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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.
***
Mr. ___ was admitted to the hospital and taken to the
Operating Room where he underwent ___ esophagectomy,
esophagoscopy and wrapping of anastomosis with intercostal
muscle. He tolerated the procedure well and returned to the
SICU extubated and in stable condition. He maintained stable
hemodynamics and his pain was controlled with an epidural
catheter.
He had periods of delirium post op and unfortunately removed his
nasogastric tube on post op day #1. He subsequently desaturated
and required reintubation. A bronchoscopy was done which showed
clean airways and he was eventually extubated. Antibiotics were
not started as his WBC was 10K. He was reintubated on ___
due to hypercarbia and marginal saturations. He underwent
another bronchoscopy and bile was noted in his airways. At that
point he was placed on broad spectrum antibiotics and he was
sedated and paralyzed as his CXR demonstrated ARDS. His
hemodynamics suffered and he required pressor support
additionally. He was leukopenic for 24 hours then gradually had
a leukocytosis of 25K. An EGD demonstrated an intact
anastomosis and healthy tissue. As his hemodynamics stabilized,
his pressors were weaned off and his sedation and paralytics
were also gradually weaned. He was eventually weaned and
extubated from the respirator on ___. He stayed in the ICU
for additional days for close monitoring and he gradually
improved.
Following transfer to the Surgical floor he had both a
videoswallow which ruled out aspiration and a barium swallow
which showed no anastomotic leak. From a neurologic standpoint
he had periods of delirium and confusion, possibly medication
related. He was placed on his pre op dose of Seroquel along
with pain medication including pre op Methadone. His S.O. felt
that he had some intermittent confusion pre op while on
Methadone. His post op pain was minimal and his Methadone was
decreased to 5 mg daily and eventually stopped. He used
oxycodone ocasionally with effect. A head CT was done also which
ruled out any abnormal pathology.
He had an episode of vomiting a small amount of bile and
subsequently underwent an EGD to rule of pyloric stenosis. His
anastomosis appeared healthy and the pylorus was dilated without
difficulty. Some bile was noted in the endotracheal tube and it
was suctioned out along with bile in the oropharynx. He
subsequently underwent a bronchoscopy to evaluate and wash out
the airway. He developed severe bradycardia during the
procedure which resolved without treatment but for that reason a
BAL was not obtained. He had no further bradycardia but
unfortunately developed rapid atrial flutter on ___ and
returned to the SICU for closer observation and rate control.
He was seen by the Cardiology service and subsequently
cardioverted into NSR. He remains in NSR on oral Amiodarone
which will gradually be weaned off over the next 4 weeks. His
blood pressure was controlled with his pre op Clonidine and his
Diltiazem was not restarted due to its interactions with
Amiodarone. He will follow up with the Cardiology service in 4
weeks.
Nutrition was maintained post operatively initially with replete
via his J tube then eventually Nepro as he had some unexplained
hyperkalemia in the low 5 range with a normal creatinine. He
tolerated cycled feedings over 18 hours at 55 cc's per hour and
was eventually advanced to soft foods in modest amounts which
were also tolerated well. His potassium level remained in the
4.0-4.4 range with Nepro.
The Physical Therapy service evaluated him on a regular basis
and noted improvement in his mobility and endurance. He was able
to walk independently as well as climb stairs. The Occupational
Therapy service also evaluated him and felt that he was at his
baseline functional capacity but had some anxiety issues that
bothered him. He was given some relaxation exercises to work
on.
After a long and protracted post op course, he was discharged to
home on ___ and will follow up in the Thoracic Clinic in 2
weeks.
***. | STOMACH ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
====================
TRANSITIONAL ISSUES
====================
Discharge weight: 63.73 kg (140.5 lb)
Discharge BUN/Cr: 19 / 0.8
Discharge diuretic: furosemide 40 mg daily
[] Adjust diuretics as needed
[] Continue to encourage patient to consider CRT-D
[] Encourage smoking cessation. Prescribed nicotine patch/gum.
Consider adding bupropion and/or varencycline.
[] Patient had significant constipation and a single episode of
hematochezia while hospitalized. Consider referral for
colonoscopy.
Advanced Care Planning:
#CODE: Full code
#CONTACT/HCP: ___
===============
BRIEF SUMMARY:
===============
___ y/o M with h/o 5-vessel CABG in ___, ischemic cardiomyopathy
(EF 15%), LBBB with wide QRS (offered CRT-P but declined),
ongoing tobacco use, who presented with acute onset respiratory
distress and chest pressure, found to have NSTEMI and acute
pulmonary edema vs. CAP. He briefly admitted to the CCU for
BIPAP and quickly improved with diuresis and antibiotics.
Nuclear stress test showed large fixed defects but no reversible
ischemia. He was offered CRT-D but declined. He was discharged
home at functional baseline, and close f/u was arranged with
___ Heart Failure team and his prior cardiologist.
====================
ACUTE ISSUES
====================
# Acute on chronic HFrEF (LVEF 15%) / ischemic cardiomyopathy:
# NSTEMI, likely type II:
# CAD s/p CABG (LIMA to first diagonal [due to small caliber of
LIMA], SVG to LAD, SVG to PDA, SVG to ramus intermedius, SVG to
second OM):
Patient presented with acute onset shortness of breath and chest
pressure and was found to have found to have an elevated
troponin-T (0.14 -> peak 0.64), proBNP of 5177, and right-sided
consolidations on CXR. EKG was difficult to interpret for
ischemia due to baseline LBBB and frequent PACs/PVCs but was
unchanged from prior. We suspect he had flash pulmonary edema
from ischemia, likely type II due to hypertension (SBP was 200s
on first EMS evaluation) or pneumonia (see below), though type I
NSTEMI also possible (see below). Repeat TTE showed EF 15% with
both global and regional dysfunction. Nuclear stress test showed
fixed defects in the LAD and RCA territories but no reversible
ischemia, so cath was not pursued. He was treated with IV lasix
-> PO lasix 40mg daily, IV heparin for 48 hours, aspirin, and
atorvastatin. Beta-blockers were not started due to very low EF.
Entresto was continued and spironolactone added. He was offered
CRT-D multiple times for cardiac optimization and prevention of
lethal arrhythmias but he declined. Close f/u was arranged with
___ Heart Failure team and patient's prior cardiologist.
# Community acquired pneumonia:
Given his respiratory distress, unilateral right-sided
consolidations, and leukocytosis to 15, he was treated for CAP
with ceftriaxone/doxycycline -> cefpodoxime/doxycycline for
5-day course.
# Acute hypoxemic respiratory failure:
Thought to be due to acute pulmonary edema vs. CAP as discussed
above. Briefly required BiPAP. Resolved with diuresis and
empiric antibiotics.
# Left bundle branch block with wide QRS:
# Frequent premature atrial and ventricular contractions:
___ CRT-D multiple times to optimize cardiac function and
prevent sudden cardiac death but declined.
======================
CHRONIC ISSUES
======================
#Tobacco use disorder:
Started nicotine patch and gum.
#Hematochezia:
#Constipation:
Patient had significant constipation and one episode of
small-volume hematochezia while inpatient. Hgb remained normal
and stable. Started bowel regimen. Consider outpatient
colonoscopy for further evaluation.
***. | ACUTE MYOCARDIAL INFARCTION DISCHARGED ALIVE WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ yo man h/o morbid obesity, DM2, HTN, CVA, chronic LBP,
asthma/COPD, OSA admitted with acute on chronic LBP and urinary
retention/incontinence after obtaining a colonoscopy.
# acute on chronic LBP. Mr. ___ was transferred from OSH
ER for concern for cauda eguina syndrome with c/o urinary
retention, saddle anasthesia, and worsened LBP. Here in the
___ ER, a lumbar spine MRI did not reveal any spinal
cord/cauda equina compression. There was clearly evidence of
degenerative disc disease and some evidence of root compression
at various levels. While here, he was treated initially with
dilaudid and valium - but he became hypoxic and confused. Both
those medications were stopped with good resolution.
He was placed on oxycontin 30 mg twice a day and given
oxycodone 5 mg every ___ hours as needed. On this regimen, his
pain was much better controlled and he was able to ambulate to
the bathroom. ___ was consulted and felt that he was safe enough
to go home with home ___. He is well aware of the importance of
wt loss and even optimization of sleep apnea (which may lead to
hyperadrenergic/hypercortisol state that lead to increased
weight). He has expressed interest in following up with the
Weight Clinic at ___.
He will have senna in the meantime while being on oxycontin -
to be sure that he stays ahead of the opioid.
# Urinary retention: No evidence of cauda equina on the lumbar
MRI. The urinary retention apparently preceded the use of
opioids (other than oxycodone) and followed immediately after a
colonoscopy. It is theoretically possible that the colonoscopy
aggravated an underlying enlarged prostate and thus led to
prostate inflammation and urinary retention. He was placed on
terazosin and was on foley temporarily. Off the foley, he has
been able to urinate without difficulty and had no evidence of
urinary retention.
# Sleep apnea - during the nights, Mr. ___ had hypoxic
events while asleep. He was placed on CPAP and adjusted
pressures. He was placed on oxygen NC with some good effect,
although he is a mouth breather at times.
A follow up sleep clinic visit has been set, as detailed
below.
# DM2 - He was well controlled in house with metformin and
insulin sliding scale. He may resume the insulin glargine when
he returns home.
# HTN - well controlled on zocor, imdur, norvasc, ACEI, HCTZ
# COPD/asthma - continued with advair, spiriva, albuterol PRN
# Proph: Heparin SQ
***. | MEDICAL BACK PROBLEMS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is a ___ yo woman with Afib (not on coumadin), HTN,
previous left hemisphere stroke in ___ (left inferior division
MCA), now with acute new right hemispheric ischemic stroke. Exam
indicates patient is obtunded, no vocal response, does not
respond to commands, dense left hemiplegia. CT/CTA/CTP shows
complete infarction of right hemispehre including MCA/ACA and
deep striatocapsular branches. In addition, she has an old left
inf division MCA stroke. The patient presented
outside conventional 3 hour iv-tpa window and 6 hour ia window.
CT perfusion studies indicate complete infarction with massively
prolonged MTT and severely reduced CBV which was indicative of a
severe stroke. A follow-up CT head the next morning revealed an
evolving infarct with hemorrhagic conversion, edema, mass
effect, and early herniation. She was kept with HOB > 30
degrees, BP allowed to autoregulate, and fluids limited due to
cerebral edema. Given her extremely poor prognosis, a family
meeting was held and it was decided to make the patient comfort
measures only as this would be most consistent with her wishes.
Approximately 24 hours after transitioning to CMO care the
patient passed away.
***. | INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is a ___ with recent diagnosis of hypoplastic MDS
with del 13q, recent admission for initiation of ATG and
cyclosporine, now admitted for GNR bacteremia.
# GNR Bacteremia: Etiology was unclear, though most likely is GI
vs GU. Pt w/urostomy and hx of UTIs with known nephrolithiasis,
though no change in urine per patient. New bands and
thrombocytopenia on exam. No diarrhea, cough, abdominal pain. Pt
had stable VS and no fever. Lactate wnl. Culture found pan
sensitive GNR. Ciprofloxacin 500 mg BID was started. Urine
culture grew Pseudomonas. Patient remained afebrile with stable
VS on Cipro.
# MDS: Hypoplastic MDS, s/p ATG and cyclosporine initiation,
C1D1 ___. Has been on cyclosporine 100 mg BID. Prednisone
10mg prednisone qd. Was given Atovaquone 1500mg qd, Acyclovir
400mg BID ppx.
# Electrolyte Imbalance: Pt with new hyponatremia and AG
acidosis. Most likely in setting of new high grade infection.
Maintained aggressive hydration with LR. Lyte ibalance and
acidosis resolved.
CHRONIC ISSUES
==============
# CKD: Gave fluids. Monitored urine output which remained
stable. Baseline Cr 1.2-1.6, was 1.5 on admission, 1.5 on
discharge.
# HTN: Held patient's losartan 12.5 mg w/c/f possible sepsis. VS
remained stable and pt's losartan 12.5mg was restarted.
# MEDREC: continued with home calcitriol, B12
***. | SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Overnight Ms ___ abdominal pain improved and serial
abdominal exams were performed with no concern for acute
abdomem. A CT of the abdomen showed no evidence of bowel
obstruction, and no evidence of bowel distention. Overnight her
pain was treated with vicodin and she received IV fluids. She
was not incontinent of stool or urine. Her WBC fell from 10.2 to
8.0. She felt significantly improved on HD1 (POD2) and she was
discharged home.
***. | UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is a ___ y/o male with a history of mixed lineage
leukemia s/p auto SCT day ___ who was sent in from clinic due to
nausea, vomiting and diarrhea.
.
# Diarrhea: The concern was for GVHD however infectious etiology
was also a consideration. He denied any fevers, chills or night
sweats however he notes that multiple family members had been
sick with similar symptoms. He had a colonoscopy with biopsy
that did not reveal GVHD. He stool sample came back rotavirus
positive which was consistent with his symptoms. All other stool
studies were negative. He was discharged on Prednisolone 20mg
daily and Vancomycin 125mg QID due to his history of C. diff.
The Vancomycin can be titrated down as an outpatient.
.
# Transaminitis: On his last admission he was diagnosed with
acute GVHD of the liver. He continued to have elevated LFTs
however they trended downward during his admission. He was
discharged on Prednisolone 20mg daily and his Tacro was
continued at 1.5mg twice a day.
.
# Hypoglycemia: He was noted to have a couple of episodes of
hypoglycemia with BS in the ___. These episodes happened in the
morning. His glargine was subsequently stopped and he was paced
on a sliding scale that was less aggressive than the sliding
scale he presented with. He was discharged on this sliding scale
which can be adjusted as an outpatient. He was followed by
___ during his admission.
.
# MLL s/p SCT: He was day ___ on admission after his SCT. His
differential continued to be reassuring. Although he has been
having isssues with GVHD, he has been doing well. He was
continued on acyclovir and started on Micafungin for fungal
prophylaxis. His Fluconazole was discontinued due to elevated
LFTs.
.
# Knee Pain: He was having knee pain due to increased activity.
He was going to bring this issue up during his clinic visit
however he was admitted for his diarrhea. He was discharged on a
short course of oxycodone and will discuss this issue with his
outpatient providers.
***. | ESOPHAGITIS GASTROENTERISTIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient presented to pre-op on ___. Pt was evaluated by
anaesthesia and taken to the operating room for laparoscopic
sleeve gastrectomy. There were no adverse events in the
operating room; please see the operative note for details.
Pt was extubated, taken to the PACU until stable, then
transferred to the ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a PCA and then
transitioned to oral Morphine once tolerating a stage 2 diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. On POD1, the NGT
was removed and an upper GI study was negative for a leak,
therefore, the diet was advanced sequentially to a Bariatric
Stage 3 diet, which was well tolerated. Patient's intake and
output were closely monitored. JP output remained
serosanguinous throughout admission; the drain was removed prior
to discharge.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a stage 3
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
***. | 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.
***
Ms. ___ was admitted to the ___ service after being struck
by a truck on ___. She has a history of alcoholism and prior
spine trauma
Injuries include: intracranial hemorrhage, a left humerus fx,
acute on chronic L1-2 burst fx, and left rib fractures ___ and 3
& 8.
Neuro: Neurosurgery was consulted for patient's right falcine
SDH, SAH and IVH. No vascular injury was found on CTA
head/neck. Repeat CT head was stable on the following day.
Keppra was continued for one week, per neurosurgery. On HD 2,
she developed hallucinations after ketamine drip which was
discontinued. Epidural was not placed per APS, as the patient
had a SAH. The patient was reintubated on HD 3 or agitation.
Precedex was trialed as a bridge to extubation but the patient
remained agitated. She was then placed on propofol and fentanyl.
When she was extubated on ___, she received PO oxycodone with
good pain control. Her mental status steadily improved.
Resp: The patient was intubated on HD 3 for agitation and
combativeness. Also on HD 3, the patient developed thick
secretions and cultures were sent which revealed GPCs on gram
stain, so empiric vancomycin and cefepime were started on ___.
Initial difficulty was encountered while attempting attempted to
wean to pressre support. She was extubated then re-intubated on
___ (HD 7) for poor mental status. The patient was extubated on
___ (HD 9) and weaned to room air. Cultures eventually
speciated as MRSA, so vancomycin was continued.
GI/FEN: The patient received tube feeds via OGT while intubated
and NGT when extubated. She passed a speech and swallow for
grounds and thin liquids on HD 12, so the plan is to wean
tubefeeds as her oral intake improves. Nutrition was following
patient and she was getting calorie counts. She developed
hyponatremia so started on 1 g NaCl TID and was free water
restricted.
GU: Foley was placed for urine output monitoring and UOP was
appropriate. In her state of delerium, the patient was noted to
be pulling at the foley and developed some hematuria, which
resolved. The foley was d/c'd on HD13.
MSK: Orthopedics was consulted for the left humerus fracture and
ortho-spine was consulted for the L1-L2 fractures. The left
humerus fracture was splinted with ___ to LUE and she
will follow up in clinic as an outpatient. The L1-L2 fractures
were deemed acute on chronic and non-operative. She was fitted
for TLSO brace on HD 3.
An MRI C-spine was completed on HD 5 and showed no new or acute
fractures or obvious ligamentous injury. C-spine clearance was
attempted on HD 12, but collar was replaced due to pain with
neck movement.
Heme: SQH was held for 48 hours after head injury due to
intracranial hemorrhage then restarted on HD 3. On HD 5, she
received 1 pRBC for Hct 21.9.
ID: Sputum culture from ___ grew MRSA and she was initially on
vanc and cefepime for HCAP. The patient was intermittently
febrile, so cipro was added for double pseudomonas coverage.
Fevers stopped when vancomycin level was therapeutic, so
cefepime and cipro were discontinued on HD 12. U/A was negative
and UCx was negative. BCx showed no growth. She transitioned to
Bactrim on HD13 and will complete a full 2 weeks course of
antibiotics for MRSA pneumonia.
Prophylaxis: SQH was started on HD 3 once imaging showed stable
intracranial hemorrhage. The patient was out of bed with
physical therapy.
On discharge the patient was overall doing well. She was
hemodynamically stable and medically cleared to be transferred
to rehab to continue her recovery. The patient and her husband
were aware of the plan and expressed verbal agreement. The
patient had follow-up appointments made with ACS, neurology, and
orthopedics. She will follow up with her PCP after discharge
from the rehab.
***. | 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.
***
___ female with a history of recurrent stage IIIC
adenocarcinoma of the ovary who presents with a GI bleed.
#. GI bleed: Her hematocrit on admission was 20.1 which was
decreased from her recent baseline of about 28. She remained
hemodynamically stable but was transferred to the ICU for
monitoring. She was given 4 units of PRBCs and had an
appropriate hematocrit increase post-transfusion. There was
concern that her pelvic mass had invaded her bowel mucosa and
vasculature causing a GI bleed. GI was consulted who did an EGD
and colonoscopy both not revealing for a source of bleeding.
Patient then had a capsule endoscopy and was discharged home
with close follow-up with oncology. She was counseled on
warning signs of further bleeding and fatigue.
#. DM: She was continued on lantus and SSI.
#. Recurrent ovarian cancer: She was given her dose of topotecan
prior to admission. There was concern for continued growth of
her pelvic mass despite recent chemotherapy. She is to
follow-up with her primary oncology team a few days after
discharge.
#. Hypothyroidism: Continued on home levothyroxine.
#. Code Status: She was full code during this admission.
***. | 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.
***
Patient was initally seen in clinic. Please see clinic note for
details. Patient was then seen in the pre-operative area, and
once again the severe risks associated with the procedure were
discussed with her and her family. ___ again consented to the
procedure as she stated that she could no longer live
comfortably as she was, and wanted to do anything to get to a
better state of health, despite the risks. In the operating
room the planned procedure was carried out (see operative note)
however, the patient became asystolic and ACLS protocol was
carried out. She was asystolic for approximately 1 minute and
underwent chest compressions. She was intubated and taken to
the ICU. B/L chest tubes were placed, the right sided for the
operative site and the left for inspriatory deficit.
Her course from there on out was complicated mainly by a massive
air leak and was unable to take adequate inspiratory volumes in
order to maintain her oxygenation ad respiration. She was awake
and alert for the majority of her stay. A second right sided
chest tube was placed on POD 1, for residual apical
pneumothorax, which improved with decompression. Tube feedings
were maintained for nutrition. Her urine output was normal with
a normal creatinine. She did have a large amount subcutaneous
emphysema, which was lessened somewhat with chest tube suction
on the right side.
By POD 5, she was still unable to wean off the ventilator.
Despite other organ systems being stable, she decided, after
multiple conversations with the housestaff, Dr. ___ the ICU
team, that she did not want to continue on a respirator and did
not want a tracheostomy if there was little hope of improving to
the point of weaning off ventilatory support.
After conversation to this effect, she decided that she wanted
to be extubated and made Comfort Measures Only. This was done
in the afternoon ___. She expired shortly thereafter.
***. | MAJOR CHEST PROCEDURES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is a ___ man with history of HLD, PMR on
prednisone presenting with abdominal pain, found on imaging to
have abdominal mass likely of pancreatic origin now awaiting
pathology from biopsy.
# Abdominal pain
# Abdominal mass likely pancreatic primary
Patient presenting with 1 week of abdominal
pain, found to have abdominal mass and elevated lipase on
ultrasound suspicious for malignancy. Up to date on colonoscopy
screening. On CT scan found to have large mass with multiple
areas of likely metastasis. ___ was consulted biopsied mass
___. Pathology is currently pending. He is to follow-up in
the multidisciplinary pancreatic ___ clinic once pathology
has resulted. For his pain he was started on low-dose
oxycodone. He does have a past history of alcohol use disorder,
we discussed the risks of opiates and the red flag symptoms
which should make him call his PCP.
[] Follow-up pathology results
[] ___ clinic
#Anxiety
Patient with severe anxiety in the setting of new cancer
diagnosis. Was given low-dose Ativan given his continued racing
thoughts. Social work met with him to talk about his new
diagnosis. He was well supported by his family and partner. He
was discharged with 10 tablets of 1 mg Ativan. He was counseled
on the risks of benzodiazepines. Have contacted his primary
care office to alert them that I have started him on this
medication. He will need close follow-up an appointment has
been made in 2 days from now with his primary care provider
___ than 30 minutes were spent on complex discharge
***. | MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS 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 HIV/AIDS (CD4=68) and h/o CNS toxo, HIV-dementia, h/o
seizures and chronic pain on opiates who presented with chest
pain and initially diagnosed with pnuemonia and then further
workup discovered that he had metastatic lung adenocarcinoma
with mets to the bone leading to cord compression now s/p T4
corpectomy who continues to have pain management issues.
# Metastatic adenocarcinoma with Left upper lobe likely primary
and new T7 compression fracture status post spinal surgery
(transpeidcular corpectomy) for a T7 pathologic fracture on
___ with multiple other lesions on bone consistent with lung
adenocarcinoma. Oncolgy was consulted regarding scheduling
outpatient oncology follow-up for patient. Ortho oncology was
consulted for the lesion to the acetabulum, but this was deemed
non-operative. Radiation oncology was consulted and they
recommended outpatient followup. Pallative care was consulted
and they recommended increasing pain medications and began
discussion with the patient about goals of care planning.
Details are within their notes. Orhto spine said that he may get
chemo, radiation at site of spine surgery after ___ weeks due to
healing.
He needs to continue wearing TLSO brace while walking. Pain
control as below.
#Chronic body pain: Patient with history of chronic right sided
body pain secondary to thalamic pain syndrome and now metastatic
cancer reported continued pain throughout his hospitalization
that was very challenging to control. Because of this, the pain
service was consulted and recommended his current regimen of
oxycontin, standing dilaudid and prn dilaudid. He was tolerating
this regimen at the time of discharge. He was continued on
lyrica and started on tizandadine on ___.
#Femoral lesion: Ortho onc does not believe need for surgery yet
of femur met recommended rad onc. Role for zoledronic acid- less
likely because poor dentition although pt doesn't have any of
his own teeth will not need right now and would defer to ortho
onc and oncolgoy about decision.
#HIV/AIDS and CNS toxo: Has not had acute change in neuro exam
since time of admission. His CD4- 68 on this admission. We
continued Truvada/raltegravir/etravirene - talked with patient
about importance of not refusing HAART. He recived dapsone for
PCP ppx and we continued pyrimethamine for CNS toxo and
leucovorin 25mg daily.
