need adjustment of her doses.
- Check creatinine and potassium at follow-up
***. | MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Upon admission, an CXR was taken of Mr. ___ chest,
revealing a large left pleural effusion. A chest tube was
placed, which drained 2.5 liters of serosanguinous fluid. He
was placed on IV lasix. Vancomycin was started for sternal
erythema. Left EVH site was found to be open with purulent
drainage. This was cultured. Abx therapy was broadened to
include cipro and flagyl. His vein harvest site improved
greatly. Pt. has remained stable and is ready for discharge
home. He should follow-up in the wound clinic in 1 week.
***. | HEART FAILURE AND SHOCK WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year old man with past medical history signficant for chronic
pancreatitis and heptatis C admitted with abdominal pain
.
1. Abdominal pain: Likely due to intermittent gallstone
pancreatitis. His pain improved significantly after 3 mm
gallstone was removed from distal common bile duct with ERCP.
Initial differential include acute on chronic pancreatitis (No
elevation in lipase and unchanged CT abdomen speaks against it)
vs cholecystitis (No inflammatory changes seen on CT abdomen but
still on the differential) vs pancreatic cancer (no weight loss
or jaundice) vs pneumonia (no cough, shortness of breath, chest
pain and unchanged CXR speaks against it) vs liver pathology
(not consistent with clinical presentation) vs duodenal ulcer
(not consistent with clinical presentation and negative stool
guiaic) vs AAA aneurysm (not abdominal bruits and not consistent
with clinical presentation).
.
RUQ ultrasound showed increase in dilatation of common bile duct
from 5 mm to 10 mm compared to previous but no cholecystitis.
MRCP showed nonobstructing 3 mm stone in the distal common bile
duct. Once the stone was removed with MRCP, his abdominal pain
improved significantly and he was able to tolerate po intake and
pain meds. He was instructed to stop smoking and continue to
not drink alcohol, both of which can worsen his chronic
pancreatitis.
.
2. HTN: Held atenolol 100mg daily and amlodipine 10 daily as we
did not want to mask sinus tachycardia from volume depletion and
pain due to pancreatitis.
.
Labs to be followed by PCP
___ pylori antibody
***. | DISORDERS OF THE BILIARY TRACT 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 with history of stage IB grade 2 endometrioid endometrial
cancer s/p TLH-BSO ___ and adjuvant vaginal cuff
___ transferred to ___ from ___ with newly
diagnosed DVT and CT imaging of pelvic sidewall lymp node, for
which she was
transferred due to concern of recurrent malignancy.
ACUTE/ACTIVE PROBLEMS:
# Acute right lower extremity DVT: Patient with a prior history
of endometrial malignancy, currently in remission, although with
enlarged pelvic lymph node. Given concern for recurrent
malignancy, she was started on lovenox. Initial plan was to
discharge on lovenox BID due to possible underlying malignancy.
However, copay $900 for a one month supply. Given no diagnosis
of recurrent malignancy had been established, she was discharged
instead on xarelto. If biopsy returns consistent with malignancy
would transition back to lovenox as an outpatient given likely
superiority in patients with cancer-associated DVT. Discussed
with patient and she is aware of this. Will likely require 6
months of anticoagulation
# History of endometrial cancer s/p TLH-BSO with adjuvant
brachytherapy, now with CT evidence of enlarged pelvic lymph
node. She underwent ___ guided biopsy of pelvic lymph node with
results still pending at discharge. She also had a CT chest
without evidence of metastatic disease in the chest. She was
initially started on a heparin drip and was transitioned to
lovenox post biopsy, then xarelto at discharge (see below). She
will follow up in ___ clinic as an outpatient
to discuss biopsy results
CHRONIC/STABLE PROBLEMS:
# Hypothyroidism: continued home levothyroxine 150 mcg daily
# Hypertension: continued home metoprolol 25 mg daily
Transitional Issues:
- initial plan to discharge on lovenox BID due to possible
underlying malignancy. However, copay $900. Discharged instead
on xarelto, but if biopsy returns consistent with malignancy
would transition back to lovenox as an outpatient given likely
superiority in patients with cancer-associated DVT. Discussed
with patient and she is aware of this. Will likely require 6
months of anticoagulation
- if continues on xarelto, transition to 20mg daily after 21
days
- pelvic lymph node biopsy results pending at discharge
- will f/u with Dr. ___ gynecologic oncology on ___
***. | 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.
*** w/ CNS lymphoma admitted for C34 HD MTX.
CNS Lymphoma: remains stable w/o evidence recurrence on
admission brain MRI done ___, but reports some worsening short
term memory. Reassuring neuro exam and last MRI without
progression. However, MTX aborted as she reported worsening URI
see below. Rescheduled for 2 weeks from now ___ readmit.
Upper respiratory viral illness. Reported cold symptoms of nasal
congestion and mild headache and feeling run down since day
prior to admission. Initially felt these were improving and
wanted to proceed w/ MTX but then felt worse from viral
respiratory standpoint and wanted to go home. We did a flu PCR
to rule out flu, and she will call in to office tomorrow to find
out results. If positive she can be prescribed acyclovir. No
symptoms were terribly concerning; lungs were clear, no
coughing, no fever, hemodynamics stable. WBC normal. Symptoms
seemed consistent with mild viral illness. Suggested she stay
for PCR results or monitoring overnight for clinical trajectory
but she strongly wished to go home.
Word finding difficulties - describes memory issue of short
term, misplacing object, MRI brain stable as above, prelim 24
hr EEG w/ some temporal lobe spikes but no seizure activity. No
other neurologic changes, other possibility is methotrexate
leukoencephalopathy but would be very early, had mild
periventricular ___ matter changes on MRI but this has been
stable. Cont MTX spaced out q4 months and dose reduced. Continue
prophylactic/empiric keppra in case subclinical seizure
contributing. Pt was supposed to get MRI this admit but will get
staging MRI when she comes back in 2 weeks for MTX.
Depression: Continued home venlafaxine
***. | 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.
***
PATIENT SUMMARY
================
Ms. ___ is a ___ woman w/hx of severe AS, HFpEF, B cell
lymphoma (chemo: Bendamustine/Rituximab), HCV/ETOH cirrhosis
(c/b esophageal varices and recurrent ascites), initially
admitted to ___ from clinic with concern for tumor lysis
syndrome s/p rasburicase. She had a prolonged hospital course
with multiple ICU stays, but in brief:
Patient was initially admitted to ___ service from clinic with
concerning for TLS and recieved rasburicase. She was also
administered a chemo regimen of bendamustine and rituximab.
While on the ___ service, she developed Afib with RVR, NSTEMI,
and hypoxemic respiratory failure due to pulmonary edema and
ultimately required FICU transfer and intubation. Cardiac work
up was notable for a TTE showing severe AS and a LHC/RHC which
showed partial occlusions of ostial RCA and mid RCA. The patient
was transferred to the cardiac service where no coronary
interventions were pursued and the patient was managed
medically. Her course was further complicated by continued
hypotension, hypoxemia due to persisting pleural effusions and
CHF, and concern for numerous infections (including HAP, SBP),
requiring several ICU/floor transfers. A chest tube was placed
for drainage of the effusions and later removed after
resolution. Ultimately, the patient underwent a TAVR on ___
for treatment of her severe valvular disease complicated by CHF.
Post TAVR, the patient was treated for VRE UTI, NSTEMI, volume
overload, cdiff, as well as progressive cytopenias. She was
treated with antibiotics, diuresed until respiratory status
improved, and her blood counts were monitored, though with
ongoing cytopenias by time of discharge.
ACTIVE ISSUES
==================
# Triliniage Cytopenia
# Neutropenia
The patient had persistent cytopenias of unknown origin
throughout admission. While she was recently diagnosed with low
grade B cell lymphoma, her malignancy could not explain the
cytopenias as there was no significant bone marrow involvement
noted on biopsy. It was postulated that her cytopenias may
possibly be an effect of linezolid vs cirrhosis vs CMV, though a
definitive diagnosis was not reached. She was continued on
acylovir for viral prophylaxis in the setting of neutropenia.
Her labs were trended while admitted and the patient was
discharged with heme onc follow up.
# Dyspnea
# Aortic stenosis
# Pleural effusions
Throughout the patient's course, she had multiple problems that
could have contributed to dyspnea including severe AS
complicated by congestive heart failure s/p TAVR and diuresis,
pleural effusions s/p chest tube placement, and hospital
acquired pneumonia s/p antibiotics. However, despite the
therapeutic interventions noted above, the patient still had
persisting intermittent dyspnea late in her hospital course.
This was felt to be due to anxiety as she was not hypoxic. The
patient was started on buspar and provided coping strategies.
# ___ Edema
The patient developed lower extremity edema even after adequate
diuresis. Vascular studies were negative for DVT. She was
continued on spironolactone on discharge, but home lasix was
held as she was otherwise euvolemic.