Inactive problems:
# GERD - tums prn
# Bowel regimen
- bisacodyl prn
- miralax added prn
- senna and docusate scheduled
# Vit D deficiency
- 50,000 units a week
#Pneumonia: Patient with infiltrate on CXR of unclear etiology.
Given the patient's recent housing in a SNF and his severe
immunocompromise it was felt that he warranted empiric treatment
of HCAP. He was treated with vancomycin and cefepime narrowed to
levoquin.
#Long QTc: Patient was noted to have a prolonged QTc at time of
admission in setting of having recently been perscribed a
Z-pack. There was additional concern that narcotics may have
been contributing to his long QTx. The patient did not have any
other known medication exposures or electrolyte abnormalities to
explain his prolonged QTc. QT prolonging medications were
avoided during admission and the patient's QTc normalized.
Translational Issues:
Coordination of care- between oncologists, id, rad onc, ortho
spine, and
# CODE: Full Confirmed
# CONTACT: Unknown, no HCP- as documented in social works
patient is estranged from family and has fired court appointed
guardian and is currently competent to refuse decision.
The following follow-up was recommended by the spine service:
1. Use the TLSO brace when walking, but okay to be out of bed to
a chair without it
2. Continue ___
3. Follow-up with ___ , who will determine when to
remove the staples and may repeat an xray
***. | SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE OR MALIGNANCY OR INFECTION OR EXTENSIVE FUSIONS 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 evaluated by surgical service in the ED. Patient had
intense abdominal pain with peritoneal signs and tenderness. A
CT scan shows a small bowel obstruction with transition point in
the pelvis. She was taken to the OR for SBO and underwent
Exploratory laparotomy, over sew of enterotomy and lysis of
adhesions. She tolerated the procedure well and was admitted
the floor. Acute pain was following her for her epidural and
pain control.
She was transferred to the SICU on ___ with hypotension and had
multiple bouts of diarrhea. She received 2 L on the floor and
another 1 L in the ICU for resuscitation and her BP, her Hct was
Hct: 34->26->29. Her BP was stable after being bolused.
Patient is Jehovah's witness and refuses all blood products. C
diff was sent for her diarrhea and she was started of empiric
Flagyl. C diff was negative x 3 as were blood and sputum
cultures.
Following transfer to the Surgical floor she continued to
complain of some abdominal pain and nausea. She was seen by the
Chronic pain service for management and she seemed to improve
slowly on Oxycodone and Flexeril. She was eventually able to
get up, ambulate without difficulty and increase her intake.
Her chronic nausea persisted and she was evaluated by the GI
service who felt that it was possibly made worse by Flagyl. Her
C diff's were all negative therefore her Flagyl was
discontinued. She was gradually able to increase her intake and
eventually tolerated a regular diet. She was also seen by the
Bariatric service who will continue to follow her as an out
patient.
Her abdominal wound was healing well and she will have her
staples removed at her first post op visit. She was finally
discharged on ___ and will follow up in the ___ in 2
weeks.
***. | MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is an ___ year old woman with hypertension,
paroxysmal atrial fibrillation on eliquis, diabetes, prior TIA,
suspected dementia, recent diagnosis of
seizure disorder on keppra with reported side effect of
increased sleepiness presenting as OSH transfer with new right
frontal IPH.
# Right frontal IPH
Patient received Kcentra (on Eliquis) and labetalol (SBP >200)
at OSH prior to transfer to ___. On arrival to ___, exam
notable for left facial droop, L arm > L leg weakness, and right
leg weakness (baseline). Her interval head CT on arrival showed
bleed to be stable. Her SBP goal was <140, gradually liberalized
to <150. This required nicardipine gtt and antihypertensives as
below. Her Eliquis was held, but ASA 81 mg was restarted on
***** for anticoagulation given history of afib.
Attempted to obtain MR brain, but patient did not tolerate
despite premedication with seroquel. Review of MR ___ brain from
OSH from ___ does not reveal large underlying lesion. GRE
with blood products in same area of current bleed and her
history of cognitive decline suggests a history of amyloid.
Etiology of her IPH most likely amyloid compounded by
anticoagulation for atrial fibrillation and uncontrolled
hypertension.
#Epilepsy
Concern that increased sleepiness could represent nonconvulsive
seizures. cVEEG with right frontal slowing. Her home keppra 500
mg BID was continued without change. Review of OSH GRE
(performed ___ on presentation for first time seizure)
reveals blood products in area of current bleed. This is
concerning for an underlying amyloidosis leading to ___,
resulting in seizures.
#Dementia
Home donepezil held during hospitalization, but should be
resumed at time of discharge.
#Hypertension
Goal blood pressure on admission of systolic less than <140.
Required a nicardipine gtt to achieve blood pressure goal as
well as continuation of all her home antihypertensives and the
addition of 2 new antihypertensives, chlothalidone and
felodipine. Her systolic blood pressure goal was liberalized to
less than 150. At time of discharge her blood pressure regimen
is as follows:
- Clonidine 0.2 mg BID (Home medication)
- Atenolol 100 mg qAM, 50 mg qPM (Home medication)
- Hydralazine 100 mg TID (Home medication)
- Losartan Potassium 50 mg BID (Home medication)
- Chlorthalidone 25 mg PO/NG DAILY (started ___
- Started Felodipine 5mg (started ___
#Atrial Fibrillation
Eliquis held in setting of IPH. ASA restarted for
anticoagulation on ___. It was felt that patient is not a good
candidate for resumption of oral anticoagulation given the
presence of superficial siderosis on MRI from OSH.
# Mood
Concern for depression during hospitalization. Started
fluoxetine 20 mg daily ___.
# Diabetes
No changes to home mediations upon discharge. Home meds were
held during hospitalization and blood sugar was controlled with
sliding scale insulin.
================================
Transitional Issues:
[ ] Stroke Neurology Follow Up
[ ] Established Outpatient Neurologist: continued management of
cognitive decline, epilepsy
[ ] PCP: perform thyroid ultrasound to assess interval increase
in size of hypodense thyroid nodules noted on ___ ___
CTA head/neck.
[ ] PCP: follow 4.3 cm fusiform ascending aortic aneurysm over
time.
[ ] PCP: ___- chlorthalidone and felodipine
added to home antihypertensive regimen
[ ] PCP: ___ depression. Fluoxetine 20 mg daily started ___
[ ] PCP: consider restarting donepezil
===============================
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No.
If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(bleeding risk, hemorrhage, etc.)
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form?
(x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No. If no, why not? (I.e. patient at
baseline functional status)
***. | 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.
***
Ms. ___ is an ___ yo woman with thrombocytopenia secondary to
ITP receiving monthly IVIG, atrial fibrillation (previously
anticoagulated with warfarin but stopped in ___ due to
SDH/SAH and ITP), type 2 diabetes mellitus, hypertension,
moderate-severe AS (valve area 0.9 cm^2, peak gradient 42 mm
Hg), and recent admission (___) with syncope and NSTEMI
managed medically due to thrombocytopenia who presented with
NSTEMI complicated by development of cardiogenic shock
necessitating transfer to the CCU.
# Hypotension: Patient presented with systolic blood pressures
in 90-100's with rising lactate and decreased urine output
concerning for hypoperfusion. She was found to have an NSTEMI
and new reduction in LVEF on this admission. She was medically
treated for her NSTEMI with aspirin and heparin drip. She
continued to have recurrent chest pain with persistent elevation
in cardiac biomarkers (peak CK-MB 59), raising concern for
ongoing ischemia and worsening pump function. On physical exam,
she had warm extremities, crackles throughout the lungs, and
trace pitting edema. She was afebrile and does not have any
symptoms and signs of infection. Hypotension, rising lactate,
low urine output were suggestive of progressive cardiogenic
shock due to recent and possibly ongoing ischemia and acute
decompensated of HF with new decrease in EF. Patient underwent
cardiac catheterization (see below) and subsequently improved
and was sent to floor where her BPs were stable prior to
discharge.
# NSTEMI/CAD: Patient presented with substernal chest pain with
EKG showing diffuse ST depression and T wave inversions as well
as elevated troponin-T, higher than on previous admission (0.3
on previous admission to peak 1.8 on ___. Initially coronary
angiography was deferred in an effort to avoid committing her to
anti-platelet therapy given her thrombocytopenia and history of
SAH/SDH less than one year earlier. However, her chest pain
became refractory to nitroglycerin gtt and she was
decompensating, so was transferred to the CCU for more serious
consideration of cardiac catheterization in conjunction with
hematology and neurosurgery. During her CCU stay, patient
underwent urgent cardiac catheterization with documentation of
cardiac index 1.8, PCW 26, PA 72/30/44, SBP 70-80s and had IABP
placed. Angiography also revealed Lcx disease and RCA chronic
occlusion but vascularized by collaterals. She was begun on
heparin for her CAD and IABP and diuresed. She received
increasing doses of isosorbide mononitrate, hydralazine and was
begun on metoprolol. As her condition improved, patient was
weaned off of the IABP. She was deemed to be a poor candidate
for revascularization given comorbidities so was treated
medically with amlodipine, ASA, atorvastatin, clopidogrel,
isosorbide mononitrate, metoprolol, and nitroglycerin with
successful elimination of chest pain at time of discharge.
# Decompensated systolic CHF: Patient presented in decompensated
heart failure with cold extremities, obvious hypervolemia on
physical exam, elevated lactate and NT-pro-BNP, and decreased
urine output. She was started on a furosemide gtt with initial
improvement in her urine output, normalization of her lactate,
and improvement in her clinical status. However, as her chest
pain became more difficult to manage she developed rising
lactate again and was transferred to the CCU. A TTE on ___
revealed severe hypokinesis/near-akinesis of the inferior and
inferolateral LV with EF ___ (decreased from 50% on ___
during prior hospitalization). On arrival to the CCU, patient
appeared mildly hypervolemic on exam with concern for
cardiogenic shock. She was diuresed aggressively with furosemide
boluses and gtt from 15 to 20 mg/hr before transition to an oral
regimen. She was discharged with ongoing lower extremity edema
but no shortness of breath or chest pain at weight 67.5 kg. She
was discharged on torsemide 80mg BID for maintenance.
# UTI: Patient noted to have hypothermia, UA with increased WBCs
and GNR, started on empiric ceftriaxone given hypotension,
___. UCx ___ growing Klebsiella sensitive to
cephalosporins. WBC uptrending, on chronic prednisone. Patient
treated with a 5 day course of ceftriaxone from ___.
# ___: Patient with worsening ___ likely multifactorial
secondary to cardiorenal syndrome, recurrent hypotension, and
contrast from coronary angiography but has improved with
diuresis to Cr 2.0 at time of discharge. Per family, would
preferential keep patient euvolemic with goal of comfort and
willing to sacrifice kidney function if necessary as a result of
diuresis.
# Hyponatremia: Thought to be hypervolemic hyponatremia in the
setting of CHF and water-avid state. Uosm 360s, Sosm 314
(elevated given high BUN predicted is ~305). AM cortisol 31.5,
TSH 1.1. Improved with diuresis.
# Atrial fibrillation: Rate controlled with metoprolol. Not
anticoagulated at home despite h/o CVA due to ITP and history of
SDH/SAH.
# ITP: Patient with ITP and history of SDH/SAH. Platelets 5 on
___, received IVIG and Rombipostim with recovery of platelets to
47 on admission and 270 at time of discharge.
Hematology/oncology followed the patient during her
hospitalization. She received romiplostim on ___. She is
going home on hospice for management of life-limiting illness
including CAD and CHF but as ITP is potentially life threatening
(especially while on dual anti-platelet therapy to treat her
severe coronary artery disease and recurrent myocardial
infarcts), she will continue on management of this condition
with romiplostim as discussed in goals of care. Per heme, her
prednisone will be tapered to 20 mg daily starting ___ and 10 mg
daily starting ___. She should follow up with heme regarding
whether to discontinue the medication at that time.
# Goals of care: Patient was made DNR/DNI on this admission.
Patient was discharged on hospice due to life-limiting nature of
CAD and CHF but per family patient will continue on treatment
for ITP as it is unrelated to her life-limiting illnesses and is
within her goals of care to prevent bleeding by maintaining her
platelet count at safe levels.
Chronic issues:
# Hypertension: BP medications as above
# Hypothyroidism: Continue levothyroxine
# DM: on glipizide at home, continued on discharge. SSI in house
discontinued on discharge.
TRANSITIONAL ISSUES:
- Patient on Romiplostim weekly; will require CBC every week and
follow up with heme-onc to adjust the dose.
- Patient was discharged on home hospice care
- Patient started on amlodipine. Defer to outpatient provider
for titration of dose to optimize blood pressure.
- Patient had ___ on CKD but after discussion with the family
they value maintaining euvolemia and reduction of symptoms over
maintaining kidney function.
- patient discharged on dilaudid for symptomatic treatment of
chest pain.
# CODE: DNR/DNI
# CONTACT: Daughter ___ ___
___ weight: 67.5 kg
Discharge Cr: 2.0
***. | 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.
***
Ms ___ was admitted admitted to the neurosurgical service for
close neurological observation. An MRI of the entire spine
showed: At C7-T1 level there is widening of the interspinous
distance with anterior compression of T1 vertebra identified.
There is disruption of the ligamentum flavum seen at C7-T1 level
with increased signal in the interspinous region. Subtle
increasing spinal cord signal is seen at T1 level. The right
facet joints are mildly subluxed but no evidence of perched or
locked facet seen. The left facet joints are normally aligned.
The prevertebral soft tissue
thickness is maintained. The remaining thoracic vertebral bodies
demonstrate
normal signal. There were no cervical from C6 and above or
lumbar abnormalities.
She was kept on strict flat bedrest with log roll precautions.
She was fitted for a Somi brace. On ___ she underwent a
posterior cevical/thoracic fusion and right iliac crest bone
graft under general anesthesia. She tolerated this procedure
well, was extubated, transferred to PACU and then floor when
stable. She was maintained in Somi brace though pt did take it
off on her own on morning ___. It was replaced and refit by
ortho tech. She was transitioned to PO pain medication,
activity advanced. Her right leg continued to be slightly weak
as pre-op. She was seen in consultation by ___. Wounds were
clean and dry. She had occipital scalp laceration that was
followed by the Trauma service for poor healing.
Discharged to home following clearance from ___, agrees with
plan of care. Follow up as outlined in discharge instructions.
***. | SPINAL PROCEDURES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ arrived to ___ intubated for airway protection.
He was examined by our ED neurology resident and found to have a
blown pupil on the right with little spontaneous movements or
withdrawal to painful stimuli in his extremities. A repeat CT
scan of his head obtained in the ED confirmed the devastating
size of his CNS intraparenchymal hemorrhage. He was admitted to
the neuro ICU. On further family discussions, the family
confirmed that he would not want to remain intubated and depend
on mechanical life support. They agreed for comfort measures.
Subsequently, Mr. ___ was terminally extubated and placed
on a morphine drip. He peacefully passed away at 2045hrs on ___ with his family at bedside. All of their questions were
answered. The medical examiner's office was informed about the
patient's death, and declined to perform an autopsy.
***. | INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient is a ___ year old male with severe COPD on chronic
Prednisone therapy who is was admitted with abdominal pain and
dyspnea. Pt's abdominal pain resolved on admission and did not
recur.
.
#. COPD, acute on chronic: Patient initially evaluated for
abdominal pain but subsequently evaluated with impression of
COPD flare. Chest film is without infiltrate, no increase in
sputum production from baseline. Pt breathing better today, with
improved exercise tolerance.
Patient was treated with steroid burst with 40 mg for 2 days,
and then will be discharged with a rapid taper back to his
previous 10 mg po qod. Antibiotics were withheld, as there was
no evidence of infection. He was continued on Advair, and was
treated with standing nebulizers. He was evaluated by physical
therapy, and he mainained oxygen saturations 87% and greater
while ambulating, with rapid return to 96% with rest. Pt was
referred to pulmonary rehab at time of discharge.
.
#. Abdominal Pain: Per OMR review, symptoms are not new. Mid
abdominal pain with normal CT; sx currently resolved. Patient's
dose of PPi was increased to 40 mg po bid.
- continue PPI bid with consideration of gastritis vs. PUD as
etiology of symptoms
- would consider outpatient H. Pylori testing and treatment if +
for potential PUD vs. non-ulcer dyspepsia
- will defer further workup to pcp if symptoms recur.
.
#. Diabetes Mellitus II controlled without complication
- held Metformin for 48 hrs after IV contrast for abd CT
- provided Insulin sliding scale while in house
- resumed Metformin/Glipizide on discharge
.
#. Hypertension, Essential: Poorly controlled on admission with
SBP 180/80.
Pt's lisinopril currently at reduced dose s/p previous
hospitalization d/t hyperkalemia. K currently at upper end of
normal, so increased amlodipine from 5 to 10 mg with improved BP
control.
.
#. Tobacco Abuse: Previous 5PPD, now ___
- continue efforts towards abstinence
.
#. Anemia, B12 Deficiency - continue B12 therapy as outpatient
.
#. Glaucoma: Continue gtts per outpatient regimen
.
#. FEN - Cardiac Heart Healthy Diet
.
#. Code - Full, confirmed with patient
.
#. Dispo - to home today with services and referral to pulmonary
rehab
.
#. Communication - Patient
***. | 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.
***
She is a ___ female with musculoskeletal neck pain and
cervical spinal cord compression on MRI with a prior fusion at
C6-C7. She presents for elective surgery.
#cervical stenosis
On ___ Patient underwent a ACDF C6-7. The procedure was
uncomplicated and well tolerated. On POD#1 she was tolerating PO
diet without no dyaphagia, pain remained well controlled, she
was ambulating, and voiding. She was discharged home in stable
condition.
***. | CERVICAL SPINAL FUSION WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ y/o M with PMHx significant for CAD s/p CABG in ___,
multiple stents in ___ and ___, sCHF (EF 35%), recent h/o PEA
arrest, MAT, COPD on 2L home O2, ILD, IDDM, PVD, CKD (baseline
Cr 1.1-1.4) and probable cholangiocarcinoma not amenable to
surgery or chemo with multiple recent admission now returning
from his rehab with fevers to 102.8, hypoxia (84% on 2L) and
tachycardia to 128.
# Sepsis
Per report at rehab, patient met ___ SIRS criteria with fever to
102.8 at rehab, tachycardia to 128, leukocytosis upon arrival
and tachypnea with desaturation at his rehab. On arrival to the
floor he was hemodynamically stable and started on
vanc/cefepime/flagyl. He continued to spike low-grade fevers
intermittently. Potential causes included a lung source given
continued pleural effusions(but patient declined thoracentesis),
transient GI bacteremia from his biliary mass, or tumor fever.
Other potential etiologies, such as UTI or SBP, were unlikely
based on examination and labs. He remained lucid throughout his
hospitalization. His blood cultures had no growth to date (final
results still pending) and he was ultimately discharged on
Levaquin to complete a 7-day course of antibiotics, per patient
and family's request.
# Goals of Care
Patient admitted under full code, but had declined certain
therapies. After a goals of care family meeting with palliative
care and a ___ interpreter, the patient decided that he
wants full medical work-up for his medical problems, but wishes
to be DNR/DNI, in line with his ultimate goal of returning home
as quickly as possible.
# Hyponatremia
Na 131 upon admission from ___ prior, likely secondary to
insensible losses from fever and poor PO intake. His sodium
improved later that morning with gentle fluids but returned low
the following day. His levels were unable to be monitored
further as patient declined further laboratory draws.
# AoCKD:
Cr. 1.6 on admission from baseline 1.1-1.4. Likely volume
depletion as above. Cr did not improve significantly with time,
though patient declined further laboratory draws.
# INACTIVE ISSUES
-sCHF (EF 35%): held Lasix and metoprolol initially
-CAD s/p CABG and DES: Aspirin was continued
-COPD/ILD: Per report, patient's home O2 is 2L and he was
desatting to ___ on this. However, per last d/c summary, home O2
is 3L and he is now stable on 3L.
-h/o Spontaneous Bacterial Peritonitis: Bactrim was held while
he was on broad spectrum antibiotics as above
-T2DM: Home dose Lantus 4U qhs was continued with added insulin
sliding scale
-Anemia: H/H at baseline; continued home iron supplement
-Likely cholangiocarcinoma: per last d/c summary, he is not a
surgical or chemotherapy candidate and he did not want further
workup.
-BPH: Tamsulosin was continued
-Ischemic gastritis: Protonix was continued
-Sleep/Appetite: Trazodone/Mirtazapine were continued
# TRANSITIONAL ISSUES
- Patient discharged to complete 7-day course of levofloxacin
(Day 1= ___
- If he has fevers, may treat symptomatically if he is
hemodynamically stable -- as there is no clear infectious source
identified
***. | SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is a ___ year old woman with Childs C HCV cirrhosis
(c/b esophageal varices, ascites, HE), history of portal vein
and superior mesenteric thrombosis on Coumadin, s/p TIPS c/b
liver ischemia ___, history of PE, and aortic stenosis s/p
TAVR (___) who presents with abdominal pain.
***Acute Issues***
#Abdominal pain
Pt has longstanding history of abdominal pain related to
umbilical hernia. She presented to an OSH where an abdominal CT
was performed that showed patent TIPs, pancreatic head lesion,
umbilical hernia with minimal fat stranding and no bowel
inflammation or obstruction. Pt reported pain located at area of
small subcutaneous nodule and RLQ. Imaging notable for soft
tissue abnormality at area of tenderness, likely related to
medication injection. Otherwise, LFTs were at her baseline and
lipase was only mildly elevated. She has a known umbilical
hernia that was operated on in the past and has recurred but it
is reducible on exam. No ascites on CT. Given baseline LFTs,
normal lipase, normal lactate and no ascites, her abdominal pain
was unlikely due to biliary pathology, pancreatitis, bowel
ischemia or SBP. A RUQ US was also performed in the hospital and
did not demonstrate etiology of her pain. Etiology appears
chronic given history and acute processes ruled out.
# Anasarca:
Patient with worsening edema of the ___ and CT scan with evidence
of anasarca. B/l ___ US were negative for DVT. Etiology likely
due to both known diastolic heart failure and cirrhosis.
Recently switched to torsemide 40 daily. EKG w/o evidence of
ischemia and hx not c/w this. No evidence of infection. CXR
clear and pt w/o hypoxia. No ___. Patient has had recent changes
to her diuretic regiment (On 40 mg furosemide BID recently
changed to 40 mg torsemide daily) and it is unclear if she was
properly taking her medications. She was treated with IV lasix
and then transitioned to PO torsemide 40mg daily at discharge.
#Pancreatic head lesion
Discussed with radiology and mass seen on OSH stable and
possibly improved when compared with prior CT scan in ___ and
MRCP. No repeat imaging indicated.
# HF with preserved EF
# Severe AS s/p TAVR
# Hypertension
Follows with Dr. ___ in cardiology. S/p TAVR ___ for severe
AS. Aortic valve gradients have been stable on recent echo. She
was recently seen in clinic and with worsening shortness of
breath and peripheral edema, furosemide 40 mg PO BID was changed
to torsemide 40 mg PO daily. Because of her volume overload, she
was treated with IV lasix in the hospital. She was continued on
clopidogrel. She was discharged on torsemide 40mg daily.
# HCV Cirrhosis:
___ Class B, MELD-Na 21 on admission (on Warfarin).
Complicated by portal HTN with variceal bleed s/p TIPS,
recurrent episodes of HE, ascites controlled by diuretics, and
PE/PVT/SMV thrombosis. T bili and ALT/AST at baseline on
admission. Patient being evaluated as transplant candidate.
Pancytopenia at baseline with new neutropenia, likely ___
splenomegaly, portal HTN & cirrhosis. She was continued on home
lactulose, rifaximin and spironolactone. Torsemide was 40mg
daily upon discharge. Patient will see transplant surgery as an
outpatient.
# SMV and portal vein thrombosis
# Pulmonary embolism
Diagnosed during prior admission for abdominal pain in ___.
On warfarin at home. Pt treated with warfarin in the hospital.
She will be given warfarin 3.5mg prior to discharge and then
will be managed by ___ clinic on ___. Repeat
INR on ___.