# Chest Pain
# NSTEMI
Early in her hospital course, the patient complained of chest
pain with labs notable for troponemia. Coronary angio ___
with moderate CAD ostial and mid RCA, no intervention performed.
She was continued on aspirin, statin, and beta blocker. She
later was found to have recurrence of troponemia, felt to be
demand ischemia in the setting of her numerous other medical
problems. Also, a component of the patient's chest pain was felt
to be musculoskeletal in nature, so the patient was given pain
medications to good effect.
# Macrocytic, Hemolytic Anemia
Macrocytic anemia on admission, baseline ___. Blood smear
suggestive of intra-vascular hemolysis, supported by elevated
LDH, haptoglobin <10, increased absolute reticulocyte count in
the setting of severe aortic stenosis. Direct antiglobulin test
was negative. The patient underwent TAVR for treatment of her
aortic stenosis and her anemia was otherwise managed as
discussed above.
# Anxiety
# Delirium
History generalized anxiety disorder and substance use disorder,
prolonged hospital stay complicated by multiple episodes
delirium, often with visual hallucinations. She was given
Haldol, with improvement in hallucinations. Substance abuse
consult while inpatient resulted in 5 mg buspar BID and 0.25-0.5
mg.
# C. difficile colitis
She was originally diagnosed on ___, completed 14-day course
of PO vancomycin. She had an episode of recurrent C diff colitis
in setting of antibiotic use and was restarted on oral
vancomycin with plans for prolonged taper as outlined by ___
guidelines and infectious disease consult:
- 125 mg orally four times daily (___)
- 125 mg orally twice daily for 7 days (___)
- 125 mg orally once daily indefinitely
# Fevers
# Infectious disease
The ___ hospital course was complicated by recurrent
fevers and numerous infections. She received empiric antibiotics
several on several occasions and was treated with antibiotics
for hospital acquired pneumonia (vanc, Cefepime/zosyn,
transitioned to ceftriaxone), VRE UTI (linezolid), and c diff
(described above).
CHRONIC/STABLE ISSUES
=====================
# B-Cell Lymphoma
Recent diagnosis prior to admission. She was admitted with
concerns for tumor lysis syndrome. Her high uric acid level was
treated with rasburicase and started on allopurinol. Her B-cell
lymphoma was treated with bendamustine, rituximab and
dexamethasone. However, given cardiorespiratory issues as
discussed, further chemotherapy was held for the remainder of
the patient's admission.
# Subacute rib fractures
Minimally displaced subacute appearing fractures involving the
posterior right ninth rib, in the anterior right eighth rib, and
the posterior left eleventh rib. Bilateral L5 pars defects are
noted. unclear etiology, as no suspicious osseous lesions.
corrected Ca WNL. Per patient, she had an accident years ago
with injury to her R ribs, however it was unclear if this was
the true cause.
# HCV/EtOH Cirrhosis
Previously complicated by ascites and grade I varices (Last EGD
___. Patient was s/p Harvoni treatment with SVR in early ___
with requirement of intermittent paracenteses. MELD score 10,
Child ___ 8 class B. Peritoneal fluid positive for malignant
cells consistent with high-grade B cell lymphoma with plasma
cell differentiation. Liver U/S showed patent liver blood flow
through portal veins and IVC. Her hospital course was
complicated by hypotension and fluid shifts likely related to
paracentesis. Diuretics including IV and PO Lasix, were titrated
during her stay and the patient was ultimately discharged on
only spironolactone only.
# Hypotension
The patient was noted to have orthostatic hypotension even after
being treated for various shock states due to cardiogenic and
infectious etiologies. She was started on midodrine, with
stabilization of BPs.
# Tobacco Abuse
# Anxiety
Current 1ppd smoker. Hx of polysubstance abuse. Tobacco use was
treated with nicotine lozenge and patch. Substance abuse consult
for mgmt of substance use and addiction while inpatient started
her on 5 mg buspar BID and 0.25-0.5 mg Ativan PRN for acute
anxiety. Sleep problems treated with ramelteon and trazodone.
# Protein calorie malnutrition
Prior history of heavy EtOH abuse, last drink was 6 weeks prior
to admission. No prior history of withdrawal. Continued folate,
thiamine, and multivitamin, and patient was followed by
nutrition throughout hospitalization.
TRANSITIONAL ISSUES
=====================
[] In addition to PCP, the patient should have post discharge
appointments with heme/onc, cardiology, and hepatology services.
Please ensure that the patient follows up with each of these
specialists.