======
CHRONIC ISSUES:
# GERD:
Continued home omeprazole 20 mg daily
# Vitamin D Deficiency:
Continued vitamin D 5000 units daily
# Narcolepsy:
Continued home concerta
***TRANSITIONAL ISSUES***
[] Discharge Weight: 63.0kg
Medication changes:
-Discharged on warfarin 3.5mg daily on ___. ___
___ called and confirmed will manage starting
on ___
-Torsemide dose left unchanged at 40mg daily
-Spironolactone increased to 150mg daily
-Consider standing potassium based on lab tests on ___
[] Will need labs including CBC, CHEM 10, LFTS, INR, PTT on
___. Will be drawn by ___.
[] Follow up with transplant surgery and hepatology to continue
transplant workup
[] Continue to monitor I/O, K and weight.
***. | 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.
***
Pt admitted to postpartum service for IV antibiotic treatment of
mastitis refractory to PO treatment. On admission, pt febrile
to 102.7 with WBC of 23.1. On day of admission, pt underwent
u/s guided drainage of 5cc of thick greenish- whitish fluid.
Fluid sent for gram stain and culture. Pt started on IV
vancomycin for presumed MRSA. Breast surgery consulted. Pt
underwent three additonal U/S guided drainage of abscesses while
in house, the last on ___. Wound cultures from ___ and
___ proved to be positive for MRSA. Pt also seen by ID who
made recommendations regarding length of treatment, family
testing, and laboratory testing to ensure resolution of
bandemia. Pt continued to improve. On ___, vancomycin trough
checked and found to be subtherapeutic. Vancomycin dose
increased to 1.25g Q12hours. Repeat trough on ___ found to
be therapeutic. Blood cultures negative. CBC demonstrated
resolution of bandemia.
PICC line placed placed on ___. Found to be in improper
placed by CXR and readjusted. Pt c/o chest pressure/irritation
so PICC removed. Initial plan was for replacement of PICC on
___ or ___. However, after discussion with infectious
disease, it was determined that pt would only need IV vancomycin
treatment for a few additional days to complete her 14D course.
Decision was made to keep pt in house rather than risk the
morbidity of PICC reinsertion. Pt discharged on ___ after she
had completed a total of 14D on IV vancomycin with several U/S
guided drainage during her hospital course. Pt will follow up
with Dr. ___, Dr. ___ infectious disease as an
outpatient.
***. | POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT 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.
***
This is a ___ yo M with a hx of DM who p/w lightheadedness and
hypoglycemia in setting of Wt. loss and decreased PO intake with
same dose of NPH.
.
# Hypoglycemia: This is the likely etiology of his
lightheadedness. It is likely that in the setting of weight loss
and nausea and vomiting that he is requiring less insulin but
has as of yet to decrease his insulin. ___ was consulted as
he was planning on obtaining an appointment with them. He was
stopped on the NPH. He was started on Lantus 30 U at night. He
was also given a sliding scale that will provide him with 10 U
or more of humalog prior to a meal. He will follow up with
___ in early ___.
.
# Nasuea/Vomiting: Patient with extensive GI work up including
gastric emptying study as well as an EGD. It seems that he has
gastritis as well as an element of gastroparesis. Patient was
tried on reglan but did not like it as he thought it made his
symptoms worse. We discussed reglan and the patient was willing
to try it. Aside from gastroparesis his fluctuating sugars may
also have been contributing to his nausea.
.
# Chronic kidney disease stage III: Pts creatinine is close to
his baseline. Will continue his current medications.
.
# HTN: Patient currnetly HTN, not taking his metoprolol. Patient
thought he was supposed to stop this medicaiton. He was
instructed to take the metoprolol XL. He was also started on
lisinopril. He will need a chem-7 at his follow up with his
nurse practitioner to assess his creatinine after starting an
ACE-i.
.
# CODE: FULL
***. | DIABETES WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
He presented to the ED and was admitted to the ___ 1 service.
Admission LFTs were elevated with alk phos of 136 and t.bili of
3.6.
___, blood cultures were drawn and he was started on Unasyn.
Diet was NPO and IV hydration was given. Liver duplex was done
to assess for portal vein thrombosis given ascites. The
following was noted:
1. Choledocholithiasis with a 1.1 cm stone/sludge; no
intrahepatic biliary
dilatation seen and the common bile duct measures 6 mm in
caliber.
2. Cholelithiasis, distended gallbladder but equivocal ___
sign and
gallbladder wall edema; ensuing cholecystitis cannot be ruled
out.
3. Patent portal vein, but reversal of flow in the right, left,
and main
portal veins.
4. Echogenic liver consistent with cirrhosis as well as ascites,
varices, and
splenomegaly.
On ___, an MRCP was done to assess for CBD stone. Results as
follows:
1. Choledocholithiasis with stone within the distal CBD at
ampulla of Vater.
This results in extrahepatic and new mild intrahepatic biliary
dilatation.
2. Cholelithiasis including stones seen at the gallbladder
neck/origin of the
cystic duct. The gallbladder is somewhat distended. There is
pericholecystic
fluid, but this is nonspecific in the setting of ascites.
Therefore, the MR
findings are not suggestive of acute cholecystitis.
3. New partial thrombosis of the distal SMV/portosplenic
confluence. Patent
small caliber portal vein.
4. Small amount of ascites and moderate right pleural effusion.
INRs were elevated to 2.0 without medication treatment.
On ___ an ERCP was performed after FFP without correction of
inr of 2.0. Results as follows:
A single 8 mm stone that was causing partial obstruction was
seen at the lower third of the common bile duct. The bile duct
was dilated to 9 mm.
The cystic duct was dilated and overling the bile duct.
Procedures: A 7cm by ___ ___ biliary stent was placed
successfully.
Despite FFPs, patients INR was 2 and therefore a sphincterotomy
could not be performed.
Post ERCP, LFTs improved. Vital signs remained stable and diet
was slowly advanced and tolerated.
On ___, an EGD was done to assess further characterize varices
given potential anticoagulation. Prior to the procedure, he was
given ffp for an inr of 2.0. At the end of the 2nd bag of ffp,
he developed some hives. A transfusion reaction w/u was done and
low dose benadryl was given with resolution of hives.
EGD results as follows:
2 cords of grade I varices were seen in the lower third of the
esophagus.
Stomach:
Mucosa: Mosaic appearance of the mucosa was noted in the
stomach body and fundus. These findings are compatible with
sever portal hypertensive gastropathy.
Protruding Lesions Several protruding lesion were seen in the
stomach antrum, compatible with portal hypertensive gastropathy.
Duodenum: Normal duodenum.
Impression: Varices at the lower third of the esophagus
Mosaic appearance in the stomach body and fundus compatible with
sever portal hypertensive gastropathy
Gastric nodules
Otherwise normal EGD to third part of the duodenum
On ___, vital signs were stable. He was tolerating his diet and
ambulating independently with his cane. INR was 2.0. Coumadin
2mg was started. His PCP's office ___
___ contacted to arrange for management of
coumadin/inr. Goal inr was 2.5. He was scheduled to follow up
for INR check at Dr. ___ office on ___ at 9am.
He was discharged home in stable condition.
***. | 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.
***
Pt was admitted to the epilepsy service for evaluation and
management of increased seizures. She was monitored via LTM EEG
while admitted. She was noted to have several seizures from
sleep the first night of monitoring. They were typical for her
usual seizures. The events were captured with video EEG and
results are reported above. She was then started on phenobarb
30mg at evening to attempt to control the nightime events. The
night after starting the phenobarb she had better control. She
had some signs of a possible focus on her EEG and will be
presented at surgical conference. She was discharged on her
routine meds plus the phenobarb. She was otherwise stable
throughout the admission. She will follow-up as an outpt with
the epilepsy clinic as scheduled.
***. | AFTERCARE 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 M with glaucoma presents after falling down 15 stairs in
the setting of ongoing balance difficulty, and found to have
non-displaced C4 fracture.
.
# Mechanical fall: Patient's account of events is not typical of
an arrhythmia or seizure that my have caused this event. Most
likely etiology mechanical fall; patient is supposed to ambulate
with cane, but is still climbing onto roofs at baseline. Patient
with significant shoulder pain ___ ___ut no fractures on
x-ray. Recent history of gait unsteadiness could make patient
more likely to fall; unclear what extent, if any, this has been
worked up as an outpatient. He was evaluated by physical therapy
who recommended home ___, he was given services including
hospital bed at home, home ___, ___ and home attendant. He was
discouraged from using ladders or strenuous activity in the
future.
# Left shoulder pain: Patient with history of left rotator cuff
injury. After the fall, he was unable to ABduct or extend at the
shoulder. Plain film was negative for fracture or dislocation.
He was seen and evaluated by orthopedics who recommended weight
bearing as tolerated. ___ and follow up with ortho sports. Family
preferred to see local orthopedist. He was discharged with
Tylenol standing for pain; Oxycodone 2.5 mg for breakthrough
pain.
.
# Non-displaced C4 lamina fracture: Patient was evaluated in the
ED by orthopedic surgery who advised immobilization with ___
collar and outpatient evaluation by Dr. ___ in 2 weeks. He
was given instructions to maintain ___ collar at all times
except for personal hygiene. He will follow up with orthopedics
in 2 weeks.
.
# Lacerations and scalp avulsion: Patient was evaluated in the
ED by plastic surgery who sutured face and scalp lacerations and
advised wound care. Plastic surgery also advised CT face to
evaluate for facial fractures which was negative for fracture.
He had absorbable sutures placed in his scalp and a non
absorbable suture placed near his left eye. He will follow up
with plastics to have the sutures removed. Wound care:
Antibiotic ointment/xeroform dressing to wound on scalp, wet to
ry dressing on right lower extremity laceration
.
# Dysarthria: Patient complained of progressive dysarthria 1
month prior to fall. Suspicion for acute stroke was low given
negative head CT. His neurological exam was limited by pain in
the right upper extremity and otherwise non-focal. He was given
follow up with speech language pathology.
.
# Leukocytosis: Patient had a WBC of 17.8K on admission with
left shift, which may be an acute stress response secondary to
his fall. He has been afebrile and with no signs or symptoms of
UA or PNA. CXR with no signs of pneumonia. This is likely a
stress response rather than a sign of sepsis.
.
# Glaucoma: Stable.
-Continue Travatan gtts
.
TRANSITIONAL ISSUES
- follow up with ortho spine in 2 weeks
- follow up with plastic surgery ___ for suture removal
- physical therapy and sports orthopedic evaluation for right
shoulder rotator cuff injury
- speech language pathology follow up for dysarthria
***. | MEDICAL BACK PROBLEMS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with PMHx dementia, CHF, HTN, IDDM, and recent UTI presents
with nausea and vomiting for 2 days.
#Nausea/Vomiting:
Differential on admission included recurrent UTI, viral
gastroenteritis, or adverse reaction to recent new antibiotic.
Urine culture was negative. Symptoms were resolved by time of
admission, therefore no further workup was necessary. Due to
concern for dehydration, pt was given IVF and her home lasix was
stopped. She appeared euvolemic on discharge. Pt was able to
tolerate po. She was kept on a dysphagia diet, as her daughter
had mentioned a concern for swallowing. We did not observe any
aspiration or concern while here.
#AMS:
On HD1, pt was noted to be sleepy throughout the day and
combative with nursing. Infectious workup, including negative
urine culture and CXR, was negative. No new neurologic sx to
warrant head imaging. She slept well overnight and was improved
by hospital day 2. This was most likely hospital induced
delirium and will improved with return to her normal daily
routine.
#Insulin-Dependent Diabetes:
Pt was noted to be hypoglycemic during her admission. We reduced
her insulin to 10 units lantus HS plus humalog sliding scale.
This can be uptitrated as needed by her PCP.
#Hypertension:
She was continued on her home amlodipine, metoprolol, and
losartan.
#dCHF:
Home lasix was held due to concern for dehydration. She appeared
euvolemic on discharge. This can be restarted as needed.
#Hyperlipidemia:
Continued on home simvastatin.
# Code: DNR/DNI (confirmed)
# Emergency Contact: Name of health care proxy: ___
___: Daughter Phone number: ___
TRANSITIONAL ISSUES:
#uptitrate lantus as needed
#restart home lasix if increase in weight or edema
#speech and swallow eval at nursing home
***. | 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 morbidly obese female with severe
borderline personality disorder a history of DVT/PE and OSA vs.
obesity hypoventillation syndrome who presented after leaving
AMA from ___ with her usual chest pain and in addition,
recent fevers and documentation of bacteremia. The patient was
initially admitted to the MICU due to her history of
unresponsive episodes requiring intubation as well as
difficulties with behavioral control on the medicine floor
requiring frequent nursing attention during her previous
admission. These issues were resolved and the patient was
transferred to the general medical floor on ___ where she
remained until her discharge.
# Borderline Personality Disorder / Psychiatric issues: Ms.
___ has severe borderline personality disorder and may
additionally have a mood disorder, although exact
characterization is difficult due to the severity of her
personality disorder. Previous providers have diagnosed her
with "depression", "PTSD", and "bipolar disorder". The patient
was actively followed by the psychiatry consult service who
created a behavioral plan to assist the medical team in working
with the patient and to minimize splitting of staff. The
psychiatry consult service also provided recommendations
regarding psychiatric medications for the patient. Many of the
patient's former psychiatric medications were tapered and
stopped as it was felt that they were providing little benefit
to the patient and contributing to her somnolence. After her
PICC line was placed on ___, droperidol 1.25 - 2.5 mg IV and
ativan 05.- 1.0 mg IV were used for chemical restraint and the
patient was also allowed to request these medications if she
felt herself becoming agitated. While these medications did not
completely calm the patient, they did help to take the edge off
of her agitation. When the patient did allow EKG monitoring and
blood draws after receiving these medications, no abnormalities
were noted. Additionally, she did not become hypoxic after
receiving ativan. After her guardianship hearing zyprexa ___
mg PO and ativan 0.5-1.0 mg PO were made available to the
patient, however, she did not utilize the former. The only
standing psychiatric medication that the patient was ordered for
was Aripiprazole (Abilify) 10 mg PO daily, however, the patient
routinely refused this medication throughout the course of her
admission, taking it only intermittantly.
The patient frequently exhibited difficulties around periods of
transition and change in her care, often requiring additional
monitoring for safety. The following is a summary of the
behavioral plan extracted from Dr. ___ note of
___:
a) Emotional Dysregulation/impulsivity: Ms. ___ tends to
get very mad very quickly. During these times, trying to talk
through the situation tends to only make the anger worse. When
this happens use the following strategies:
--Tell ___: "I see that you are very angry. I'm going
to give you 20 minutes to cool off then come back to check in on
you." Come back in 20 minutes and say, ___, it has been 20
minutes, I've come back to check in. Are you ready to discuss
your medical care."
--Encourage ___ to utilize "distraction" techniques
such
as watching television, listening to music, or drawing/coloring.
--Encourage ___ to place ice on her arms/wrists to help
decrease the urge to cut herself.
--___ will rate her anxiety/agitation on a scale
("emotions thermometer"). If her self-rating is over 60, she
may
request .5mg IV lorazepam up to twice daily. This medication
will be closely monitored given concern for respiratory
depression.
--If ___ is acutely agitated c extreme agitation &
warrants "chemical restraint", may use zydis 5mg, may repeat x 1
for max dose of 20mg in 24 hours. Alternatively, if refusing
oral medication and in need of chemical restraint, may use IM
olanzapine ___ &/or lorazepam .___ PO/IM/IV.
Alternatively,
--If possible, avoid placing hands on patient when she is
dysregulated, unless there is a fear that patient is a danger to
self, others, or is attempting to leave. In those cases physical
force may be necessary and this was told to the patient.
b) Consistency for ___: Ms. ___ has a difficult time
adapting to new treaters and changes in the routine. She does
better with those she is more familiar with. As much as is
possible in an academic hospital, she would do best with having
the same staff involved in her care. At changes of shift, new
staff should make an extra effort to introduce themselves and
let
her know the plan for the shift.
c) Consistency for treaters: There should be extra efforts to
ensure that all treaters are on the same page. All treaters
should be instructed to read this treatment plan. We should
have, at a minimum, weekly interdisciplinary team meetings to
discuss ongoing challenges to providing Ms. ___ with the
highest level of care.
d) Safety issues: Patient should have all sharps removed from
room. She should be given only plastic silverware. Silverware
should be removed immediately after she finishes eating.
In further regards to safety, hospital security had to be called
on several occassions to return the patient to her room when she
left the MICU or to forcibly restrain her after she hit and spit
at staff or after she refused to stop harming herself. During
most of her hospital stay she was 1:1 with either a security
sitter or a hospital staff sitter. Security were also called on
several occassions when the patient's room was searched.
# Facial cellulitis: On the morning of discharge the patient was
noted to have an erythematous left cheek that was slightly
warmer than her right cheek. No induration or fluctuance was
noted. Given her history, it is possible that this finding was
self-induced, though no evidence of trauma was noted. As the
patient has a prior history of facial cellulitis she was started
on bactrim for a 10 day course given her history of medication
non-compliance. The area of erythema was outlined with a pen
prior to discharge. If this area expands significantly or
becomes indurated, a medicine consult should be obtained to
evaluate for a change in therapy.
# Positive blood cultures: Documentation from ___ showed
Staph. simulans (a coagulase negative Staph.) and Enterococcus.
The Enterococcus was resistant to vancomycin. The two bacteria
together were only both sensitive to linezolid and rifampin.
Two blood cultures drawn at the beginning of this admission were
sensitive to vancomycin. The nidus of the patient's infection
was never discovered. A transthoracic echo showed no
endocarditis or valvular vegetations. Her admission chest
x-ray was without infiltrates. Urine culture on admission was
negative. A dental consult was obtained, as the patient
complained of tooth pain, however, dental panorex was negative
for abscess and the dentist felt there was no acute oral
disease. A right upper extremity ultrasound did show a
partially occluded thrombus in the cephalic vein. However,
blood cultures from ___ through ___ did not grow any
bacteria. On admission the patient was started on a 14 day
course of linezolid to treat her documented bacteremia at
___. The patient intermittantly refused to take this
medication. She had no further fevers during her hospital stay.
She did intermittantly have mildly elevated temperatures, but
these often occurred in association with episodes of agitation.
# History of DVT/PE: The patient has a documented history of DVT
in the right subclavian and branchial veins with associated PE
in ___ at ___. A CTA performed at ___ on
___ demonstrated no central or segmental pulmonary
embolism. On this admission the patient was initially placed on
a heparin gtt due to a subtherapeutic INR. Heparin was stopped
when the patient's INR became therapeutic. The patient
frequently refused warfarin as well as blood draws (despite
having a PICC line) for INR monitoring. However, despite only
taking about 50% of her prescribed doses (4 mg daily) the
patient maintained an INR of ~2. Initial recommendations from
the ICU team were for warfarin anticoagulation for a period of 6
months following her ___ PE. On transfer to the medical floor
the patient continued to complain of chest pain and request a
repeat CT scan. She was informed that this was not medically
indicated and that she was already receiving the recommended
medical therapy for this condition. She continued to frequently
refuse to take warfarin, despite multiple conversations on this
subject. On ___ warfarin anti-coagulation was discontinued
after the patient intentionally harmed herself by gouging
herself with a pen, requiring three stitches, and punching her
hand into a door multiple times. The following day she punched
her other hand into a door. Given that the patient's DVT/PE
occurred in the setting of having a PICC line, that she is now
nearly three months after initiating anticoagulation with
documented resolution of her PE in ___, that she is
intermittantly compliant with warfarin therapy, that she
routinely refuses blood draws for INR monitoring, and that she
is at risk for intentionally harming herself and for bleeding,
it is recommend that the patient no longer be anticoagulated.
If, in the future, the patient agrees to take warfarin on a
regular basis, to submit to INR monitoring, and stops physically
harming herself, anticoagulation could be reconsidered. If this
occurs, consideration of fingerstick monitoring of INR should be
considered as placement of a PICC line imposes a risk of
infection and permits the patient an opportunity to fight over
the types of labs drawn and whether the PICC needs to be
removed. If the patient has new hypoxia, it would be reasonable
to initiate medical evaluation and reassessment for PE.
# OSA / Obesity hypoventilation syndrome: On her prior ___
admission, the patient had an episode of somnolence with
hypercarbia requiring intubation. It was felt that this episode
was related to oversedation. Her psychiatric regimen has
changed considerably since that episode and the patient has not
been allowed to have ambien for sleep as the team wanted to be
able to use ativan if necessary and not risk oversedation.
During episodes on this admission in which the patient was found
"unresponsive" and intubated, her blood gases were within the
range of normal for her (baseline pCO2 ___. Subsequently,
the MICU team began further investigating these episodes. The
patient's O2 sat was generally in the low- to mid-90s during
these episodes and arm drop tests often indicated volitionality.
The medical team subsequently decided to monitor O2 sats and
not to proceed with further intervention if her O2 sat was >
85%. During her stay on the general medical floor, the patient
became upset several times when her episodes of
"unresponsiveness" were "ignored" by medical staff (i.e., O2 sat
> 85%). When questioned further, the patient stated that she
could hear what staff were saying when they came to check her O2
sat and she was "unresponsive".
The patient was repeatedly advised to wear BiPAP/CPAP while
sleeping and consistently refused to do so. She also refused
supplemental oxygen by nasal cannula. Continuous O2 sat
monitoring in the ICU demonstrated that the patient does
occasionally desat to the ___ or ___ (pleth reading was at times
poor) while sleeping, but recovers spontaneously on her own.
From a medical standpoint, the patient would benefit from
wearing BiPAP/CPAP, but has clearly demonstrated that she is in
no imminent danger when not wearing it and she consistently
refuses to wear it. The change in her psychiatric medications
with less sedating medications have likely helped in this
regard. Her most recent unresponsive episodes appear to be
psychogenic and not true medical emergencies. If the patient
ever does indicate a willingness to wear a BiPAP/CPAP mask, she
would benefit from a formal sleep study and fitting of an
appropriate mask.
# Suture removal: On the evening of ___ the patient gouged
herself with a pen that she had hidden and was not discovered on
a room search earlier in the evening. Three sutures were placed
on ___. They should be removed sometime between ___ and
___.
# Urinary incontinence: The patient has previously taken
ditropan, but this medication was stopped as she claimed it was
not helping her. She was frequently incontinent of urine, and
often this incontinence was volitional. The patient requested a
trial of Detrol, however, this medication was not started due to
its anti-cholinergic effects and potential to exacerbate her
underlying psychiatric issues.
# Restless leg syndrome: The patient was formerly on Requip.
That was changed to Gabapentin 100mg QHS per psychiatry recs.
The patient frequently declined this medication.
# Headaches: Could be related to a variety of factors including
poor sleep cycle. The patient stated that she has a history of
migraine headaches which she treats with caffeine, typically by
drinking large amounts of coffee. This habit was discouraged
and she was offered tylenol and ibuprofen, but often refused
these medications.
# Asthma: The patient was written for scheduled fluticasone and
bronchodilators. She routinely refused these medications.
There was no clinical suspicion for asthma exacerbation during
her hospital stay.
# Diarrhea: Most likely an antibiotic side effect which resolved
with time. Her stools were C. diff negative x 3. Stool O&P
negative x 2. The patient was written for prn immodium.
# Vaginal yeast infection: The patient was treated several times
during her admission for this condition with both miconazole
vaginal cream daily x 7 days and oral fluconazole. She was
advised to stop purposefully wetting herself and lying in her
urine to prevent recurrence of yeast infections. She was also
written for miconzole powder for yeast in her intertriginous
folds.
# Medication non-compliance: The patient frequently refused her
scheduled medications and rarely used her prns.
# The patient frequently refused to participate in her own
medical care, but also often voiced somatic complaints as a way
of seeking attention and often requested specific medical
interventions. Many of these complaints and their subsequent
evaluation are further outlined below. Additionally, she
frequently quizzed staff on medical topics and then later
manipulated that information when she voiced medical concerns.
a) Chest pain - The patient frequently complained of chest pain
during her admission. At times chest pain was reproducible with
palpation. At times the pain was anterior, at other times
lateral, and at times in her low to mid back. Multiple EKGs and
cardiac enzyme checks during this hospitalization were negative
for ischemia. The patient was already on appropriate therapy
for PE as described above. As outlined in her previous ___
discharge summary and briefly reviewed in her HPI, this
complaint has been a frequent and chronic one for the patient
over the past year and despite multiple evaluations no organic
etiology for her pain has been defined. The patient was written
for omeprazole per prior regimens to treat presumed GERD,
however, she took this medication only intermittently.
b) Abdominal pain/Nausea - LFTs, amylase, lipase normal. UA
normal. Vital signs normal, afebrile. The patient's
intermittant abdominal pain and/or nausea was attributed to poor
diet.
c) Finger subluxations - The patient has repeatedly subluxed her
right ring finger, and at times other fingers. The initial
episode occured when attempting to push herself up from bed,
however, multiple subsequent episodes appear to be purposeful
and attempts to seek attention. Plastic surgery was consulted
and saw the patient several times and finger x-rays were
performed. Per plastic surgery, the patient has a swan neck
deformity caused by a lax ligament which she can fix on her own
or can be easily reduced by staff. The finger is not truly
dislocated and does not require emergent/urgent reduction. They
recommended a special splint for the patient, however, she
refused to wear it. When the patient requested a hard cast,
plastic surgery stated that this was not indicated. The patient
was provided prn tylenol, ibuprofen, and ultram for pain. No
narcotics were given.
The patient also endorsed hypoasthesia in the dorsal aspect of
the ___ and ___ digits, consistent with a disruption of the
dorsal sensory branch of the ulnar nerve, potentially caused by
one of her numerous lacerations to the right forearm and wrist.
This is condition is chronic and does not require further
evaluation.
When the patient is more stable psychiatrically, and if she has
no ongoing medical issues, the patient may pursue surgical
correction of the lax ligament. The plastic surgery team felt
that this should be done as an outpatient.
d) Mouth lesion: The patient bit the inside of her lip while
eating one day. Despite her request for stitches, these were
not placed as it was not felt to be indicated. Her laceration
is healing well.
e) Polydypsia/polyuria: Blood glucose normal. Patient with high
PO fluid intake at times. No need to evaluate further.
f) Hot/cold flashes: The patient intermitantly complained of
"hot flashes" or being extremely cold. She did not have any
fevers during these periods and blood cultures were drawn and
were negative during some of these occassions. TSH was 2.2 on
___. The patient requested "hormonal testing" and was
advised that she should follow-up with an endocrinologist as an
outpatient. Of note, during her previous ___ admission the
patient did have hyperprolactenemia induced by risperdal and
that medication was stopped.
g) Left shoulder pain: For several days during her MICU stay the
patient complained of left shoulder pain. It was unclear if
this was an attempt to get attention or if it was real. She had
full ROM of on exam and x-rays were deemed unnecessary.
Ibuprofen, tylenol, and ultram were provided on a prn basis.
After a few days the patient no longer complained of shoulder
pain.
h) "Laryngitis": One day prior to discharge the patient
complained of "a sqeaky voice", speaking is a whispered/raspy
voice in association with a sensation of throat swellinng and
her typical chest and "lung" (really low back) pain. There was
good air movement and no wheezing on exam. There was no
evidence of facial or neck swelling. She was offered a cepacol
losenge. The patient's voice improved markedly a few hours
later when she became agitated at staff. By the following day
her vocal issues had resolved.
i) Unresponsive episodes: as outlined above.
# Access: The patient is extremely difficult, if not impossible
to obtain peripheral access in. A PICC line was placed by ___ on
___. It was removed a couple of weeks later due to discomfort
at the site and continued picking at the site on the part of the
patient. A new PICC line was placed in the opposite arm,
however, the patient continued to complain of pain at the site
(the patient routinely complained of IV or PICC site pain
throughout her hospital course). As the patient repeatedly
refused lab draws, even noninvasive lab draws from the ___
line, and due to the risk of infection and thrombophelbitis
posed by invasive lines, it no longer made sense to maintain a
PICC line solely for lab draws given tenderness at the ___
site. Reinsertion of a PICC line would be indicated if the
patient develops a need for IV medications or treatment.
# Indications for further medical evaluation:
- widening area of facial cellulitis and/or induration or
fluctuance
- new hypoxia (room air O2 sat < 90% while awake, not holding
her breath, or < 85% while asleep)
- fever > ___ F
# Legal: ___
was pursued. In a court hearing on ___ ___ (___:
___ was appointed as the patient's guardian.
***. | 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.
***
The patient was admitted to the acute care surgery service at
___ on ___ after presenting to the ED with a 24 hour
history of RUQ pain. Ultrasound revealed an impacted 1.3 cm
stone in the gallbladder neck with wall edema, gallbladder
distention and a positive sonographic ___ sign. He was
admitted to the floor was made NPO and was started on IV fluids
and ciprofloxacin and flagyl. That evening he was taken to the
OR for a laparoscopic cholecystectomy. He tolerated the
procedure well, was extubated and taken to the PACU in stable
condition. For full details of the procedure please see the
operative report. The following morning he was given a regular
diet and he was started on his home ___. He was discharged
to home on ___ with a scheduled follow up appaointment in the
___ clinic. At the time of discharge he was ambulating, he was
tolerating a regular diet and his pain was well controlled.
***. | LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. 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.
***
1) GI bleed: Onset in setting of intractable hiccups, nausea,
and vomiting. CT head negative for a central cause of these
symptoms. Initially admitted to the MICU on PPI and octreotide
drips for observation. His hct dropped from 29.4 to 26.5 without
evidence of active bleeding, for which he received 2 units
pRBCs. The hct then improved to 33.5 with subsequent stability.
RUQ U/S with Doppler showed good vascular flow. CT abdomen was
unremarkable. Hepatology was consulted and EGD was performed,
showing evidence ___ tear, small antral ulcers, and
mild portal hypertensive gastropathy. He remained
hemodynamically stable throughout his MICU course without
pressor requirement. His PPI and octreotide gtt were stopped and
he was transferred to the floor, where he remained
hemodynamically stable. By the time of discharge, he had been
switched to oral pantoprazole.
2) HCV Cirrhosis: No ascites on CT or exam. Received 3 days of
oral cipro for SBP prophylaxis. MELD score was 15 on transfer to
the floor. His total and direct bili trended up, but other LFTs
including alk phos remained stable. Discussion with radiology
confirmed no biliary pathology on CT or U/S. Hepatology felt
this was secondary to alcohol use and can be followed up as an
outpatient. HCV genotype and viral load were sent and pending at
discharge. He will follow up at ___ liver ___ in 1 month.
3) HIV: Continued on his home ARV regimen with TMP-SMX and
azithromycin prophylaxis. Initially started on fluconazole due
to concern for ___ esophagitis, but this was not apparent on
exam or EGD, so was discontinued. His outpatient ID physician
was alerted of this admission.
***. | MAJOR ESOPHAGEAL 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.
***
A ___ year-old man with a history of CAD s/p multiple
interventions presents with chest pain suspicious for unstable
angina.
.
# CORONARIES: Given his extensive coronary history and the fact
that he states that his pain is similar to prior cardiac events,
recent chest pain is concerning for unstable angina. He had been
chest pain free since arrival to outside hospital ED. Patient
reports that stress tests in the past have never been
diagnostic; hence, he was referred for catheterization. He was
initially on a heparin drip. He underwent cardiac
catheterization demonstrating LAD proximal in-stent restenosis
and RCA in-stent restenosis. Both were re-stented. Medical
management of coronary disease including ASA, Plavix, beta
blocker, ACEI, statin were continued. Lipids were checked and
were at goal (LDL 45).
.
# PUMP: He gives a history of orthopnea and had trace edema on
exam but clear lungs and JVP not well visualized. He is not on
lasix at home. TTE was done and demonstrated essentially normal
systolic function (although sub-optimal windows). On
right-heart cath he was noted to have evidence of mild diastolic
dysfunction. He remained apparently euvolemic and did not
require diuresis.
.
# RHYTHM: He was in sinus rhythm and was monitorred on telemetry
with no events.
.
# Diabetes: Metformin was held in anticipation of
catheterization. Fingersticks were in the low 100s. He was
instructed to restart metformin 48 hours after catheterizaiton.
.
# Hyperlipidemia: Lipids were at goal . Atorvastatin 80 mg
daily was continued.
.
# History of bladder cancer: No current issues.
.
# Tobacco use: He was given nicotine patch and counselling
about smoking cessation. He agreed to a prescription for
nicotine patch on discharge and seemed enthusiastic about
stopping cigarettes.
.
# EtOH abuse: He was counseled about cessation of alcohol. He
was contemplative.
***. | 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.
***
Legal: ___
Psychiatric: The patient was admitted with suspected delusions
of abuse at home. He participated in group, individual and
milieu therapy. He was started on Risperdal 0.5mg PO QAM and
1mg PO QHS and initially refused the medication. His parents
were contacted with the pt's permission and informed staff that
the pt had become intoxicated on a family trip, was sick, and
was put to bed by his mother, who removed his clothes because he
had vomited on them. The patient was presented with this story
and initially did not believe it to be true. He was generally
unwilling to allow his parents to visit or to keep in contact
with them. The patient eventually began taking his medication
and reported that it was helpful in making him feel less
anxious. He was agreeable to retracting his 3 day notice and
staying on the unit to continue on his medication. The pt's
risperdal was increased to a final dose of 4mg PO QHS. He
tolerated the medication well, although noted side effects of
dry mouth and blurry vision. He reported that he did not feel
these side effects were bad enough for him to want to
discontinue the medication. He began to consider that perhaps
his family members ___ abused him, and possibly the incident
had occurred as they stated, however did not seem committed to
this being completely true. He reported that he had never been
close with his family members and had no plans to try to improve
his relationship with his family. He repeatedly requested
discharge in the setting of a scheduled trip with his co-op that
he was hoping to attend. Given that the pt did not exhibit
acute risk of harming himself or others, and was able to care
for himself, he was discharged to return to school. On the date
of discharge, the pt was assessed to be safe and appropriate for
discharge.
Medicine: The patient had no active medical issues during his
hospitalization. His labs were within normal limits. He
continued to complain of inability to fully empty his bladder,
however UA x 2 were normal.
Dispo: The patient was discharged to home with follow up as
listed below.
***. | PSYCHOSES |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient was admitted to the General Surgical Service for
evaluation and treatment. After a brief, uneventful stay in the
PACU, the patient arrived on the floor NPO, on IV rescusitation
and IV antibiotics consisting of Linezolid and Cipro, with a
foley catheter and G-J tube to gravity drainage, IV Morphine for
pain control. The patient was hemodynamically stable. Contact
precautions for VRE maintained throughout hospitalization.
___: Transfused 1UPRBC for post-operative hematocrit less
than 21% with partial response; remained hemodynamically stable.
Continued NPO, on IV fluids.
___: Received second UPRBC for post-operative anemia with
adequate response. NG tube discontinued. G-J tube: G-tube to
gravity drainge; J-tube portion clamped with flushes initiated.
Cipro discontinued; changed to IV cefepime. Started on CPAP for
OSA risk; patient occasionally refused during stay. Patient out
of bed with assist. Remained stable; progressing slowly.
___: G-Tube clamped; flushes started. Trophic J-tube feeds
begun with good tolerability. Foley replaced secondary to h/o
UTI. ___ following. No other events.
___: Tube feeds advanced without problem. Episode afib
without chest pain; treated with IV Lopressor. Diet advanced to
sips with good tolerability; tubefeeds slowly advanced toward
goal. No N/V. Remained stable.
___: Diet to clears; tube feed rate increased. Excellent
tolerability. No events.
___: Experiencing loose stools; otherwise no progressing
well. Tolerating tube feeds, diet. Improving activity tolerance
with ___. Foley discontinued; experienced incontinence of urine.
No other events.
___: Regular diet and J-tube feeds to goal with good
tolerability. (R)LQ JP discontinued. G-Tube clamped. Foley
re-inserted for repeat U/A and incontinence management.
At the time of discharge, the patient was doing well, afebrile
with stable viral signs. The patient was tolerating a regular
diet and tube feeds at goal, ambulating with assistance, and
pain was well controlled. Patient discharged to ___
___ with follow-up.
***. | CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is a ___ woman with PMH notable for asthma,
CKD, CHF, AF on warfarin, and IDDM who was admitted for further
management of asthma exacerbation. O2 saturation and respiratory
symptoms improved with prednisone burst and scheduled breathing
treatments.
ACUTE ISSUES:
===============
# Acute asthma exacerbation: The patient was found to have
shortness of breath and diffuse wheezing on admission in the
setting of recent pollen exposure as well as inability to afford
home inhaled steroids. The patient was treated with IV
solumedrol, nebulizers and Magnesium in the ED. She was then
started on a 5 day steroid burst of prednisone 40mg and
scheduled breathing treatments with improved respiratory
function. On the day of discharge, ambulatory saturation was
89-91% on room air, with peak flow 180; patient appeared well
without shortness of breath. She switched from home flovent
(which was expensive) to symbicort (which was covered by her
insurance). She will follow up with her PCP for continued
management of her asthma.
CHRONIC ISSUES:
===============
# Diabetes Mellitus, type II: Continued on home glargine 15
units BID, Humalog 10 units with breakfast and 15 units with
dinner.
# Chronic HFpEF: No evidence of acute exacerbation. Continued
home lasix 80mg PO BID.
# Atrial fibrillation: Rate controlled with carvedilol 25mg BID,
and anticoagulated with warfarin with an INR of 2.2 on
admission.
# HTN/HLD/primary prevention: Continued carvedilol as above,
amlodipine, atorvastatin 10mg daily, ASA 81.
# Diabetic neuropathy: Continued home gabapentin
# GERD: Patient complained of reflux symptoms and was started on
ranitidine this admission.
TRANSITIONAL ISSUES:
====================
[] Consider discontinuation of ASA 81 given pt therapeutically
anticoagulated and may not be indicated for primary prevention
[] Pt was started on Symbicort as this was the only inhaled
steroid covered by insurance. (Prior home flovent was
discontinued.)
[] Discharge peak flow: 180
[] Discharge ambulatory O2: 81-91% RA
[] Last day of 5-day course of prednisone will be on ___
#CODE: Full (presumed)
#CONTACT: ___ (daughter/hcp) ___
***. | 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.
***
___ hx AF on warfarin presenting with abdominal pain found to
have elevated transaminases c/f cholangitis/cholecystitis
admitted for ERCP.
# Choledocholithiasis w/ obstruction: imaging concerning for
cholangitis from gallstone obstruction with intra and
extrahepatic dilation on imaging. Started on Ciprfloxacin, made
NPO, aggressively hydrated. After INR reversal, ERCP ___
failed biliary cannulation. Repeat ERCP ___ w/ sphincterotomy
successful with stenting and stone removal. Received Cipro
through ___. Held anticoagulation through ___ (due to
bleeding risk post sphincterotomy). Diet advanced. ERCP team to
arrange 6 week f/u ERCP for stent pull and re-evaluation.
# Acute combined systolic/diastolic heart failure: required O2
initially, no prior requirement. Patient had ___ dasy of blood
tinged sputa. Symptomatically improved with empiric diuresis
while awaiting EHCO. Had murmur suspicious for AS (PCP had no
echo on file). ECHO confirmed severe AS, EF 45%, elevated
pulmonary pressures, and regional wall motion abnormality.
Diltiazem stopped and switched to Metoprolol.
# Severe Aortic Stenosis w/ heart failure: New diagnosis here.
Cardiology consulted and patient transferred to Cardiology (Dr.
___ for further management and evaluation for possible TAVR,
however declines TAVR workup.
# CAD (presumed) w/ wall motion abnormality on ECHO: Statin low
dose initiated. Moved to beta blockade. Betablockade was
uptitrated to 75mg Metoprolol tartrate TID, and patient was
discharged on Metoprolol Succinate XL 100mg BID.
# Atrial fibrillation (CHADS2=3): Warfarin reversed on
admission, and was held through ___ after sphincterotomy.
Goal INR ___. Home diltiazem switched to Metoprolol after echo
resulted. Digoxin was continued. Coumadin restarted ___ at 5mg,
needs INR ___.
# Hypokalemia, severe: As low as 2.6, resolved
# FEN: low salt
# Contact: ___ (daughter ___,
___ (daughter ___ or ___
# Code status: DNR/DNI (confirmed with patient)
***. | 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.
***
1. Hypotension, Seroquel Overdose, Suicidal Ingestion, Suicidal
Ideation
- Concern for hypotension with overdose, which he experienced,
which reponded to fluids, however if recurrs, per POISINDEX,
should only use alpha-agonists, not beta-agonists
- Additionally per POISINDEX the patient is at risk for QT
prolongation, although on all our EKG's the patient actually has
a shortened QT.
- It is unclear whether the barely clinical ST depression is
related to the ingestion, or is simply his baseline EKG. Given
his lack of anginal symptoms, this would be unlikely to be
subendocardial ischemia
- Unclear whether lethargy is simply from being tired, from
being up most of the night, or the CNS depression of the
medication. He is maintaining his airway without difficulty, and
is easily arrousable. Given that, I would favor simply being
tired.
- Seizure Watch x24 hours
- Psychiatry Consultation
- Under ___
- 1:1 Sitter for safety
2. Substance Dependence Alcohol/Withdrawal
- CIWA Scale with Valium
- MVI, Folate, Thiamine
3. Substance Dependence Opiates
- SW Consultation
***. | 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.
***
This is a ___ year old female with poorly controlled DM and PVD
who presents with several days of necrotic appearing R foot toes
and elevated ___ to > 500.
.
# Necrotic toes: Evaluated by vascular surgery in ED and found
to have weak but dopplerable pulses. Given history, appears to
be dry gangrene with no signs of infection and no need for acute
intervention by vascular currently. Vascular wanted to do
angiography on patient on ___ however patient refused stating
that she had to leave on ___ to get home to her daughter.
___ surgery explained the potential risks and benefits of
this decision. She was given the name of the vascular surgeon
as well as the telephone number and told to call first thing
___ morning in order to schedule an outpatient angiography.
Vascular decided to hold on ABI/PVR as plan to go directly to
angiography. Will defer to vascular surgery as to whether
patient should be started on Plavix and also which dose of
aspirin would be preferable for patient with exxtensive vascular
issues. Patient was started on statin as well for elevated LDL
and total cholesterol in the setting of vasculopath and
diabetic.
.
# Hyperglycemia: Patient has long history of poorly controlled
DM1. Only very slight AG on presentation. No signs of infection
with normal chest x-ray and urine culture consistent with mixed
flora. EKG unchanged and cardiac enzymes were negative.
Consulted ___ in house for furthur sugar management,
reccomending continuing current management at this time and that
they would follow patient with us. As patietn insisted on
discharge, there was not enough data points to alter her current
insulin regimen. Patient has appointment to follow up with
___ this week. Instructed her to bring a journal of
her fingersticks as well as a food diary with her. Patient was
treated in house with IVF and additional insulin. Sugars were
not well controlled when patient insisted on leaving. Last ___ in
300s.
.
# HTN: Patient was continued on home clonidine, metoprolol, as
patient is a diabetic with elevated blood pressure will start
low dose ACE inhibitor.
.
# Elevated Alk phos - Patient with persistently elevated
alkaline phosphatase of unclear etiology. Patient with ___
core antibody positive suggesting previous infection with
negative surface antigen suggesting that she is not acutely
infected. Would consider outpatient GI follow up as needed.
.
# Dyslipedemia- Patient with elevated triglyerides to 748 on
admission also with elevated LDL and patient was started on
statin as well as given prescription for statin on discharge.
.
# Depression/anxiety: Continued home clonazepam
.
# Hyponatremia: Patient appeared dry on initialyexam so likely
hypovolemic hyponatremia. Na resolved back to 137 with IVF
alone. U/A without evidence of infection, urine lytes
demonstrate Na 87 and Urine osm of 260
.
# Phantom pain: Con't home neurontin. Patient prefers outpatient
percoset so gave patient prescription on discharge
.
# FEN: Cardiac/diabetic diet, replete lytes prn
.
# PPx: subq heparin
***. | PERIPHERAL VASCULAR DISORDERS WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Patient was admitted to L&D for advanced cervical dilation with
out evidence of intrauterine infection, labor or abruption at
this time. She underwent a vaginal delivery of a stillborn male
infant with no signs of life. Please see delivery for full
details.
Her postpartum course was uncomplicated. Her pain was treated
with oral pain medications. She ambulated and her foley was
discontinued and she voided spontaneously. Her diet was advanced
without incident.
By postpartum day 1, she was tolerating a regular diet,
ambulating independently, and pain was controlled with oral
medications. She was afebrile with stable vital signs. She was
then discharged home in stable condition with postpartum
outpatient follow-up scheduled.
***. | ABORTION WITHOUT D&C |
What is the most likely Medicare Severity Diagnosis Related Group (MS-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 ___ speaking woman with multiple readmissions for
HFpEF, OSA/OHS/pHTN on home 3L and BiPAP, poor medication
adherence, presenting with acute on chronic hypoxemia and
hypervolemia, likely HFpEF exacerbation.
# CORONARIES: unknown
# PUMP: LVEF >55% ___
# RHYTHM: NSR
#Acute on Chronic Diastolic Heart Failure (HFpEF)
HFpEF exacerbation most likely -- has findings of both left
heart failure (pulmonary edema, hypoxemia) and right heart
failure (elevated JVP, ___ edema, weight gain). RV failure
possible given chronic pulmonary disease and pulmonary HTN.
Trigger is likely medication non-adherence given prior
non-adherence and multiple readmissions. No evidence for
ischemia or infection. Patient received Lasix boluses 120mg IV
in addition to Lasix gtt @ 20mg/hr. Patient was transitioned to
PO diuretics on ___. Patient maintained euvolemia on Torsemide
60mg daily.
#HTN:
Per clinic notes, has chronic poorly controlled HTN, likely
contributing to HF and CKD. Patient was started on nitro gtt in
ED for persistent HTN to 150s-190s, later weaned off on floor.
Losartan was started this admission. Home amlodipine and
metoprolol were continued.
#T2DM, INSULIN-DEPENDENT:
Patient was also followed by ___ while in house to manage her
diabetes. It was recommended to the patient that she follow up
with an endocrinologist, but the patient declined. The patient
also complained of pain in her legs and arms which has been well
described before and attributed to calcified tendinitis/rotator
cuff tear in her shoulder, diabetic neuropathy, and meralgia
paresthetica. Cardiac ischemia was ruled out via EKG and
troponin. No edema or erythema to suggest gout/CPPD. Pain was
managed with tramadol and gabapentin. Patient refused working
with ___ multiple times during hospitalization
#Chronic normocytic hypochromic anemia:
Hgb at baseline. Last iron studies in ___ not c/f iron
deficiency or anemia of chronic disease. Last colonoscopy ___
showed benign polyps.
#CKD: Baseline Cr unclear, approximately 1.8-2.2, roughly stable
this admission (2.2 on discharge). Likely due DM and HTN.
Losartan was started this admission.
#Leukocytosis with epigastric pain:
Patient complained of epigastric pain on admission but was
unable to clarify time course or associated symptoms. Exam,
labs, and KUB benign. Likely due to abdominal distension from
fluid retention. Also has history of GERD per records. Received
stool softeners and home omeprazole with improvement in symptoms
and resolution of leukocytosis.
================
CHRONIC ISSUES
================
#H/O Breast CA: Continued home anastrozole
#Asthma: No signs of wheezing on exam. Continued albuterol PRN.
#HLD: Continued home atorvastatin
#Osteoporosis: Continued home alendronate
#Glaucoma: Continued home latonoprost
======================
TRANSITIONAL ISSUES
======================
DISCHARGE WEIGHT: 98.7
DISCHARGE PRELOAD: Torsemide 60mg daily
DISCHARGE AFTERLOAD: Valsartan 80 mg PO/NG BID amLODIPine 10 mg
PO/NG DAILY
DISCHARGE NEUROHORMONAL: Metoprolol Succinate XL 100 mg PO BID
Please follow up blood sugars and adjust insulin as needed
Please recheck Chem10 at PCP appointment to evaluate renal
function and electrolytes. Cr was stable at 2.2 on day of
discharge.
Please consider mental health counseling/increasing patient's
antidepressant as this may be contributing to her chronic pain.
Please consider referral to orthopedics for L shoulder injection
and physical therapy. We were unable to set up home ___ for
patient as she refused working with ___ while in house.
Chronic normocytic anemia: Last iron studies in ___ not c/f
iron deficiency or anemia of chronic disease. Last colonoscopy
___ showed benign polyps. Consider repeat retic count, iron
studies.
***. | 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.
***
___ y/o gentleman with a h/o epilepsy, MSM, who presents with
fever, diarrhea, headache, sore throat, and report of recent
positive HIV testing.