[] The patient was noted to have ongoing cytopenias of unknown
origin. Please re-check CBC with differential and consider
further work up such as repeat bone marrow biopsy or further lab
testing.
[] The patient's treatment of B cell lymphoma was put on hold
due to her complicated hospital course. Defer to outpatient
oncologist regarding when to re-start chemotherapy.
[] The patient was not immunized against hepatitis B, please
vaccinate when able.
[] Lasix was stopped on discharge as the patient was felt to be
euvolemic. She was continued on spironolactone for additional
benefit in the setting of cirrhosis. Please assess volume status
and diurese as needed.
[] Please ensure appropriate post TAVR monitoring including
repeat TTE if indicated.
[] The patient endorsed significant anxiety due to her numerous
medical problems. Please assess the patient's mental status and
consider titration of medications or supportive therapy.
[] Re-check vital signs, consider discontinuing midodrine in the
future if BPs stabilize.
[] The patient was discharged on an oral vancomycin taper to be
continued indefinitely. Due to lack of insurance, the patient
was only able to receive a 30 day supply from the ___ Care
Pharmacy. A prior authorization was submitted through the
___ Drug Utilization Review Program (phone:
___ for further supply of oral vancomycin. Please
ensure that this is processed and that the patient has access to
her required medications.
Vancomycin regimen per ID:
- 125 mg orally four times daily (___)
- 125 mg orally twice daily for 7 days (___)
- 125 mg orally once daily indefinitely
# CONTACT/HCP: ___ ___
***. | 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.
***
___ yo M with ESRD s/p DDRT in ___, DM, HTN, dCHF, CVA here with
worsening anemia, UTI and ___ on CKD.
# Anemia with HCt 21 from baseline ___. No obvious bleeding
source, guaiac negative. Likely a combination of iron deficiency
anemia and anemia of chronic inflammation/kidney disease.
Received 2u pRBC with appropriate response. H/H stable for the
remainder of hospitalization.
# UTI: Pt presented with positive UA. UA/UCx from rehab showed
cipro/ceftriaxone sensitive E.coli. Patient also with recent
admission for urosepsis(cipro sensitive E.coli), s/p 2 wk cipro
___. Given recurrent UTI, ID consulted. Pt with hx
of urinary retention and despite mostly low PVRs during
hosptialization, recurrent UTI thought to be due to urinary
retention. Small concern for chronic prostatitis, but no
tenderness on rectal exam. Was initially on ceftriaxone, but
clinical improvement, transitioned to ciprofloxacin for a total
two week ___ last day ___. Day prior to
presentation, pt with isolated fever that resolved w/o
intervention. Pt will follow up with urology for hx of urinary
retention.
# Acute on chronic kidney disease: Cr of 2.8 on admission up
from baseline of around 1.9. Likely from hypoperfusion in the
setting of anemia, recent BPs in the 100s(relative hypotension),
and infection. Txp renal ultrasound with mild fluid around
kidney, debris in bladder, but otherwise unremarkable. With
holding home diuretics/blood pressure meds, tx of infection, Cr
improved back to baseline. Home blood pressure meds/diuretics
started except for valsartan. Will be restarted as outpatient as
needed.
# BPH/ high PVR: He had previously been started on straight
caths are part of bladder training per the recommendation of his
outpatient urologists and nephrologists. He continued to have
high PVRs (500), but began refusing straight catheterization.
The risks and benefits of intermittent straight catheterization,
long term foley vs no catherezation was discussed and was
decided to continue with intermittent straight catherization as
needed. Later in hospitalization, pt had low PVRs. Tamsulosin
0.8mg was contiued. Will follow up with outpatient urologist.
# Hypertension/CAD : Had difficult to control HTN last admission
on a complex 5 drug regimen. On admission this time, he had
relative control without his full home regimen likely reflective
of relative hypotension. His home regimen was restarted as his
blood pressure increased, and on discharge he was on home
labetalol, hydralazine, amlodipine, and isosorbdide mononitrate.
Valsartan 160mg BID held and not restarted on discharge in the
setting of resolving ___ and SBP of 130-150 on discharge.
Restart as needed
# dCHF: Home furosemide was held due to ___. Restarted once
improvement in ___. O2% mid ___ on discharge.
# CVA: His atorvastatin 40mg QPM was continued. His
Clopidogrel 75mg PO daily was held in case biopsy was needed in
the event his creatinine did not imporve, but improvement was
restarted.