#Acute HIV with fevers, diarrhea, headaches, and sore throat:
Patient presented with fever, diarrhea, headache, sore throat,
and report of recent 90% positive HIV testing. Upon testing this
admission, his HIV viral load was positive but his antibody was
negative. His CD4 count was 378. He was started on Truvada and
Dolutegravir on ___. His fevers persisted but down trended
toward the end of his admission. His diarrhea was likely
secondary to HIV but improved over admission. Microsporidium,
campylobacter, O and P, cyclosporidium, and giardia were
negative. C diff was also negative. He had a +NG rectal test and
a -CT rectal test so was given Ceftriaxone 250 mg IV once ___
and Azithromycin 1000 mg PO/NG once ___. Patient's headache and
sore throat also improved over his hospital course. He was
worried about losing weight on therapy so ensure shakes were
added to his diet three times/day. He also developed lymphopenia
and thrombocytopenia likely secondary to acute HIV. His lipid
panel was normal with slightly lower HDL (38). Quantiferon gold
was negative as were his blood cultures, urine culture, urine
CT/NG, Toxoplasma IgG, VZV, CMV IgG/IgM, RPR, HbsAg, HBsAb,
HBcAB, HAV ab, and HCV. He will follow up with ___.
#Anal pain:
Patient with pain and small amount of blood on the toilet paper
with bowel movements. Likely multifactorial with acute rectal N.
gonorrhea infxn and anal fissures. We treated him with
antibiotics as above, and gave stool softeners, and witch ___.
#Hematemesis:
Small amount of bright red blood post swallowing ibuprofen on
___. GI consulted given HIV status and recommended
conservative management with PPI and trending his H and H. The
patient did not have any further hematemesis, and it was felt
that it could possibly have been a red-colored beverage present
in the room.
#Pancytopenia:
Patient with all three cell lines decreased. Initially some
concern for TTP, but labs were not indicative of hemolysis and
no schistocytes were seen on blood smear. Therefore,
pancytopenia likely secondary to HIV infection. Haptoglobin was
high but likely in the setting of HIV infection as well.
#Social Situation:
Patient did not want to tell family members about current
medical situation, but did call father and let him know of
diagnosis. He has a tenuous support system. Social work was
consulted and is working on setting him up with a therapist. He
has arranged to tell his aunt and live with his aunt after
discharge.
#Withdrawn affect:
Withdrawn and sometimes nodding off during exam. Social work was
consulted and was working on arranging therapy. Patient was
still hesitant about therapy. This should be continued to be
evaluated as an outpatient.
#Nipple discomfort:
Patient was worried that his nipple piercings were infected
although there was no erythema, drainage, or warmth. Patient
endorses pain and usually treats this at home with warm
water/non-iodized salt. He was treated in the hospital with warm
compresses.
CHRONIC/STABLE PROBLEMS:
# Epilepsy - Stable. Not on medications.
===========================
Transitional Issues
===========================
[] Follow up HIV genotyping
[] Patient might benefit from outpatient therapist to help with
coping of new diagnosis.
[]
[]consider outpatient Anal Pap testing (has received Gardasil
x3)
[] double check which vaccinations he has had, and what is
needed, before discharge
[] F/u with ___
[] F/u with infectious disease
# Code status: Full presumed
# Contact: Father, but patient would prefer to have him not be
contacted at this time
>30 minutes spent on discharge planning
***. | HIV WITH OR WITHOUT OTHER RELATED CONDITION |
What is the most likely Medicare Severity Diagnosis Related Group (MS-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 paraplegia, recurrent UTI/nephrolithiasis, and h/o
recurrent MRSA ___ abscesses presented with
fever/chills, foul smelling urine, abdominal and testicular
pain, and reported history of blood streaked emesis.
#. Pyelonephritis/UTI. Likely secondary to stopping his
prophylactic macrobid ___ weeks ago and persistent self straight
catheterizations. CT suggestive of pyelonephritis, no clear
abscess. Patient has had recurrent UTIs and nephrolithiasis in
past, mostly E.coli sensitive to ceftriaxone, meropenum, zosyn
and others. He has a history of MRSA colonization. He was
stareted on vancomycin (D1, ___ and meropenem (D1,
___ due to risk for ESBL. His antibiotics was switched
to cefpodoxime on ___, with the plan to complete a total
of 14 day antibiotics course starting from ___, so patient
will complete his antibiotics course on ___. Patient was
instructed to see his urologist and ID doctors ___ 1 week of
discharge to determine the long term antibiotics therapy and
follow up of the GC/Chlamydia, blood culture, stool culture
results.
#. Abdominal pain/vomitting/nausea/diarrhea. Resolved. Likely
gastroenteritis, may have been bacterial or viral contaminant in
food from restaurant, possibly Staph aureus secondary to acute
nature of vomitting after eating. His symptoms completely
resolved while in the hospital. He was started on pantoprazole
40 mg once daily for a trial for the scant hematemesis (which
resolved, see below) for 2 weeks until ___, which can be
followed up by his primary care physician.
#. Hematemesis, mild (streaks). Resolved. Likely ___ vomiting,
possibly small ___ tear. No signs of coffee ground
emesis to suggest PUD. His symptoms resolved during ICU stay.
He did not require any transfusion. There was Hct drop, but
likely dilutional in nature as he is about 6L positive. He was
started on pantoprazole 40 mg po daily for 14 days trial and
zofran for nausea, and he gradually advanced from full liquid to
regular without issues. He should be followed up by his primary
care physician on trial of anti-acid.
#. Anemia, microcytic. Baseline has anemia of chronic
inflammation by previous iron studies. Also the more acute
change is likely dilutional given about 6L positive since
admission to the ICU and unlikely from the mild hematemesis
noted above as that resolved. He does not have any active signs
of bleeding after resolution of the mild hematemesis. This
should be followed up by his primary care physician.
#. Epididymitis. Improved. Likely ___ trauma. Urology was
curbsided and thought that his current symptoms can be managed
conservatively with pain medications, NSAIDs, and elevation. If
pain worsens, will need to repeat ultrasound and consult urology
urgently. Patient is aware of what to do if his testicular pain
worsens. He was instructed to continue with elevation, NSAIDs,
and acetaminophen. This will need to be followed up by his
urologist.
#. History of recurrent MRSA abscesses on buttocks. Patient
continues to have open wounds, requiring daily wound care. The
area was dressed Mepilex daily. Patient should continue to have
wound care.
#. Tobacco smoking. Patient is in the pre-contemplation state
and refusing nicotine patch. Plan is to continue with education
and encouraging cessation. This should continue to be addressed
by his primary care physician.
***. | 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.
***
Ms. ___ is a ___ female with
history of hypothyroidism, HTN, bipolar disorder,
nephrolithiases
who presented with back pain, and a question of manic episode.
#Bipolar disorder
-Patient was admitted from ED on ___ for concern of ?manic
episode. Psychiatry saw the patient in ED on ___ and deemed
her unsafe
to leave AMA at that time.
-The patient was re-evaluated on ___ by the same
psychiatrist who saw her in the ED (Dr. ___. I discussed
with Dr. ___ also had spoken to Dr. ___ (the
patient's outpatient psychiatrist). He found her markedly
improved from the day prior, and our assessment was that the
patient is safe to return home. For my exam of her on ___,
she had linear thought processes, no SI or HI, no
pressured/rapid speech, no grandiose thoughts or delusions.
There was no psychomotor agitation or distractibility. In fact,
I had seen this patient a week prior when she was here for
constipation on ___, and my exam of her that time was no
different than my assessment of her today on ___.
-OT was consulted; she will now be seen by home ___ services
starting on ___ as well. She has appointment with her
outpatient psychiatrist and her PCP next week. This discharge
summary was faxed to them. The husband, ___, was updated at
bedside about the above and agreed with the discharge plan.
-Otherwise, metabolic work up was unremarkable. TSH was within
normal limits. CT head without acute intracranial
process. Urine analysis not suggestive of UTI. There is no
evidence of infection or metabolic causes that could provoke
delirium at this time.
-Continue home valproate, diazepam qhs prn for insomnia. No
medication changes were made.
-In regards to the valproate, her NH3 level was 47 on
presentation.
#Chronic back pain and right sided sciatica
-Stable
-No neurologic deficit of weakness, new neuropathy,
incontinence, or dysreflexia on exam
-Continue home lidocaine patches
-Patient stated the back pain is improved and back to baseline
since admission from the ED.
#Recent opioid induced constipation
-Daily bowel regimen
-Counseled patient on not taking any narcotics unless they are
directly prescribed to her. She had been taking her husband's.
#Hypothyroidism
- continue home synthroid
- TSH here normal.
#HTN
-Continue home lisionpril
Greater than 30 minutes was spent in discharge planning and
coordination.
***. | 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.
***
___ y/o gentleman with FLT3-ITD NC- AML s/p MRD allogeneic stem
cell transplant ___ and chronic GVHD not on
immunosuppression admitted for myalgias/arthralgias, weakness,
fatigue, and orthostasis found to have GVHD flare with new liver
involvement, treated with steroids and mycophenolate mofetil.
#GVHD Flare
#Mucositis with oral ulcerations
Patient has a history of chronic GVHD. His eosinophils were
elevated on admission at 28.1% and LFTs also elevated, which
were concerning for a GVHD flare. He also had prominent oral
ulcerations on the buccal mucosa and palate. Patient has an
extensive hx of chronic GVH of eyes, skin, but his symptoms had
been stable during his ___ outpatient appointment.
Immunosuppression was discontinued at that time on ___ and pt
presented with the above symptoms. He was treated with IV
steroids with improvement in his oral lesions but persistently
rising transaminitis. Tacrolimus and mycophenolate mofetil were
restarted. Tacrolimus later discontinued as levels remained
undetectable. Liver biopsy obtained showing chronic GVHD. RUQ US
with patent hepatic vasculature. Transaminases peaked at ALT
637, AST 235 and downtrended.
#Keratoconjunctivitis sicca- Patient complained of severe dry
eyes and photophobia on admission. He also had mild hyperemia
around the eyelids. He was evaluated by ophthalmology and felt
to have symptoms and findings c/w keratoconjunctivitis sicca
which can be a manifestation of ocular GVHD. Patient was started
on artificial tears and lacrilube with significant improvement
in his symptoms. To follow-up with Dr. ___ in ophthalmology in
2 weeks.
#AML s/p allo transplant in ___. CBC without evidence of
leukemia relapse. Most recent chimerism 99% donor, no evidence
of leukemia, FLT3 negative. Patient has a history of chronic
GVHD as above. He was continued on atovaquone for PCP
prophylaxis and ___ for viral ppx, micafungin for fungal
prophylaxis. Discharge ___ fungal prophylaxis per primary
oncologist.
#Rotator cuff tendinosis
#Mild subacromial bursitis
Patient complained of ___ pain that he has noted over the
last few months, with pain on extending arm. MRI revealed
rotator cuff tendinosis and mild subacromial bursitis. Patient
was continued on oxycodone 5 mg q4h prn moderate pain. ___ was
consulted and provided patient with stretching exercises.
Consider outpatient physical therapy if persists.
#Hx of CMV viremia: hx VL that was intermittently detectable,
last level on ___ not detectable. Patient was continued on
acyclovir ppx.
#Depression- Continued citalopram 40 mg daily
#Hypertension: Continued metoprolol tartrate 25 mg bid
#Peripheral neuropathy: Continued Lyrica
TRANSITIONAL ISSUES:
==================
*Medication Changes:
-New:
-Artificial tears, preservative free
-Artificial tear ointment
-Atovaquone 1500mg daily
-Dexamethasone oral rinse
-Lorazepam 0.5 mg PO QHS PRN: for insomnia while on high dose
steroids
-Mycophenolate mofetil 1000mg TID
-Oxycodone 5mg q4h prn ___ pain
-Pantoprazole 40mg daily while on steroids
-Prednisone 50mg BID
-Trazodone 25mg PO QHS:PRN
-Ursodiol 300mg PO BID
-Held:
-Budesonide 3mg daily
[]EBV viral load ___, repeat pending at discharge. Please
follow-up
[]Please determine appropriate steroid taper and
immunosuppression regimen
[]Please determine whether to restart fungal prophylaxis
[]Follow-up as outpatient with Dr. ___ at ___ ___
___ floor ___ 2 weeks after d/c.
Name of health care proxy: ___
Relationship: Friend
Phone number: ___
***. | 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.
***
The patient is a ___ year old man who was admitted to the
Vascular Surgery service after undergoing a left ___
bypass with in situ GSV on ___. Please see operative report
for more details. After a brief uneventful stay in the PACU, he
was transferred to the VICU for further postoperative care.
On admission to the floor, he was kept NPO and on bedrest
overnight. Left posterior tibial pulse was palpable, and
remained so throughout his hospital stay. On POD#2, patient got
out of bed to chair and was able to ambulate without assistance.
A physical therapy consult was thus deemed unnecessary. Foley
catheter was removed and patient voided shortly thereafter
without problems. Vital signs were routinely monitored and he
remained stable from a cardiopvascular and pulmonary standpoint.
Pain was well-controlled throughout hospitalization with oral
medications.
On discharge, Mr ___ was doing remarkably well. His pain was
well-controlled, and he was tolerating a regular diet, voiding,
and ambulating without assistance. He received discharge
teaching and follow-up instructions with verbalized consent and
agreement with the plan.
***. | 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.
***
___ year old woman with PMHx notable for HTN and recently
diagnosed parotid tumor (possibly Warthin's based on FNA
___ recently admitted from ___ for symptomatic
bradycardia with multiple syncopal episodes who presented again
on ___ after recurrent syncopal episode overnight for
assessment for pacemaker placement and expedited work-up for
parotid gland mass by ENT.
#Recurrent syncopal episodes with symptomatic bradycardia: Pt
had several syncopal events over the last month mostly at night
which correlated to slowed HR on ___ monitor down 20's-50's. One
pre-syncopal episode during last admission and another syncopal
episode at home after discharge. These episodes are most likely
related to increased vagal tone and vasovagal syncope. Recently
diagnosed right parotid tumor which does not appear to be
positioned anatomically such that it would cause compressive
symptoms, however her neck pain alone may be contributing to her
vasovagal episodes. Scopolamine patch has not been effective.
She was re-evaluated by EP in the ED, with rec of expedited ENT
work-up for parotid tumor mass and discussion of temp pacemaker
placement prior to surgical intervention for tumor. It was
discussed with the patient that although a pacemaker is not
first line treatment for vasovagal syncope, without pacemaker
she may be at higher risk for adverse events during surgery.
After lengthy discussion with EP and Cardiology teams, patient
declined pacemaker placement, endorsing that she did not yet
feel read to undergo this procedure. During her brief
hospitalization she remained hemodynamically stable with heart
rates in the 40's on telemetry without further syncopal
episodes. She was continued on scopolamine patch. No futher
intervention was planned given that pt declined pacemaker, so
she was discharged to home with PCP ___.
#Right parotid gland tumor: Patient had FNA of parotid gland
tumor on ___, initial pathology consistent with Warthin's
tumor, although low-grade malignancy could not be excluded. Pain
from tumor may be contributing to vasovagal episodes as above.
Pt was evaluated by ENT during this admission, and based on
their review of imaging and pathology they thought the tumor was
unlikely to be causing Mrs. ___ recurrent symptoms.
Furthermore, while they feel that she will need surgical
intervention, they did not feel that surgery was emergent at
present. Pain was controlled with tylenol. Pt should ___
with ENT as an outpatient on ___.
#HTN: BP was elevated to SBP 140's-170's during last admission
so pt's home captopril was increased to 25mg BID. During this
brief admission SBP remained slightly elevated in the 150's. Pt
should follow up with her PCP regarding continued BP monitoring
and medication adjustment as needed.
#Anxiety: Per patient and her daughter, pt has had multiple
recent stressors including a death in the family and a difficult
work environment. Pt does have history of anxiety, however she
did not take any medications for this on admission. Pt should
follow up with PCP and consider counseling as an outpatient.
TRANSITIONAL ISSUES:
# Pt should consider pacemaker placement if she continues to
have syncopal episodes
# ENT ___ is scheduled on ___ for further
treatment of parotid gland tumor
# Pain management regimen for neck pain
# BP elevated during admission and captopril dose was doubled to
25mg BID during last admission. Please re-check blood pressure.
# Consider counseling as outpatient to discuss recent stressors
# Code: Confirmed full
# Emergency Contact: ___ ___
***. | 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.
***
This is a ___ year old male with past medical history of
hypertension, type 2 diabetes, admitted with biliary obstruction
and pancreatic mass concerning for pancreatic malignancy, s/p
ERCP and EUS with biopsy, stable and able to
tolerate advancing of diet, able to be discharged home with
___ clinic follow-up on ___.
# Biliary Obstruction / Pancreatic Mass - patient admitted with
concern for pancreatic mass with biliary obstruction; Tbili >
13; patient underwent EUS with biopsy, as well as ERCP with
sphincterotomy and stent placement. Patient seen by
hepatobiliary surgery service, who recommended CTA pancreas, CT
chest for staging, as well as CEA (returned mildly elevated at
10) and CA ___ level (pending at time of discharge). CT scan
showed 3.5x2.3cm pancreatic head mass. Following discharge,
biopsy returned concerning for pancreatic adenocarcinoma, and
brushings concerning for adenocarcinoma as well. Patient
scheduled for follow-up in ___ clinic on
___.
# Diabetes type 2 with hyperglycemia - patient admitted
reporting recent polyuria at home, found to have glucosuria on
admission and ongoing hyperglycemia ___ 200-300 through this
admission despite sliding scale insulin. Patient seen by ___
consult service, recommended to increase metformin dose to
1000mg BID (from 500mg BID) and follow fingersticks at home.
Patient given ___ contact information, advised to call if
persistently elevated fingersticks.
# Hyponatremia - likely secondary to hyperglycemia and
dehydration; resolved with IV fluids and improved glucose
control;
# Hypertension - continued lisinopril; restarted Hctz at
discharge
# Ascending Aortic Aneurysm - incidentally found to have have
4.5cm ascending aortic aneurysm, with radiology recommending
follow-up chest CT with cardiac gating in ___ year. Discussed with
patient.
Transitional Issues
- Discharged home
- Scheduled for multidisciplinary follow-up on ___
- Increased metformin per ___ recommendations, patient to
monitor fingersticks at home and call if elevated
- 4.5cm ascending aortic aneurysm found on CT scan, will need
repeat Chest CT with cardiac gating in ___ year
***. | MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is a ___ woman with hx of bladder cancer
(not on treatment), HTN, and HLD, who presents with suddent
onset nausea, vomiting, and ___ watery diarrhea, most
likely due to gastroenteritis.
# Gastroenteritis: Nausea, vomiting, and diarrhea likley
secondary to viral gastroenteritis. Onset and symptoms
consistent with norovirus. Norovirus PCR was sent for
confirmation. CT abdomen supported entercolitis, but transient
intussusception was also thought to be possible. Patient was
seen by Surgery, who did not think that surgical intervention
indicated at this time (Patient was also not amenable to
surgery). She received a total of 2L of IVF NS. Her lactate was
elevated to 3.6 initially, but normalalized (1.3) with
hydration. Patient's abdominal pain and diarrhea improved, and
she was able to tolerate regular diet.
# Acute on chronic renal insufficiency: Her Cr was found to be
1.5 (from baseline of 1.3). This was thought to be ___
secondary to vomiting, diarrhea, and dehydration. She received
2L of IVF NS. Her Cr returned to her baseline 1.3.
# Normocytic normochromic anemia: At admission Hct was 37.0,
above baseline of ___, likely due to hemoconcentration
secondary to dehydration. Hct was 31.3 at discharge.
# HTN: Patinent has a history of labile BPs, so she was allowed
permissive hypertension to SBP ___. She was continued on
her home dose labetalol and felodipine.
# GERD: She is on esomeprazole at home, which was not available
at ___. She received pantoprazole in the hospital.
# Anxiety: She was continued on home lorazepam.
##### TRANSITIONAL ISSUES #####
- Recheck electrolytes and Hct in one week
- ___ PCP
- ___ blood culture, norovirus PCR results
- Home ___
- Monitor outpatient blood pressure
***. | 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.
***
___ with hx of NSTEMI s/p DES to LAD (___), IDDM, morbid
obesity, presents after mechanical fall and left tib-fib
fracture.
# LEFT TIB-FIB FRACTURE: She underwent ORIF on ___. EBL
150cc. Post op course was complicated by hyperkalemia, ___, new
O2 requirement, tachycardia, and worsening hyperglycemia.
Transferred to medicine service. She will continue lovenox for 4
weeks post op (end date ___. She will follow up with Dr.
___ in 10 days. Please call to make an appointment.
# Anemia: Secondary to acute blood loss on chronic anemia. Hgb
was 12 in ___, but on this admission was 9.6. EBL 150cc and
acutely dropped to 7.9 post-op. Was transfused 1u pRBCs with
bump in Hgb to 9.7. H/H remained stable throughout admission.
Discharge Hgb 8.8. Restarted on aspirin and plavix for DES.
# ___: Baseline Cr 0.9. On admission, Cr 2.2.
Hyperkalemia peaked at 5.5 (5.8 in hemolyzed sample) requiring
kayexalate. EKG and telemetry did not show any arrhythmias or
findings consistent with hyperkalemia. Her ___ was felt to be
multifactorial including hypoperfusion and immobilization.
Lisinopril held while inpatient, then restarted on ___. Cr
on discharge 0.8. Should have CHEM 10 checked on ___ and
___. Lisinopril should be discontinued if evidence of
rising Cr.
# Hypoxia: She developed a 2L O2 requirement after operation.
CXR showed pulmonary edema and atelectasis. This improved with a
one-time dose of furosemide 20mg IV. Concern for missed cardiac
event in setting of ASA/Plavix for surgery. EKG at baseline.
Patient should be seen by cardiolgoist and ASA/Plavix should not
be stopped at any point without talkint to cardiologist.
# Post-op tachycarida: She had post-operative sinus tachycardia
to low 100s, which improved after re-starting her beta blocker.
# Insulin dependent DM 2: Her blood glucose initially ranged
from 200s-360. A1c 8.9. Patient did not know her home sliding
scale. Glargine increased to 38 units BID from 34 units, with
improving Glucose control. As clinical status improved, insulin
requirement decreased and switched back to 34U BID. Will need
further follow up for diabetes management.
# CAD: hx of NSTEMI in ___ with DES to LAD. ASA and Plavix
initially held for surgery. Restarted on ___ when H/H
stabilized. Continued Metoprolol 50mg BID and then transitioned
to succinate. Lisinopril held for ___. Restarted at time of
discharge.
# Constipation: Post-op constipation likely secondary to opioid
use. No nausea, vomiting. Aggressive bowel reg started.
CHRONIC:
# Depression: She was continued on her home paroxetine 40mg
daily and home quetiapine 600mg qHS.
# Hypothyroidism: She was continued on her home levothyroxine
150mcg daily.
=========================
TRANSITIONAL ISSUES
=========================
# Please check CBC, CHEM 10 on ___ and ___ and inform
MD of any changes to values. If Cr increasing, please stop
lisinopril. If H/H downtrending, please call Dr. ___ PCP
in regards to anticoagulation.
#Please do not stop aspirin or plavix without discussion with
cardiologist. Patient had DES placed 3 months ago and high risk
for recurrent cardiac events.
# Please call to make appointment with Dr. ___ Dr.
___.
# Pending labs: Blood cultures ___
# Lovenox to be continued for 4 weeks post op (end date ___
# Hgb on discharge 8.8.
# Cr on discharge 0.8.
# ___ and Hyperkalemia, resolved. Lisinopril held in-patient but
restart prior to discharge for cardioprotective effects. Cr
remained stable.
# Please continue to assess FSBG daily and adjust insulin
regimen as needed.
# New medications: Acetaminophen, albuterol, bisacodyl,
docusate, enoxaparin, oxycodone
# CONTACT: ___, Husband ___
# CODE: FULL CODE
***. | LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP FOOT AND FEMUR WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
PATIENT SUMMARY
================
Ms. ___ is a ___ with CAD (s/p PCI to RCA in ___, HFrEF
(last EF 35% in ___, Afib on apixaban, psoriatic arthritis,
h/o remote thyroid cancer s/p thyroidectomy c/b chronic
hypocalcemia who presented with general weakness x 1 week, and
was found to have profound hypocalcemia and RLE cellulitis.
ACUTE ISSUES
=============
#Hypocalcemia
#Hypomagnesia: On admission, Ms. ___ was noted to have a Ca
5.0, Alb 2.7, Corrected Ca 6.0, iCa 0.6, PTH 11, and Vit D 54.
Of note, on her last ___ admission she had a Corrected Ca ~8.
She noted that she has chronically been hypocalcemic since her
thyroidectomy several decades ago for thyroid cancer, however
noted that it has been worsened and more labile in the past
several months. In terms of more recent underlying etiologies,
may represent newly added diuretic vs. recent altered calcium
supplementation vs. medication non-compliance vs. poor PO
intake. Endocrine was consulted, who initially recommended a
fixed drip of Calcium Gluconate with q6 hr ionized Ca checks.
This was eventually transitioned to Calcium Carbonate 1500mg PO
BID and Calcitriol 25mcg PO qd, as she has had a tremendous
improvement in calcium levels with IV supplementation. Her
magnesium was aggressively repleted for a goal Mg >2, and she
was started on Magnesium Oxide 800mg BID. Similarly, her
potassium was repleted for a goal K >4. She had daily EKGs,
which showed improvement in QTc prolongation. Endocrinology
recommended a DEXA scan as an outpatient.
# RLE Cellulitis:
On admission, was found to have RLE erythema, swelling, and
tenderness c/w
cellulitis. She had a leukocytosis of 12 with PMN predominance.
Her recent hospitalization put her at risk for MRSA, and as such
was initially placed on Vancomycin for MRSA coverage. However,
she had a non-purulent cellulitis and as such she was
transitioned to IV Ceftriaxone and eventually PO Keflex for a
total 10 day course of antibiotics. Wound care was consulted and
provided recommendations throughout her hospitalization. Her
leukocytosis subsequently normalized and had significant
improvement in the appearance of her RLE. Her final blood
cultures demonstrated no growth.
# HFrEF: EF ___ per ___ records in ___. DDx ischemic
cardiomyopathy
given CAD vs. tachycardia-induced given h/o AF with RVR.
Appeared
euvolemic on admission, however her BNP was elevated to the
6000s. She was taking 80mg Torsemide at home, and this was
reduced to 40mg daily during her hospitalization given
persistent electrolyte derangements. Her home Losartan was also
reduced to 12.5mg daily due to symptomatic hypotension. She was
continued on her home Metoprolol.
# H/o recent fall: suspect mechanical in origin. Evaluated with
extensive imaging in the ED, which were negative for acute
fractures. Her Vitamin D level was found to be 54 (upper end of
normal). Physical therapy was consulted re: weakness and
instability, and recommended rehabilitation. She is discharging
to ___.
# Living Situation: Daughter noted on ___ that her mother's
cognition has been declining over the past several years. She
noted how her mother lives on a ___ floor apartment, and given
difficulties with stairs does not go to appointments very often.
Noted that her ___ was in disarray at her last visit (rodent
infestation, not cleaned, rodent feces on the furniture). Also,
that she had been forgetting to pay the bills (reportedly went 6
months
without health insurance last year). Of note, has history of
heavy EtOH
use. MOCA = 23 on ___ visuospatial/executive, ___ naming,
___
attention, ___ language, ___ abstraction, ___ delayed recall,
___
orientation). Social work was consulted regarding her living
situation. We recommend neuropsychiatric evaluation as an
outpatient.
CHRONIC ISSUES:
================
# Atrial Fibrillation: CHADS2VASC 5. S/p DCCV in ___ at ___.
On telemetry, she was in NSR. She was continued on her home
Amiodarone, Metoprolol, and Apixaban.
# Normocytic anemia: Was found on admission to have a mild
anemia to Hgb ___ with an unclear baseline. Iron studies
obtained were consistent with anemia of chronic disease, which
correlated with her history of psoriatic arthritis. We monitored
her CBC daily, and did not need to transfuse throughout her
hospitalization.
# CAD: Recent hospitalization at ___ for RCA stenting in
___. Trops x2 negative on admission. Continued home
ASA, clopidogrel, and atorvastatin.
# Psoriatic Arthritis: Continued home tramadol. Of note, was on
Cosentyx/Enbrel previously, but these have been held since
___ after her ___ hospitalization due to Shingles at that
time. During her current hospitalization she endorsed worsened
arthritic pain of her shoulders. Given no signs of Shingles
currently, re recommend following up with Rheumatology to
discuss reinitiation of her former medications.
# Hypothyroidism: s/p thyroidectomy as above. TSH 2.3 on
admission. Continued on home levofloxacin 125 mcg daily.
====================
TRANSITIONAL ISSUES
====================
[ ] Continue Keflex until ___ for total of 10-day course for
complicated cellulitis. (Day 1 was ___
[ ] Follow up U/A sent on ___, as patient was endorsing
increased urinary frequency however no dysuria or increased
urgency. Of note, appeared to be colonized with Gram Positive
Bacteria (alpha streptococcus or Lactobacillus sp.) on ___
urine culture but at that time did not have any urinary or
infectious symptoms.
[ ] Repeat CBC, BMP, Mg, PO4, and Calcium, albumin and ical on
___.
[ ] On ___ her ical was 0.81 and Ca 7.8 with albumin of 2.8. If
her calcium comes back lower than this on ___ please uptitrate
her calcium repletion in conjunction with endocrinology.
[ ] Weigh patient daily on standing scale and if weight changes
by more than 3 lbs in either direction please adjust her
diuretic dosing as below.
[ ] If needs further diuretic, recommend considering initiation
of Acetazolamide (given chronic metabolic alkalosis) vs. HCTZ
(given h/o hypocalcemia). We suspect torsemide at high dose of
80mg contributed to her hypocalcemia. So if needing to increase
torsemide dose would carefully monitor her electrolytes.
[ ] Please perform daily wound care and wound assessments to
ensure that her RLE wounds remain clean and heal appropriately.
Consider prolonging antibiotic course if cellulitis is
persistent.
[ ] Patient's blood pressures ranged from ___ systolics.
She was largely asymptomatic but occasion felt slightly
lightheaded. For this reason her losartan was cut from 25mg to
12.5. Please continue to assess blood pressure and if continues
to be in ___ systolics with symptoms would further adjust
hypertension meds.
[ ] Recommend outpatient Neuropsychiatric testing for disarrayed
living situation. She had a MOCA of 23 while hospitalized,
however likely has high cognitive reserve and thus may have
inaccurately represented her cognitive abilities.
[ ] Follow up with Endocrinology on ___ at ___ as scheduled
to re-evaluate hypocalcemia and electrolyte derangements.
Recommend that patient call periodically to see if a
cancellation develops so that she can been seen sooner.
[ ] Follow up with Cardiology on ___ at ___ as scheduled
(11am for cardiac imaging, 1pm with Dr. ___
[ ] Follow up with Rheumatology at ___ on ___ to discuss
reinitiation of Cosentyx/Enbrel given worsened arthritic pains
[ ] Recommend outpatient ENT evaluation of subjective voice
change - patient to schedule appointment with ENT provider
[ ] New Medications: Calcitriol 0.25mcg once daily, Magnesium
Oxide 800mg BID, Keflex
[ ] Changed Medications: Torsemide from 80mg to 40mg qd.
Losartan from 25mg to 12.5mg qd.
[ ] Consider repeating DEXA scan as outpatient.
[ ] Please obtain EKG on ___ for monitoring. QTc was prolonged
I/s/o hypocalcemia and should be periodically monitored. Last
QTc on ___ was 449.
[ ] Please determine Geriatric PCP for patient (previously saw
Dr. ___ she does not live in the ___
facility unsure if she will see the patient)
***. | CELLULITIS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ y/o female with ESRD on HD using right arm AV fistula who
presents with pulsatile bleeding from the fistula. Patient was
seen in ED earlier in the week with suture placement and
fistulogram showing an 80% stenosis.
.
Patient was taken urgently to the OR with Dr. ___ for
a revision of the right brachiocephalic fistula. Pulsitile
bleeding was found intra-op. There was an approximately 1.5 cm
hole in the mid portion of the fistula. The fistula was able to
be repaired, but did have some clot that was removed prior to
end of case. She had received two units of RBCs given the blood
loss from the inital hemorrhage.
.
The arm was stable, with good pulse and well perfused hand. The
dressing was removed on POD 2 and the incision was intact with
no bleeding or erythema and minimal swelling.
.
A left side tunneled IJ catheter was placed for hemodialysis,
and she underwent a successful HD treament using the catheter
following placement on ___.
.
Warfarin was resumed at home dose on ___. She will follow up
with INR draw at ___ with results to Dr ___
her usual routine. Of note the Warfarin was held until after
the HD line was placed.
.
Patient will restart her usual HD routine (4 days per week)
using the new catheter and allowing the arm to heal.
.
Patient was seen by ortho during this admission as she had
follow up planned that occured during her hospital stay. Patient
will be following up with outpatient ortho in 1 month per
communication with ortho in house. Patient has been informed to
obtain appointment.
***. | 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.
***
This is a ___ M with h/o HIV (CD4 492 on ___, vL nD), HCV s/p
cure ___, AF on dabigatran, and OA s/p ___ hip replacements who
presented by EMS after three falls on ___, found to have
likely LLL PNA.
#Community acquired pneumonia:
In the setting of syncope and cough, patient underwent
infectious workup. Found to have leukocytosis to 15.4 and e/o
LLL PNA on CXR. Most likely CAP given no recent healthcare
exposures. Considered TB reactivation but unlikely given
successful treatment in past and no other systemic symptoms.
Also considered opportunistic infections with h/o HIV but
unlikely with most recent CD4 492 and patient on HAART. Started
on CTX and Azithro in ED, transitioned to PO levo on floor with
plan for 5 day course (last day ___. At discharge, pending
studies include CD4 count, HIV viral load, urine legionella,
strep antigen, and blood cultures.
#Multiple falls, ?syncope:
#Mechanical fall, dehydration:
#Left hip pain:
Patient felt dizzy before at least one reported fall prior to
admission. He denied resting pain but endorsed pain in his L hip
with L knee flexion; it is unclear whether he landed on hip in
any fall. The absence of loss of consciousness or post-ictal
state make cardiogenic syncope and seizure less likely. Most
likely, this is a patient with some lower extremity weakness who
fell after becoming dizzy secondary to his morning Caverject
injection and dehydration in the setting of pneumonia and poor
PO intake. Plain films of his left hip and femur showed no
evidence of fracture or dislocation. He was evaluated by ___ and
cleared to go home without services.
___:
He presented with a Cr of 1.2 (baseline 0.9-1.0 per outside
records). He continued to produce urine and had no abnormalities
on urinalysis or urine microscopy. This was felt to be most
likely pre-renal, with dehydration in the setting of CAP and
poor PO intake. He was encouraged to maintain adequate PO
intake.
#Leukocytosis:
He presented with WBC 15.4. His urinalysis showed no signs of
UTI; he remained hemodynamically stable; there was no sign of
SSTI on exam. The most likely etiology is his LLL pneumonia seen
on CXR. He was discharged on a 5-day course of levofloxacin, as
above.
TRANSITIONAL ISSUES:
[] NEW medications:
-Levaquin 750mg daily x5 days (last day ___
[] HELD medications:
-Caverject injection (alprostadil)
-Viagra (sildenafil)
[]IMAGING findings:
-CT head with no acute intracranial processes
-CT C-spine with no evidence of fracture
-Left hip and femur plain films with no evidence of fracture or
dislocation
[] Discharge Cr 1.3 on ___
[] Should have labs checked prior to next appointment (___)
[] Please encourage adequate PO intake
Discharge took <30 minutes to prepare
***. | HIV WITH MAJOR RELATED CONDITION 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 male with history of alcoholic cirrhosis, variceal
bleed ___ months ago (___), recurrent bleed two weeks ago
(___), who presented with alcohol intoxication and a chief
complaint of severe abdominal pain and one episode of bloody
emesis, found to have severe ___ tear and gastritis
but no varices.
# ___ tear / gastritis: Due to vomiting in the
setting of heavy alcohol use. Started on carafate, increased
pantoprazole to BID. No evidence of varices or portal
hypertension on EGD during this hospitalization. Blood counts
remained stable, no hemodynamic compromise, and he had no
further episodes of hematochezia. Stool was yellow/brown and
guaiac negative.
- Needs repeat endoscopy in 8 weeks to ensure healing
# Alcoholic cirrhosis: Complicated by recent variceal bleed
(___). EGD at ___ revealed portal gastropathy and small
varices. No evidence of varices or portal gastropathy on EGD
during this admission. RUQ ultrasound on this admission with
patent vasculature. Liver team co-managed patient during this
hospitalization.
# Alcohol abuse: Reports drinking 1 pint of vodka daily since
age ___. Achieved sobriety for 8 months but relapsed over past 2
months. No history of DTs or withdrawal seizures. Maintained
on CIWA, MVI, thiamine, folate. Social work was consulted and
recommended various outpatient resources to assist in alcohol
cessation.
# Depression/anxiety: Cont home zoloft
TRANSITIONAL ISSUES
# Encourage alcohol cessation efforts
# Repeat endoscopy in 8 weeks to ensure healing of ___
tear
# Code: DNR/DNI
# Emergency Contact: Mother, ___ ___
***. | MAJOR ESOPHAGEAL 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.
***
___ female with SLE complicated by neuromyelitis optica
and transverse myelitis with chronic urostomy for neurogenic
bladder presented from nursing facility after she was found to
be somnolent and having cloudy urine. She was found to be
septic.
ACTIVE ISSUES
# Sepsis due to nephrolithiasis, urinary tract infection: Upon
arrive in the ED, she had a temperature of 101.8, white count of
29.7 with 9% band, and urine culture notable for polymicrobial
growth. Her blood eventually grew ciprofloxacin and gentamicin
resistent E. coli. Renal ultrasound showed bilateral
nephrolithiasis, new moderate right hydronephrosis, and
worsening of dilated left kidney calices. The sum of data
pointed to the urinary tract as the source of infection
especially in the setting of her atypical anatomy. In the MICU,
she was started on norepinephrine and aggressively fluid
resuscitated with MAP goal of 65 mmHg. She was also given
meropenem and vancomycin for empiric antibiotic therapy prior to
speciation. On hospital day 2, she was taken by ___ for placement
of a percutaneous nephrostomy tube in the right kidney for
decompression of the hydronephrosis. She was weaned off of
norepinephrine on hospital day 4 and transitioned to
vasopressin, which was stopped on hospital day 5. She completed
a 9 day course of vancomycin for her UTI, and a 14 day course of
meropenem for the GNR bacteremia.
# Nephrolithiasis: Pt has a Right nephrostomy tube that is
capped and will be in place until percutaneous nephrolithotomy
is done (to remove right kidney stone).
# Respiratory distress, ARDS: She also developed ARDS in this
setting, and was intubated on ___. She was ventilated
appropriately and her pulmonary function subsequently improved
and she was extubated on ___.
# Fevers: During her second week, she developed persistent
fevers and increasing leukocytosis through both vancomycin and
meropenem; extensive evaluation for occult infectious etiology
was undertaken, including multiple repeat cultures, head CT, CT
abdomen/pelvis, and LP, which were ultimately unrevealing. Her
fevers resolved and leukocytosis downtrended as well.
# Encephalopathy: Pt was noted to have altered mental status and
significant encephalopathy even as sedation was weaned down
after she recovered from septic shock. She was noted to have a
history of being slow to wean from sedation during her previous
hospitalizations. However, in the setting of continued fevers
despite a brief period of clinical improvement after being on
both vancomycin and meropenem, there was concern for a potential
CNS infection, especially given her existing baclofen pump. Pain
service was consulted and interrogated the pump, finding no
abnormalities. A stat head CT was performed in the setting of
finding pt exhibiting cyclical pupillary dilations and
constrictions; CT was negative. An LP was performed by
Anesthesia which showed a WBC of 6 with a lymphocytic
predominance; empiric acyclovir was begun while awaiting HSV
PCR. Her mental status ultimately improved significantly on
___. By discharge on ___ she was alert and oriented to person,
place and time and speech was fluent.
#Blood pressure lability: Patient was noted to have very labile
blood pressures during admission, which were at times difficult
to control. After recovering from septic shock and d/c'ing her
pressors, her blood pressure slowly increased, but she had
several episodes of hypertensive crises; during two of these
episodes, she became acutely hypoxic, tachycardic to the 140s,
and desaturated, likely due to flash pulmonary edema secondary
to congestion from the acutely increased afterload. She was
placed on a labetolol gtt which controlled her blood pressures.
She was also noted to be very sensitive to fentanyl, which often
dropped her SBPs to the ___. It was thought that these
cyclical blood pressure variations were secondary to a central
neurological process causing variations in sympathetic and
parasympathetic tone, especially given her neurologic history as
well as her pupillary findings of cyclical dilations and
constrictions. After altnernating between IV labetolol PRN and
labetolol drips, she was started on captopril and uptitrated
ultimately to 25mg captopril TID, which controlled her blood
pressures well and prevented any further hypertensive episodes.
On discharge she was transitioned back to her home losartan.
___: Most likely secondary to pre-renal hypovolemia in setting
of sepsis. Medications were renally dosed, but her creatinine
slowly normalized back to her baseline of ~0.7 with volume
resuscitation.
CHRONIC ISSUES
# Lupus c/b Devic's Neuromyelitis Optica and Transverse
Myelitis: She is on a home baclofen intrathecal pump for pain
control, which was continued after it was ruled out that she may
have had a pump infection. Her home prednisone was converted to
IV hydrocortisone while inpatient and she was given stress
doses, and then converted back to PO prednisone.
# Hypothyroidism: Stable. She continued on home levothyroxine.
TRANSITIONAL ISSUES
--Awaiting outpatient perc nephrolithotomy with urology (Dr. ___.
___. If pt develops right flank pain, fevers or worsening
renal function, please un-cap right nephrostomy tube.
--Patient is sensitive to developing encephalopathy/delirium in
the setting of infection. When this happens ___ her HCP
will consent for her. At her baseline, though, she is able to
consent for procedures.
--Tolerating normal diet on discharge
--She did not require seroquel during this hospitalization, so
this was not continued on discharge.
***. | INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURE WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mrs. ___ is an ___ woman with severe CAD 3-vessel CAD
( LMCA 70%, LAD 100% occlusion after D1, LCX 99% proximal, RCA
100% ostial disease, no stent) DM2, HTN, HL, who originally
presented to OSH with epigastric pain.
.
The patient passed away on ___ after the following sequence
of events:
.
At 2300 on ___, pt had sudden asystole, responded to
<1minute of chest compressions. Became responsive and agitated
with tachycardia. Several minutes later returned to ___,
was given epi 1mg x 1 and had brief compressions, returned to
___ rhythm. EKG significant for new LBBB. Several
minutes later returned to ___, was given atropine 1 mg x 1,
morphine 2mg, and returned to ___ rhythm. Over the next ___
minutes had several more episodes. Given 0.5mg atropine twice,
then 1 mg, also given 1mg ativan x 2 for agitation between
episodes. Then was given epi x 1 mg three times. Was now
obtunded. Intervals of tachycardia between asystole shortened in
length. Pt was started on transcutaneous pacing at 100J at rate
of 80. Family arrived at bedside approximately 15 minutes after
pacing began. Pacemaker was turned off after discussion with HCP
___. Pt not a candidate for permanent pacemaker.
Attending Dr. ___ was notified at start of event and
communicated with throughout the time course. Time of death was
1:12AM. Pt was examined and had no spontaneous respirations, no
carotid pulse, no heart sounds, and dilated and fixed pupils.
Family was at bedside and attending notified. Cause of death
coronary artery disease with cardiac arrest. No autopsy
requested after discussion with family.
Her hospital course prior to these events is as below:
.
# CORONARIES: On admission, troponin 1.5, CK 368, MBI 11%, ECG
with worsening of STE in inferior leads and new TWI laterally.
Dehydration, as suggested on exam, might have lead to
hypoperfusion of coronary arteries, worsening CAD and causing
ischemia. Given her extensive diffuse disease and multiple
medical comorbidities, no intervention was undertaken and
medical management was optimized, including heparin, aspirin,
clopidogrel, statin, and eptifibatide drip. CK was trended and
peaked at 792.
.
# Hypotension: The patient was initially hypotensive requiring
dopamine and then phenylephrine. It was unclear whether she was
in cardiogenic or distributive shock. The patient and her
family refused central line placement. Pressors were weaned
quickly over the first day.
.
# Urinary tract infection: The patient had a positive
urinalysis and was treated with a dose of gentamicin followed by
Bactrim. Cultures eventually grew enterococcus.
.
# PUMP: No sign of heart failure on exam. Echocardiogram showed
EF 20% with moderate mitral and tricuspid regurgitation.
.
# RHYTHM: Patient was in sinus rhythm until the ___
events as above.
.
# CKD: baseline Cr likely 1.3; now 1.8. This was likely
prerenal azotemia, improved to 1.4 with hydration.
.
# DM2: NPH was continued along with insulin sliding scale.
.
# Hyperlipidemia: Statin was continued.
.
.
***. | ACUTE MYOCARDIAL INFARCTION EXPIRED 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.
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 overlying dressing was
removed on POD#2 and the Silverlon dressing was found to be
clean and dry. The patient was seen daily by physical therapy.
Labs were checked throughout the hospital course and repleted
accordingly. At the time of discharge the patient was tolerating
a regular diet and feeling well. The patient was afebrile with
stable vital signs. The patient's hematocrit was acceptable and
pain was adequately controlled on an oral regimen. The operative
extremity was neurovascularly intact and the wound was benign.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity. Please use walker or 2
crutches at all times for 6 weeks.
Mr. ___ is discharged to rehab in stable condition.
***. | MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
*** is a ___ year old woman with recurrent fallopian
tube cancer on carboplatin/doxorubicin who was admitted from the
ED with several days of progressive fatigue and malaise
following chemotherapy.
# Malaise
# Leukocytosis
Presented with fatigue and confusion after chemotherapy
treatment. Confusion may have been in part secondary to
dexamethasone and fatigue due to chemotherapy. UA and blood
cultures were negative for infection. She had no respiratory
symptoms. She remained febrile overall with no signs of
infection.
She did report significant psychological distress in the setting
of her cancer recurrence and was seen by social work and
addiction psychiatry. She will follow up with addiction
psychiatry as an outpatient.
TSH was found to be elevated and dose of levothyroxine was
adjusted, but not clear if this contributed to her acute onset
of weakness.
# Elevated TSH: TSH 35. ___ be unreliable in the setting of
acute illness, though as above no evidence of infection was
found. Given this levothyroxine was increased from 175mcg to
200mcg daily. Likely should be rechecked in the outpatient
setting within the next ___ weeks given potential unreliable
results while ill
# Recurrent fallopian tube cancer: will follow with Dr. ___ as
an outpatient. Continued prn dilaudid for cancer related pain
# Recent hernia repair: s/p operative repair on ___.
Notable, removed hernia sac contained metastatic carcinoma, and
there is at least some concern for disease within subcutaneous
tissue about surgical incision on CT. She was seen by surgery in
the ED who felt that there was no evidence of surgical infection
or complication
# Neuropathy: continued home gabapentin
> 30 minutes spent on discharge coordination and planning
Transitional Issues:
====================
- consider rechecking TSH in the outpatient setting in the next
___ weeks
- will follow up with addiction psychiatry regarding possible
home delivery of methadone during chemotherapy
***. | SIGNS AND SYMPTOMS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ was admitted for intermittent chest pain. In the
emergency department, he received 3 sublingual nitro while he
was in the emergency department. He received morphine IV for
pain control. He was started on O2 supplementation. An EKG
showed ? ST depression in Lead II. Labs were siginificant for an
initial troponin < .01. He was started on a heparin gtt.
.
He was transferred to the floor and refused to stay because a
private room was unavailable. The cardiology fellow and I spoke
at great length with the patient about the risks and benefits of
leaving the hospital AMA, given his presenting symptoms. His
symptoms are very concerning for an acute coronary syndrome. The
patient understood the risks and preferred to leave the hospital
without further medical intervention. the patient was convinced
to stay until he received his second set of cardiac enzymes,
which returned back within normal limits at .01. Therefore, he
was scheduled for a stress test tomorrow. He was asked to
follow-up as an outpatient. He was discharged home with aspirin
325mg and we increased his metoprolol from 50mg to 100mg daily.