# GERD: Omeprazole 40 mg PO DAILY was continued.
# DM II: Continued on previous discharge dose of 12 units NPH in
AM as well as Insulin Sliding Scale.
# Glaucoma: Continued home eye drops.
=====================================
TRANSITIONAL ISSUES
=====================================
[ ] Home Valsartan 160mg BID held and not restarted on discharge
in the setting of resolving ___ and SBP of 130-150 on discharge.
Restart as needed
[ ] Patient with hx of urinary retention. Will need straight
cath if post void residual>400 until patient follows up with
urologist
#CODE: Full
#CONTACT: Patient, ___
Relationship: wife
Phone number: ___
***. | OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
PRINCIPLE REASON FOR ADMISSON:
___ year old male with refractory high grade DLBCL s/p 6C of
R-CHOP, C2 R-ICE and 1C of gemcitabine now presenting for CAR T
cell infusion with FLU/CY prep.
#Refractory high grade lymphoma: Admitted to receive fludarabine
and cyclophosphamide conditioning regimen in preparation for
CAR-T infusion. Received FLU/CY D-5 [___], D-4 [___] and D-3
[___]. Underwent CAR T cell infusion on ___ without acute
complications. Neuro checks were maintained q4 post infusion.
CRP/ferritin initially checked q4 hours before tapering per
protocol. Of note, CRP elevated at baseline [suspect due to
progressive lymphoma]
but downtrending since receiving CAR-T. He was started on
acyclovir and Bactrim ppx.
# Fever:
# Grade I CRS: Developed fever ___. Patient was asymptomatic and
briefly on
cefepime. CRP elevated at baseline but downtrening. No evidence
of hypotension or neuro-toxicity, CXR negative, cultures
negative
to date. Antibiotics were DC'd on ___.
#Headache: Stable bifrontal headache over the last several
months prior to admission. It has been attributed to his
underlying disease.
He continued with oxycodone prn with relief, and added oxycontin
10mg q12 hours. He had no new neurologic symptoms this
admission.
# Rash: Patient has a mild maculopapular rash ___.
Reports similar to rashes he has had in the past. Not pruritic,
may be a chronic eczematous reaction. Looks a bit better this
afternoon. No steroid cream given CAR-T therapy. Continued to
monitor and improved prior to discharge.
#Vocal Cord Paralysis: He developed left vocal cord paralysis
over the previous 2 weeks prior to admissont due to worsening
mediastinal adenopathy confirmed by CT scans and ENT evaluation.
He was started on prednisone outpatient and now currently
tapered off as below prior to CAR-T infusion. Received 20mg
prednisone on ___ received 10mg of prednisone on ___ and
completed final dose of prednisone (5mg) on ___. His symptoms
were stable this admission.
#Malnutrition, mild: weight down ~ 10lbs from admission weight,
suspect due to progressive disease and/or recent lymphodepleting
agents, consulted nutrition for recommendations.
#Constipation: stooling daily, added bowel regimen, continue to
monitor
#Anxiety: He has history of benzodiazepine addiction: Tapered
down per PCP recs, now 2mg qhs prn insomnia/anxiety only.
#Hip pain: Improved and neurologically intact, ROM intact, no
evidence of trauma, no pain on palpation. Likely secondary to
CAR T cell infusion, bone marrow stimulation, inflammatory
response that is similar to neupogen injections. Continued
oxycodone and added oxycontin 10mg q 12 hours.
#Back pain: Stable. Unknown etiology, occurred since starting
chemotherapy. He continues with oxycodone prn with relief, and
added oxycontin 10mg q 12 hours.
#Hyperlipidemia: Reports he has not been taking home meds, and
we continued to hold antilipid therapy during active
chemotherapy given drug-drug interactions
#BPH: Continued finasteride qhs
#Psych: SW followed in-house
TRANSITIONAL ISSUES:
- Started Oxycontin 10mg q12 hours
- Started acyclovir and Bactrim ppx
- DC'd home atorvastatin and prednisone
FOLLOW UP: scheduled ___ or sooner if issues arise
***. | 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.
***
Mr. ___ was admitted to the service of Dr. ___ for
a removal of hardware L4-S1. He was informed and consented for
the procedure and elected to proceed. Please see Operative Note
for procedure in detail.
Post-operatively he was administered antibiotics and pain
medication. His catheter and drain were removed POD 2 and he
was able to take PO's. His pain was well controlled and he
remained afebrile throughout his hosptial course. He will
return to clinic in ten days. He was discharged in good
condition.
***. | SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC |
Subsets and Splits