.
***. | ATHEROSCLEROSIS 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. ___ presented on ___ for elective ACDF of C5/6-C6-7.
His intraoperative course was uneventful, please refer to the
operative note for further details. He was extubated and
transferred to the PACU for recovery. He was later transferred
to the floor in stable conditions.
On ___ the patient remained neurologically and hemodynamically
stable. He was tolerating po intake without difficulty. An xray
of the cervical spine was obtained to evaluate the hardware and
showed good placement of hardware. All discharge instructions
and follow up information was given to patient prior to
discharge.
***. | CERVICAL SPINAL FUSION WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is a ___ y/o male with a past medical history of
Alport Syndrome s/p living donor renal transplant (___) on
immunosuppression with MMF/prednisone/neoral, gout, HTN, HLD,
who presents with URI symptoms and leukocytosis concerning for
walking pneumonia.
# Sepsis: Likely secondary to community acquired pneumonia.
Patient meeting SIRS criteria secondary to tachycardia,
leukocytosis and source of infection likely being PNA. Also had
lactate elevation. Patient given ceftriaxone and levofloxacin in
the ED. Initially broadened to vanco, cefepime, and azithro
given sepsis and immunosuppression. The patient was given 1L IVF
in the ED and his lactate improved. Likely etiology of pneumonia
is post-viral bacterial infection vs. ongoing viral pneumonia.
TB unlikely as previous negative PPD and no risk factors.
Legionella Ag negative. Other etiologies of infection including
UTI unlikely given normal UA and absence of symptoms. Discharged
on Levaquin to complete ___lport syndrome s/p transplant ___: continue neoral, MMF, and
prednisone
# Anion Gap Acidosis: Likely secondary to elevated lacate in
setting of infection. Repeat lactate normalized
# Hypertension: Continued diltiazem, held lisinopril in setting
of infection and risk of ___, can be restarted at f/u
# Hyperlipidemia: atorvastatin
# Gout: Continued on Prednisone, allopurinol at reduced dose
(200mg) given kidney injury
Transitional issues:
- Repeat CXR in ___ weeks to document resolution of LUL
infiltrate
- Cont levaquin for ___ompletes ___
- At rheum followup, discuss if 10 mg prednisone continues to be
necessary for treatment of gout
- F/u CMV Viral Load and other pending microbiology results
- Consider restarting lisinopril
***. | 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.
***
# Acute renal failure likely ___ urinary retention and
obstructive hydronephrosis:
A renal US was obtained which did not show the ureters but
showed mild-moderate hydronephrosis in the left kidney and
severe hydronephrosis in the right kidney with loss of cortex. A
renal consult was obtained and the patient was given IV fluids,
phosphate binders, and NaHCO3 to correct acid base
abnormalities. Note that he was refusing his sodium bicarb
during admission but states he is willing to take it as an
outpatient now that he has been educated about its purpose.
Creatinine trended down from 12 to 8.8 with excellent urine
output by the time of admission. He is to keep his Foley
catheter in place and have close follow-up of his renal
function. Vitamin D level is pending at the time of discharge.
The patient requested that he continue to f/u with Dr. ___
nephrology.
We have asked that chem 7 be rechecked when he sees his
urologist ___. He then needs chem 7 to be checked on ___ when
he has an appointment with his PCP and every week for 3 more
weeks thereafter.
Mr. ___ was cautioned about the importance of compliance
with these medications and with his follow-up visits.
# Urinary retention:
A urology consult was obtained and suggested he be started on
doxazosin 2mg. A repeat US on the third day of admission showed
no improvement in hydronephrosis on either side so a CT scan was
obtained to elucidate obstructive etiology which showed stable
hydronephrosis and thickened bladder wall. Per urology, this
did not need further inpatient assessment. We have discussed
these findings and the importance of follow-up with the patient
and his urologist.
# Anemia and Hematuria:
Patient presented with a hematocrit of 27.3 with MCV 88 which
went down to 23.4 on ___ in the setting of increased IVF, mild
to moderate hematuria. Hematuria resolved with time and was
felt to be secondary to his chronic retention. His last
hematocrit was normal at his PCP's office in ___. Iron studies
were neither consistent with iron deficiency anemia nor anemia
of chronic disease. It was thought that it was most likely due
to kidney failure and he was started on Epoietin 4000U, 3x per
week. His hematocrit had stabilized around 23.
# Hypertension:
Patient has mild hypertension. He prefers to manage this with
diet and exercise. Please continue to monitor in case he
requires medication in the future.
***. | RENAL FAILURE WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
*** with h/o CAD, HTN, hypothyroidism, and prior TIA admitted
___ with bacteremia ___ colitis and returning with
persistently positive blood cultures that are polymicrobial.
.
# Polymicrobial bacteremia ___ Acute sigmoid diverticulitis:
ESBL ecoli, bacteroides and Clostridium grew from blood cultures
over ___. These are consistent with colonic flora that
have translocated into her blood stream. Underlying issue
thought to be colitis seem on recent admission, which on repeat
CT looked more consistent with worsened acute sigmoid
diverticulitis without abscess. Pt was continued on Zosyn. PICC
line d/c'ed for line holiday. ID consulted. GI consulted given
diverticulitis rarely results in polymicrobial bacteremia over
the course of a week, raising suspicion for GI malignancy. GI
recommended repeat colonoscopy in 6wks due to risk of
perforation in setting of active inflammation. GI indicated they
will schedule her for outpatient ___. Pt looked clinically well
with small formed BMs throughout this admission. Pt will ___
with ID and GI in clinic. ___ line replaced ___ after all
cultures negative since ___. Plan for 2wk course of Zosyn from
first day of negative cultures (day 1: ___ - course to end
___.
.
>> Chronic issues:
# CAD: cont ASA
# HTN: cont coreg. BPs running high (SBPs 160-180s) and so
losartan started as well given pt has allergies to CCB and
thiazides.
# Hypothyroidism: cont levothyroxine
.
>> Transitional issues:
# CODE STATUS: Full
# Contact: son ___ ___
# GYN ___ for endometrial biopsy given thickened endometrium on
CT and U/S
# GI ___. Plan for repeat colonoscopy in 6wks to look for bowel
wall pathology that could predispose to bacterial translocation
over the course of 6 days in the setting of diverticulitis which
is quite atypical.
# ID ___
# Zosyn course to end ___ for 2wks from first negative blood
culture
# HTN mgmt: pt started on losartan. Recommend PCP titration as
needed and lytes and PCP ___ to monitor renal function and K.
# Final blood cultures pending at the time of discharge.
***. | 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.
***
___ with PMHx of UC (reportedly unresponsive remicaide,
humira, ___, recently DC'd budesonide), who presented with abd
pain, diarrhea and elevated inflammatory markers, as well as
+stool for c. diff. Per GI, Colorectal Surgery and patient, all
in agreement that colectomy was appropriate for management.
# Acute on Chronic Ulcerative Colitis flare; C. Diff Colitis:
___ recent C. Diff sp prolonged course of po Vanc, completed
___. Was planning for colectomy in ___ with Dr. ___
in ___ for UC. Budesonide stopped by pt raising concern for
UC flare. C. diff ab+ and this was thought to be possibly
conttributing. Pt self-reported fevers. She developed
obstipation and reduced BM on ___ but KUB remains reassuring.
She was taken for Colectomy by CRS on ___. Prior to this,
she received Solumederol 20mg IV q8h, tapered to BID (d1 = ___
and PO Vancomycin (d1 = ___. She tolerated the procedure well
without complications (Please see operative note for further
details). After a brief and uneventful stay in the PACU, the
patient was transferred to the floor for further post-operative
management.
Neuro: Pain was well controlled on postoperative day 3.
CV: Vital signs were routinely monitored during the patient's
length of stay.
Pulm: The patient was encouraged to ambulate, sit and get out
of bed, use the incentive spirometer, and had oxygen saturation
levels monitored as indicated.
GI: The patient was initially kept NPO after the procedure. The
patient was later advanced to and tolerated a regular diet at
time of discharge.
GU: Patient had a Foley catheter that was removed at time of
discharge. Urine output was monitored as indicated. At time of
discharge, the patient was voiding without difficulty.
ID: The patient's vital signs were monitored for signs of
infection and fever. The patient was continued on antibiotics as
indicated.
Heme: The patient had blood levels checked post operatively
during the hospital course to monitor for signs of bleeding. The
patient had vital signs, including heart rate and blood
pressure, monitored throughout the hospital stay.
On ___, the patient was discharged to home. At discharge,
she was tolerating a regular diet, passing flatus, having
adequate ostomy output, voiding, and ambulating independently.
She will follow-up in the clinic in ___ weeks. This information
was communicated to the patient directly prior to discharge.
# Lactate elevation:
Likely ___ poor po intake. Pt received IVF for this.
# Anxiety:
Continued home Ativan prn. Social work and wound ostomy consults
were involved.
# Anemia:
Chronic, anemia of chronic disease, improved from recent
discharge.
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[x] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate rehab hospital disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
dispo
[x] No social factors contributing in delay of discharge.
***. | 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.
***
This is the brief hospital course for a ___ year old woman with
ADHD on atomoxetine, on oral contraceptive therapy, and a
history of tobacco use who presented with dysarthria and left
sided weakness with a subsequent finding of a large right MCA
territory. This notably occurred in the setting of synthetic
cannabis abuse (smoking K2). She was found to have a mid-M1
occlusion of unknown etilogy with otherwise normal blood vessels
of the neck and head. She was initially admitted to the SDU but
overnight developed a headache. An NCHCT revealed 4mm of
parafalcine herniation and she was started on hyperosmolar
therapy with mannitol. She was transferred to the ICU for closer
monitoring.
.
Her NCHCTs remained stable for the next few days (except for
small amounts of hemorrhagic transformation), and her exam
continued to improve with more wakefulness, attention, and
improved speech. She remains hemiplegic with no movement on the
LEFT side, including to noxious stimuli.
.
She was found to have a PFO on her TTE, but negative lower
extremity dopplers and an MRI of her pelvic region did not
reveal any venous clots (anticoagulation is not an option for
her at this time). Hypercoagulability labs were sent, and some
remain pending at the time of discharge (see above results
section). These can be followed up at her appointment with Dr.
___ in a few weeks.
.
She conditionally passed her bedside dysphagia screen but
requires 1:1 supervision and soft consistency solids. She was
left-sided plegic when initially starting physical and
occupational therapy, and remained this way throughout her stay
with us.
.
At discharge, she will be continued on ASA 325mg daily, a daily
statin, and prozac. Until she is more mobile, Heparin SC 5000U
TID should be continued.
.
She was discharged to rehab for rigorous physical, speech, and
occupational therapy when medically stable by the neurology
team. She will have follow-up with Dr. ___ on ___.
***. | INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ yo M with AML recently transformed from MDS.
ACUTE ISSUES
# Febrile neutropenia: Patient first spiked on ___. He was
initially started on vancomycin and cefepime. He had concurrent
abdominal pain which was thought to be due to enteritis vs.
colitis vs. cholecystitis. CT abdomen on ___ unremarkable. RUQ
ultrasound on ___ showed mild distension and a small amount of
biliary sludge suggestive of early cholecystitis. Repeat study
on ___ showed no sonographic evidence of cholecystitis.
Micafungin added on ___ to cover for fungal infection. Patient
reported left calf pain on ___ which was concerning for
osteomyelitis as source of fevers. MRI of left calf the same day
showed no evidence of osteomyelitis.
Line was considered as a source of infection but absence of
significant tenderness or surrounding erythema argued against a
line infection and it was left in place. Repeat CT abdomen on
___ revealed cecal wall thickening suggestive of mild/early
typhilitis. Patient was covered with vancomycin and cefepime
until they were discontinued on ___ due to worsening rash
thought to be allergic reaction to antibiotics. Patient was
switched to daptomycin and meropenem which were discontinued
overnight on ___ also due to concern for a reaction although
this was unlikely per Dermatology. Patient started on aztreonam,
ciprofloxacin, and Flagyl the next morning. Micafungin was
discontinued ___ for another apparent reaction and patient was
started on voriconazole. He spiked to 100.9 on ___ for which
daptomycin was added for better gram-positive coverage. Patient
did not spike again after ___. His ANC gradually trended up and
he was no longer neutropenic as of ___. Voriconazole was
stopped on ___ and daptomycin was stopped on ___. His
remaining antibiotics, which included aztreonam, ciprofloxacin,
and Flagyl, were discontinued on ___. All blood cultures
returned negative. Fungal and mycobacterial cultures were
pending on discharge.
# AML: Bone marrow biopsy by oncologist at ___ revealed MDS with
poor prognostic cytologic factors and blasts of 15%.
Transformation to AML confirmed with repeat bone marrow biopsy
on ___. Patient received 7+3 for induction starting on ___.
Bone marrow biopsy on day ___ showed complete ablation. Bone
marrow biopsy repeated on ___ and results were pending on
discharge. During hospitalization he was placed on prophylactic
acyclovir and lamivudine which he should continue after
discharge.
# Rash: Erythematous maculopapular rash on chest, abdomen, back,
thighs, and legs first appreciated on ___. Likely due to allergy
to vancomycin or cefepime although daptomycin and meropenem were
thought to be possible culprits. There was also concern for a
cutaneous manifestation of AML for which Dermatology was
consulted. Their impression was that the rash was an allergic
reaction to antibiotics, likely vancomycin or cefepime, and that
thrombocytopenia caused patient to bleed into rash making it
look much worse than it actually was. It gradually resolved
after vancomycin and cefepime were stopped and was nearly
completely gone on discharge. Managed symptomatically with sarna
lotion and Benadryl PRN pruritis.
# Atypical chest pain syndrome: Patient experiencing on
admission and EKG showed ST elevation that was suspicious for
acute MI. Previous EKG showed similar pattern. He has h/o
anomalous left main coronary artery and atypical chest pain
syndrome. Given EKG was unchanged from previous chest pain
thought unlikely to represent MI. Patient monitored on telemetry
for several days before it was discontinued due to clinical
stability. Continued on home amlodipine and lisinopril. Home
aspirin was initially held due to thrombocytopenia but was
restarted on day prior to discharge given recovery of counts.
Simvastatin was held given potential drug interactions.
CHRONIC ISSUES
# Diabetes: NIDDM which was well-controlled at home with
glipizide and metformin. Oral hypoglycemics held while in
hospital and patient was managed primarily with Humalog sliding
scale until day prior to discharge. Glipizide and metformin were
restarted prior to discharge which resulted in significant
improvement in patient's insulin requirement. He was discharged
with a blood glucose monitoring kit given high blood sugars in
hospital.
# Hepatitis B virus: HBcAb was positive indicating past exposure
to HBV. Viral load was negative. Patient was started on
lamivudine prophylaxis against reactivation. This was continued
on discharge.
# History of PPD(+): Per the patient, history of a positive PPD
test when he immigrated to ___. Patient claimed to
have completed a 6 month course of PO medications (presumably
INH). Did not endorse cough, hemoptysis, night sweats. CXR on
___ and subsequent studies showed no acute disease.
Quantiferon-Gold negative. Another PPD was placed per ID and was
read as positive. No need for treatment per ID.
# Travel exposures: Patient immigrated to ___ from ___ in
___. Has history of living in refugee camp. Per ID consults
serologies for Coccidioides immitis, Histoplasma capsulatum,
Strongyloides, Schistosomiasis, and Burkholderia marneffei were
sent. All of these returned negative.
TRANSITIONAL ISSUES
- Patient to follow-up with Dr. ___ in clinic on ___
- Follow-up with Cardiology for atypical chest pain syndrome
would be advisable
- Will need ___ interpreter for appointments
- Patient will need further teaching regarding medications. Has
a ___ scheduled.
- Blood sugars high in hospital. Patient and wife will monitor
at home.
- Search for bone marrow donor among patient's siblings is
ongoing
***. | ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURE WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is an ___ w/ hx of LLE fem to DP graft in ___
presenting with rest pain of several days and non healing left
lower extremity ulcer, as well as no LLE signals concerning for
critical limb ischemia. Mr. ___ was admitted to the vascular
surgery service on ___ as a direct admit from clinic. He
was immediately started on broad spectrum IV antibiotics and a
heparin gtt.
On HD1, the patient underwent LLE duplex and ABI/PVRs that
demonstrated complete occlusion of the graft from the level of
the knee to the dorsalis
pedis artery. The lower LLE limb was most likely nonviable by
the time of admission. A discussion was started regarding
possible BKA and whether that operation would fit within the
patient's goals-of-care. Palliative care was consulted and
assisted with the discussion and completion of advance
directives. The heparin gtt was stopped since the limb was no
longer viable and further hep gtt would subject the patient to
frequent blood draws and risk of bleeding.
On HD2, the patient reported having decided against a BKA,
reporting that he did not feel that it would improve his quality
of life. A further discussion was continued between the patient,
the patient's family members and HCP, and team. The patient
reported good pain control.
On HD3, the patient's family initiated search for appropriate
discharge facility with case management. The patient again
reported wishing to avoid amputation as it would not fit in with
his goals of care. The patient expressed understanding of the
risks and benefits of his decision. The patient reported having
no pain from the LLE.
On HD5, The patient was prepared for discharge. The patient and
his family continued decline surgical intervention. Arrangements
were made to transfer the patients care to ___, in
___. He was discharged on a course of Augmentin
500 mg BID until ___. Follow was arrange with Dr. ___
___ at ___ on ___
at 3:30pm. The patient or his facility is welcome to contact
our office sooner with questions and concerns. We do expect the
patient to experience ischemic rest-pain. Infection may also
progress. There were no further options for revascularization
for the LLE. Future interventions would require below/above-knee
amputation. This remains an option if the patients goals change
or pain or infection become intolerable.
***. | OTHER CIRCULATORY 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.
***
Ms. ___ was admitted to the GYN service due to nausea,
vomiting, and diarrhea. She was discharged 3 days prior for
inpatient treatment of vaginal cuff cellulitis with continuation
of PO antibiotics at home.
*) Nausea, vomiting, diarrhea with fevers at home
Patient was not localized any pain. On speculum exam, her
vaginal cuff was found to be in tact, non erythematous, and
without purulent drainage. Patient had CT abdomen and pelvic
which was normal and not suggestive of any fluid collection,
infection, or bleeding. C difficile test was negative. Blood and
urine cultures were collected. Her labs were notable for a WBC
count of 19.3. She was continued on her po ciprofloxacin and
flagyl for treatment of vaginal cuff cellulitis. She was
afebrile on admission and during her hospital stay. Her diarrhea
decreased during the extent of her stay. She received IV fluids
for hydration given her GI losses. She did not have any emesis
while in the hospital. Her WBC count continued to downtrend in
the hospital down to 11.1. On day of discharge, her WBC count
was stable at 12.1. Her urine cultures came back as contaminated
and blood cultures continued to have no growth to date. Her
nausea was thought to be attributed to the antibiotics she was
taking. on day of discharge, her nausea had improved and
diarrhea had slowed down. she was discharged with Zofran for
nausea control.
*) ___
Patient was found to have a creatinine of 1.6 on admission. She
had adequate urine output and no urinary complains however.
Initially the ___ was thought to be due to hypovolemia due to GI
losses. However, a FeNa was drawn and returned as 2.1%. It was
then though that the ___ could be contributed to gentamycin
nephrotoxicity. all nephorotoxic medications were held. Patient
continied to received IV fluids while in the hospital and had
adequate urine output. her creatinine continued to downtrend
during her stay and came down to a 1.0.
*) Vaginal cuff cellulitis
Patient reported no pelvic or vaginal pain. There was no
erythema, discharge, or bleeding from cuff seen on speculum
exam. CT abdomen and pelvis was normal with no suggestion of
infection. She was continued on her PO ciprofloxacin and flagyl
for treatment of the cellulitis.
*)shortness of breath
Patient also complained of shortness of breath on admission. She
was not found to be tachypneic and had normal O2 saturations.
Her lung exam reveleaed no crackles or wheezing. CTA chest was
negative for a pulmonary embolism. Chest x ray was normal as
well. Patient continued to have stable and normal vital signs.
Her shortness of breath resolved within a few hours of
admission.
***. | RENAL FAILURE WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Pt admitted in setting of hepatic arteries not visualized on CTA
or duplex. On HD2 after premedication for iodine allergy
underwent hepatic arteriogram showing multiple kinking of common
hepatic artery with proximal narrowing, not amenable to
stenting. Patent rt and left hepatic arteries. Portal vein is
patent, but can not rule out narrowing.
On HD2 pt was discharged home with plans for duplex in one to
two weeks.
***. | PERIPHERAL VASCULAR DISORDERS WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient was admitted on ___ and, later that day, was
taken to the operating room by Dr. ___ R THA without
complication. Please see operative report for details.
Postoperatively the patient did well but did have pain control
issues. He was seen by chronic pain service and started on a
ketamine drip. The patient was initially treated with a PCA
followed by PO pain medications on POD#1. The patient received
IV antibiotics for 24 hours postoperatively, as well as lovenox
for DVT prophylaxis starting on the morning of POD#1. The drain
was removed without incident on POD#1. The Foley catheter was
removed without incident. The surgical dressing was removed on
POD#2 and the surgical incision was found to be clean, dry, and
intact without erythema or purulent drainage. Patients pain
medications were adjusted per chronic pain service
recommendations.
While in the hospital, the patient was seen daily by physical
therapy. Labs were checked throughout the hospital course and
repleted accordingly. At the time of discharge the patient was
tolerating a regular diet and feeling well. The patient was
afebrile with stable vital signs. The patient's hematocrit was
stable, and the patient's pain was adequately controlled on a PO
regimen. The operative extremity was neurovascularly intact and
the wound was benign. The patient was discharged to home with
services in a stable condition. The patient's weight-bearing
status was WBAT.
***. | 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.
***
BRIEF HOSPITAL COURSE
=====================
Ms. ___ is a ___ year old gentleman with history of EtOH abuse
and withdrawal seizures admitted for EtOH withdrawal with
concern for recent seizure activity. He was stable during
admission. No evidence of seizures, and CIWA scale was
discontinued as he had not been scoring for 24 hours. He was
noted to be tachycardic and have loose stools, found to be c.
diff positive, discharged on a 14 day course of PO
metronidazole.
ACTIVE ISSUES
=============
# EtOH withdrawal: He was stable on admission, notable for mild
tremulousness, mild tachycardia (though eventually as high as
140s), and mild agitation. He had no hypertension, other
adrenergic symptoms, or hallucinosis. Given his history of
withdrawal seizures and question of recent ___ mal seizure
activity prior to presentation, there was a low threshold for
benzo administration to keep CIWA score low (<10) and to monitor
him closely in the ICU. He was maintained on diazepam as needed
per CIWA (though this was rapidly stopped due to absence of
scoring), and supplementation with thiamine, folate, MVI was
continued.
# Seizures: Unclear whether strictly related to alcohol
withdrawal or whether also has underlying seizure disorder. In
the past per ___ records, he has had seizures when he missed
his medications. If reported ___ mal seizure truly occurred on
the morning of admission, it may be related to non-compliance
with home levetiracetam dosing in addition to withdrawal. He
was continued on home levetiracetam 500mg po BID. ___ MRI was
performed which showed old hemorrhagic contusions which could be
predispose him to seizures, but no active process. EEG was done
and was normal.
# C diff colitis: He was noted to be tachycardic with loose
stools and C diff returned positive. He will complete 14 days
of oral metronidazole.
# Left vertebral artery MR finding: His MRI found "possible slow
flow vs calcified plaque in the left vertebral artery." He did
not have any signs of symptoms of vertebral artery insufficiency
and it was felt to be be unlikely to be related to his current
presentation. This should be followed up in the outpatient
setting and MRA could be considered.
# HTN: He was started on Metoprolol XL 50mg daily for
persistent hypertension.
# Hyponatremia, hypovolemic: Na 131 on arrival, likely in the
setting of decreased PO intake. Supporting evidence includes
tachycardia and presumed hemoconcentration in setting of
hyponatremia and malnutrition. He was given normal saline with
improvement.
# Hypomagnesemia: Likely due to malnutrition in setting of
alcoholism. History of QT prolongation, though no reported
history of prolonged QT-induced arrythmia. He was repleted
aggressively and monitored with EKGs closely. His QTc on ___
was 423.
# Prior systolic CHF (previously reported EF ___, now 55%):
No current evidence of volume overload. He had a TTE in ___,
which showed EF ___. However, it was unclear if he had CHF
during that admission (regardless of cause - alcohol-induced or
tachycardia-induced). He underwent another TTE this admission,
which showed EF 55% and normal biventricular systolic function.
# Abnormal EKG: Revealed stable inferior lead ST seg elevation
without clinical sx of angina and flat enzymes. EKG remained
unchanged ___ and ___ suggesting these are not new
findings. He was started on a beta blocker for HTN.
# Pancytopenia, and macrocytic anemia: Macrocytosis is stable,
likely secondary B12/folate deficiency from malnutrition
secondary to alcoholism. He was continued on vitamin
supplementation. If his pancytopenia does not resolve (with
current clinical picture, most likely due to malnutrition, bone
marrow suppression in the setting of chronic alcohol abuse), he
warrants further workup.
# Medical history reconciliation: By ___ documentation in
discharge summaries, he is reported to have a history of
cirrhosis, Hepatitis C, and chronic pancreatitis. CT torso
imaging in ___ commented specifically on normal appearing
liver, spleen, and pancreas without any noted sequelae of these
conditions - however, RUQ ultrasound at ___ in ___
showed echogenic liver. His HCV antibody was positive on this
admission, confirming previous history. No abdominal pain during
this admission.
- Needs liver work-up: ___ records: No
hepatitis B Core antibody on record, though HbSAb was positive
at ___.
- He would benefit from HVC viral load and HIV.
- Needs second dose of Hepatitis A series (got first dose
___.
TRANSITIONAL ISSUES:
====================
- Code: Full code, confirmed.
- Emergency contact: Father, ___, ___.
- Studies pending at discharge: None
- Got first Hepatitis A series in ___, needs second
Hep A immunization.
- Please check HbcAb (not done at ___, though HbSAb positive),
HCV viral load, HIV.
- Needs follow-up with Hepatology and would recommend Neurology
follow-up given seizure history
- Needs outpatient PFTs (has evidence of COPD on exam, long
smoking history), started on long acting tiotropium during
admission
- Currently not interested in alcohol detox or partial
hospitalization, but will consider it in the future - please
re-address.
- Discharged on a 14 day course of PO metronidazole for c. diff.
- QTc was 423 on the day of discharge (___).
- Last EF from ___ in ___ was ___ repeat cardiac echo
___ with EF 55% and normal global and regional biventricular
systolic function.
- If pancytopenia does not resolve with nutrition, consider
further hematologic workup.
- Consider MRA to evaluate possible slow flow seen in vertebral
artery on MRI
- A copy of this discharge summary was faxed to ___,
NP, at ___ at ___.
***. | ALCOHOL DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ was admitted and started on broad spectrum
antibiotics. After evaluation and x-ray which showed osteolytic
changes consistent with osteomyelitis to the medial flare of the
distal phalanx, as well as dusky changes to the lateral distal
hallux, a disarticulation amputation was performed. He did well
and was made heel weight bearing post operatively. ___ worked
with him and found him safe to heel weight bear with a walker.
His INR on admission was supratherapeutic at 4.2 on his home
dose of coumadin 7.5mg daily . His coumadin was held and
vitamin K administered preop. On POD 1 his INR was 1.9. He was
restarted on coumadin at 5mg qhs. On POD 2 his INR was 2.4,
after just one dose of coumadin 5mg. After discussion with the
pharmacist, it was decided that he should be discharged on 2.5mg
of coumadin daily. He should be monitored closely given his
surpatherapeutic INRs, and concomitent use of anticoagulation.
His culture data was not finalized at the time of discharge. He
was placed on augmentin x 14 days. We will follow up the wound
cutlure next week and change the antibiotic if needed. He will
have ___ for wound check and INR draws. We recommend an INR draw
on ___. The INR will continue to be monitored by his
cardiologist, Dr. ___. He will follow up with vascular ___ a
week and with podiatry ___ ___ days.
***. | AMPUTATION OF LOWER LIMB FOR ENDOCRINE NUTRITIONAL AND METABOLIC DISORDERS WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is a ___ yo female G2P1 who presented for induction of
labor at 40 weeks 3 days who underwent c-section which was
complicated by post-partum hemorrhage and hemorrhagic shock. She
ultimately underwent hysterectomy.
#) Hemorrhagic Shock: Patient required 15 units pRBCs, ___ FFP, 2
bags of platelets, and 4 units of cryoprecipitate. The cause was
extensive uterine bleeding presumably from uterine atony. The
bleeding was not able to be controlled with medical therapy
(methergine, cytotec, hemabate, pitocin 40u), D+C, or ___
balloon placement and therefore she required exploratory
laparotomy and abdominal supracervical hysterectomy. She also
had cystoscopy to confirm ureters were intact. After hemostasis
was achieved the patient improved and all electrolyte and
coagulopathic abnormalities were corrected. The patient was
transferred from the FICU to the postpartum floor on ___ ___.
#) Postpartum Fevers: The patient initially received ampicillin
and gentamicin which was started during labor. She continued to
be febrile postpartum. Although patient had hypovolemic shock as
discussed above, there was also concern that she could have
sepsis as well. She had multiple possible reasons for fever
including recent URI symptoms, multiple transfusions, as well as
chorioamnionitis and other ___ and ___
complications. Therefore she was treated empirically with
Vancomycin/Zosyn for 48 hours until cultures returned negative.
She remained afebrile for >48 hours prior to discharge.
#) Pulmonary: Ms. ___ was extubated successfully in the
operating room, transitioned to 6L by face mask. On POD#2, she
had a continued oxygen requirement and was satting 95-98% on
___ nasal cannula. Given intermittent tachycardia and continued
oxygen requirement a CTA was obtained which was negative for a
pulmonary embolus. Given findings of moderate bilateral
effusions, the patient was given IV lasix as needed (total of 2
doses administered). She was successfully weaned to room air by
POD#4.
#) GI: Initially after her hysterectomy, Ms. ___ was NPO.
Given risk for ileus, she was advanced slowly and was tolerating
a regular diet by POD#3.
Prior to discharge, Ms. ___ reported a new perineal rash.
Dermatology was consulted who recommended Lotrisone for likely
contact dermatitis with ___.
Ms. ___ was discharged home on POD#5 in stable condition-
afebrile, voiding and ambulating without difficulty and
tolerating PO.
***. | CESAREAN SECTION WITH CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient is a ___ female without significant ___
transferred from ___ for further evaluation of CBD
stone and CBD duodenal fistula, with pneumobilia. On ___
patient was scheduled for ERCP, procedure was aborted secondary
to risk of perforation. Patient was started on Cipro/Flagyl
secondary to severe esophagitis and duodenitis. On ___, patient
underwent MRCP, which demonstrated 9mm CBD stone, improved
duodenitis, no evidence of fistula. Patient remained afebrile,
and her WBC returned back to normal limits. Patient was able to
tolerate regular low fat diet and denied any abdominal pain.
Patient was discharge home on PO antibiotics. She will follow up
with Dr. ___ Dr. ___ to discuss further plan of care.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
low fat diet, ambulating, voiding without assistance, and pain
was well controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
***. | DISORDERS OF THE BILIARY TRACT WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Patient was admitted on ___ to the thoracic surgery service
for a planned right thoracotomy, right lower lobe wedge
resection with decortication. She tolerated the procedure well,
was extubated and recovered in the PACU prior to being
transferred to the ICU in stable condition. For full details
please see the operative report. Three chest tubes were placed
during the procedure and a postoperative chest x-ray showed
expected right pneumothorax post surgery with three chest tubes
in place. Pathology revealed a 1.8 cm poorly differentiated
adenocarcinoma with negative margins and no positive nodes. She
was started on a clear liquid diet, her pain was controlled with
an epidural and she was started on her home medications. On POD
1 her diet was advanced to regular and she was transferred to
the surgical floor from the ICU. On POD 2 she was noted to have
increased somnolence which was thought to be related to her pain
medications so her epidural was turned down and narcotics for
breakthrough pain were discontinued. She was given a unit of
PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and
improved somnolence. On POD 3 metoprolol was started because of
elevated systolic blood pressures. She continued to have an air
leak from all three chest tubes. Her epidural was discontinued
and her foley catheter was removed. She was started on oxycodone
and tramadol for pain. By POD 4 the air leak had stopped in the
anterior chest tube so it was removed. The posterior chest tube
was removed on POD 6. On POD 7 she noted that she felt dizzy
when she was getting out of bed and was found to be in atrial
fibrillation with RVR. She was given metoprolol once without
effect and was then given IV diltiazem once with return to sinus
rhythm. Cardiac enzymes were negative and she was monitored with
telemetry without recurrence. On POD 8 the air leak had resolved
in the basilar chest tube so it was removed. A post pull chest
xray showed no PTX. Because her pain was well controlled, she
was tolerating her diet and was ambulating without assistance,
she was discharged to home on POD 9 with instructions to follow
up in Dr. ___ with a chest x-ray.
***. | MAJOR CHEST PROCEDURES WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr ___ was admitted to ___
on ___ due to left lower extremity claudication and underwent
a left lower extremity femoral-popliteal bypass with PTFE on
___. He tolerated the procedure well. During his
hospitalization he developed serousanguinous discharge from his
bypass incision, which was resolved after platelet
administration, and holding the aspirin and Plavix. He also
developed hyponatremia which was corrected with fluid
restriction. Once he was able to ambulate, tolerate a diet and
his pain was controlled he was discharged home with ___ services
for wound check.
***. | OTHER VASCULAR PROCEDURES WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is a ___ G6P5 at 39w1d for IOL for GDMA1 and thyroid
nodule with atypical cells. She was admitted to L&D and started
on pit due to grandmultiparity. She was typed and crossed for 2
units packed red blood cells. She made change from SVE 1cm ->
___ without further change despite 10 hours of pitocin at
20. She was transferred to the antepartum floor and IOL was
restarted on ___. On ___, she had an uncomplicated vaginal
delivery of a liveborn female weighing 3150g with apgars of 7
and 8. She was discharged home in stable condition on PPD#2.
***. | VAGINAL DELIVERY WITHOUT COMPLICATING DIAGNOSES |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
BRIEF HOSPITAL COURSE
=========================
___ w/ DM2, recurrent diabetic foot infections, PVD, recent
admission to ___ ___ for RLE angioplasty and R
first metatarsal head resection, then recent admission to
___ for sepsis attributed to a non-healing tract
that probed down to her R ___ MTP joint, clinically consistent
with osteoyelitis/septic arthritis. The wound was washed out at
bedside at the OSH and she was started on 6 weeks of Ancef after
an OSH blood culture grew group A strep. She was also managed
for RVR on that admission by increasing her metoprolol succinate
from 100 mg daily to 75 mg BID, and by addition of diltiazem 120
mg daily.
The patient reports that she was still a little delirious while
they were explaining medication changes, and also thought it was
presumptuous that they had not discussed the new nodal agents
with her outpatient cardiologist. For these reasons, she did not
take the new cardiac meds, and now was re-admitted to our
hospital in ___.
Records were obtained from ___ and she was re-started on the
appropriate doses of diltiazem and metoprolol. These are not
changed from what was prescribed at the outside hospital.
She was seen by podiatry who felt her feet were not acutely
infected and did not advise any surgical intervention (although,
per outside records, she obviously recently had a serious
infection and will still need to complete the existing
antibiotic plan). She will complete her course of Ancef as
planned prior to this admission.
She will be discharged home with close follow up with her
outpatient PCP and cardiologist.
======================
TRANSITIONAL ISSUES
=======================
[] She is discharged on cefazolin for recent bacteremia
diagnosed at ___. She will continue with cefazolin 2g IV q12
hours through ___. This is unchanged from prior to
admission, and we confirmed with ___ that this
would still be dispensed using the pre-existing prescriber at
___.
[] She presented with AF with RVR in the setting of not taking
her medications as prescribed on discharge from ___. Please
continue to advise medication adherence as an outpatient to
control AF. She is discharged with metop succ 75mg BID and dilt
XR 120 daily for rate control.
[] Please note that per patient preference she is not discharged
on anticoagulation. Please continue to discuss risks and
benefits of anticoagulation given her CHADSVASC is 4.
[] She is discharged with felted foam dressing on left foot.
This can be removed in 1 week (___) and she should then
remain hell WB in surgical shoe to help midfoot ulceration to
heal.
[] Please note that per podiatry recommendations, the
ulcerations on her right foot do not require dressing at this
point.
[] She will need to follow up with Dr. ___ for
further evaluation of her feet
ACUTE ISSUES
================
# AF w/ RVR
She presented with AF with RVR to the 120s reportedly in the ED.
Per ___ record review, she was supposed to take 3x25mg succ
BID (75mg BID), but she was taking only 1 tab daily, thus
explaining her RVR to the 120s. This admission she remained
initially with HR in low 100s and up to 130s intermittently when
walking. She was treated with metoprolol XL this admission and
discharged on 75mg XL BID, and restarted on her diltiazem. Per
chart review and patient report, she has been recommended
anticoagulation in the past (for CHADSVASC 4) but declined.
Discussed anticoagulation again this admission but she adamantly
declined. She is willing to discuss further with her
cardiologist, Dr. ___.
# Troponinemia
# Type II NSTEMI
On admission her EKG showed V4-V5 STD w/ I and aVL TWI. This was
thought to be type II NSTEMI likely from demand ischemia from
tachycardia. Her troponins down-trended with IVF and rate
control.
# Recent GAS sepsis at ___
# hx of Right ___ MTPJ ulcer
# RLE erythema
She was recently admitted to ___ for sepsis (___),
found to have blood cultures + for GAS (___), in the
setting of a R foot wound that probed to bone. Now with L PICC
(placed ___ at ___. We discussed with ___,
and confirmed she is on cefazolin. Regarding her foot wounds,
she has left foot with felted foam dressing and right foot has
well-healed medial ___ MTPJ surgical site. She had lower
extremity ultrasound that showed no clots. She was evaluated by
podiatry on ___ who felt that there was no concern for ongoing
infection of the lower extremities. They recommended continuing
wound care, but no antibiotics necessary as far as foot wounds.
Patient to continue Cefazolin 2g ___ for
osteomyelitis.
# Leukocytosis, improving
# Supratherapeutic INR
# Elevated Alk Phos
# Hypobicaronatemia
# Hyperkalemia
# ___ on CKD
It was thought that her lab abnormalities on admission were
explained by her resolving sepsis from recent hospital
admission. Creatinine and potassium improved with fluids.
Records reveal that on day of discharge from ___ (___) WBC
21, Cr 1.7. He white count continued to improve while an
inpatient at ___. Cr was 1.9 on discharge.
***. | ACUTE MYOCARDIAL INFARCTION DISCHARGED ALIVE WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Assessment/Plan: ___ with h/o COPD, venous insufficiency, and
depression here for evaluation of persistent cellulitis.
# RLE cellulitis: Pt presented with worsening pain and erythema
of a RLE that has been chronically infected. She was most
recently treated with cefepime x5 days without improvement. ___
was negative for DVT. The pt was started on vancomycin with
significant improvement in pain and erythema. She was switched
to cephalexin 250mg PO TID x7 days which she will continue as an
outpatient.
# COPD: No evidence of exacerbation. The pt was continued on
home meds: albuterol prn, advair (substitution for symbicort),
tiotropium
# Osteoporosis: Continued calcium, vit d, alendronate.
# CKD: Cr at baseline. 1.1 on discharge.
# Depression: Mood/affect appear wnl. Continued home quetiapine,
paroxetine and trazodone for sleep
# Hypertension: Normotensive during admission. Continued
Lisinopril. Records imply patient also on amlodipine, but does
not appear to be on rehab list. Can consider restarting
amlodipine as an outpatient.
# Hyperlipidemia: Lipids last checked in ___, appears well
controlled. Continued home simvastatin.
# Chronic normocytic anemia: At baseline. Continued B12
supplements.
# Gastritis: EGD in ___ c/w gastritis. No current complaints
of abd pain. Continued home omeprazole and viscous lidocaine.
# H/o diarrhea and Cdiff: No current complaints of diarrhea.
# Spinal stenosis: Not currently complaining of back. Records
imply this is the indication for her gabapentin. Continued
gabapentin.
# Communication: Patient, Case manager ___
___.
# Disposition: ___
TRANSITIONAL ISSUES:
# Monitor BP, if it is persistently elevated, consider starting
amlodipine or increasing lisinopril.
# ___
# Keflex x7 days for cellulitis, monitor for continued
improvement.
***. | CELLULITIS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ was admitted to the ___ on ___ for a cardiac
catheterization in preparation for mitral valve surgery. His
cardiac catheterization revealed disease in a large diagonal
artery. He was worked-up in the usual preoperative manner. On
___ he was taken to the operating room where he underwent a
mitral valve repair and coronary artery bypass grafting to one
vessel. Please see operative note for details. Postoperatively
he was taken to the intensive care unit for monitoring. Over the
next several hours, he awoke neurologically intact and was
extubated. On postoperative day one, he was transferred to the
step down unit for further recovery. He was gently diuresed
towards his preoperative weight. The physical therapy service
was consulted for assistance with his postoperative strength and
mobility. He had ___Fib and converted to SR with
titration of Lopressor and IV Amiodarone. He will not require
anti-coagulation. 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.
***. | CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
HOSPITAL SUMMARY: Mr. ___ is a ___ man with a long
history of smoking who presented to ___ with small
volume hemoptysis. Chest Xray and Chest CT imaging was
suggestive of an endobronchial mass and possible
post-obstructuve pneumonia. He was transferred to ___ for
diagnostic bronchoscopy.
# Pneumonia: On admission he denied fevers, cough, or chills but
because of imaging at ___ suggestive of
post-obstructive pneumonia he was treated with Zosyn for 3 days.
Because bronchoscopy did not show evidence of infection and
there were no clinical or laboratory evidence of pneumonia,
antibiotics were discontinued.
# Endobronchial Mass: Bronchoscopy on ___ showed a mass
obstructing the right lower lobe. Biopsies of the mass and the
surrounding lymph nodes were obtained. Chest, abdomen and pelvis
CT showed no clear evidence of metastases. However, there were
several mediastinal lymph nodes that were slightly enlarged.
Brain MRI showed no evidence of metastases. The patient will
follow up with the Thoracic ___. The findings on
bronchoscopy were discussed with Mr. ___ and his family,
however they prefer to further discuss when the biopsy results
return.
.
# Hemoptysis: He continued to have ___ episodes per day of about
1tsp of bloody sputum through ___. After the bronchoscopy and
cauterization of the bleed, he was observed for 24 hours and was
without hemoptysis for the rest of his hospitalization. His Hct
was stable at 33-34 throughout his hospitalization.
.
# CAD: he has a history of MI in ___ and had a
recatheterization with two stents placed in ___. He denied any
recent chest pain or shortness of breath. Aspirin was held for
the brochoscopy procedure. Metoprolol and simvastatin were
continued. He was instructed to resume the aspirin after
waiting 5 days after the bronchoscopy.
# Acute Kidney Injury: Creatinine at admission was 1.3 but
improved to 0.9 after IV fluids. It remained at 0.9 for the
rest of his hospitalization.
# Anemia: MCV of 74 and iron studies indicated iron deficiency
anemia. His Hct was low to mid-30s but remained stable
throughout his hospitalization. It was suggested that he have
an outpatient colonoscopy for further workup. He was started on
iron.
# Tobacco abuse: He was encouraged to quit smoking.
***. | RESPIRATORY NEOPLASMS WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mrs. ___ is a ___ w/ anal mucinous adenocarcinoma not yet
treated, AFib, UPJ obstruction s/p stent placement in ___ c/b
chronic Klebsiella bacturia, IgG myeloma on lenolidamide,
currently residing at ___ since
___, who is admitted from clinic by her primary oncologist,
Dr. ___ rectal pain and expedited treatment. Also w/ blood
loss anemia on admission.
#Anal Mucinous Adenocarcinoma
Diagnosed in ___. Restaging ___ shows T4 disease extending
beyond the anal verge, progressing through external muscle of
anal sphincter, progression from 3 months ago.
-- plan for 5 fractions per Drs. ___ on thurs
___ w/ first session ___ cancelled due to machine
malfunction, resumed ___ and completed ___.
-- pt evaluated by Dr. ___/ colorectal surgery with plans
for surgical resection proctectomy and end colostomy on ___,
one week following completion of radiation.
-- pt received ostomy teaching during her stay
#Rectal Pain - ___ above
-- cont metamucil, senna, colace, prn miralax/bisacodyl
-- pain control w/ oxycodone prn and tylenol
#Rectal bleeding - persistent hematochezia ___ mass/oozing. no
large vol bleeding. stopped lovenox. Anticipate ongoing oozing
until surgery but improved w/ radiation and stopping
anticoagulation.
#Blood loss anemia/ACD - Recent Ferritin and TIBC suggest anemia
of chronic inflammation but recent rectal bleeding and low HCT
on admission concerning for acute blood loss. HCT 15 in ED on
admission likely spurious as Hgb was 9 at ___ earlier that day
and on repeat in ED HCT 27.
- Normal TSH and b12
- Hgb gradually downtrending ___ bleeding. Was given 1U PRBC on
___ for Hgb 8.6 in anticipation of slow oozing over next week
prior to surgery
#Hypophosphatemia - poor PO vs GI loss while on bowel regimen vs
lasix effect. remained low despite PO phos x 3 days so stopped
lasix. PTH secondarily
elevated. vitD borderline low will increase to 2000U. Phos 1.9
day of discharge repleted with 500mg
#AFib
#HTN
CHADS2Vasc at least4, coumadin reversed in ED out of initial
concern for GI bleed, was transitioned to lovenox.
- plan was to cont lovenox perioperatively as needs bridge prior
to surgery-- however held in setting of worsening rectal
bleeding, risk of bleeding in short term felt to outweigh risk
of stroke. off lovenox since ___
-- cont home dilt and metoprolol, decreased dilt dose as BP in
low 100s-120s
# Neutropenia - resolved. likely ___ revlamid, we are holding
revlamid perioperatively for now per primary oncologist. No
fevers
#CKDIII - renal function is good on arrival but reportedly
carries this diagnosis, likely prior myeloma kidney
-- avoid nephrotoxins
#IgG Myeloma
IgG kappa, ISS stage II, Durie-Salmon stage II (IgG greater than
5 g). ___. On Rev-Dex, stable History of vertebral
compression fracture ___. Last skeletal survey in ___ neg.
-- holding revlamid while hospitalized and perioperative per
outpt onc but cont qthurs 20mg po dex
-- Zometa given in ___.
***. | 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.
***
TRANSITIONAL ISSUES
====================
[] Consider whether apixaban can be stopped once out of the
___ window (CHADS2VASC score 0)
[] Consider starting a different medication for anxiety (such as
SSRI), as propranolol was stopped during this admission (at the
direction of the EP team, due to his bradycardia)
BRIEF HOSPITAL COURSE
=======================
Mr. ___ is a ___ w/ hx early persistent afib s/p unsuccessful
DCCV on apixaban, anxiety on propranolol, obesity s/p gastric
bypass, OSA, who underwent elective PVI on ___ with post-op
course c/b bradycardia and hypotension likely due to beta
blockade from AM propranolol dose requiring dopamine, admitted
to the CCU for management of hemodynamic instability. He
required dopamine gtt initially for bradycardia which was weaned
and stopped.
#CORONARIES: unknown
#PUMP: LVEF 65%
#RHYTHM: NSR
ACUTE ISSUES:
=============
#Hypotension
#Tachycardia
Labile BPs during procedure, also with post-procedural
hemodynamic instability requiring dopamine. Most likely etiology
is excess beta blockade after conversion to NSR causing
bradycardia and subsequent hypotension post-procedurally vs
vasovagal. Unclear etiology of labile BPs during procedure. No
lactate sent, patient mentating well on floor and lukewarm on
exam less concerning for shock. Afebrile and without localizing
symptoms other than nausea and vomiting, which per patient has
been ongoing for about a month particularly with water, low
concern for occult infection. On AC, unlikely PE, especially w/o
desats or tachycardia. Patient was started on dopamine drip but
was weaned off. His home propranolol was held, and per EP
patient should not resume this medication at this time. He was
also discharged with a PPI for one month for esophageal
irritation following PVI.
#Persistent atrial fibrillation
#s/p PVI with conversion to NSR
Profoundly symptomatic. HR 50-60s in CCU after procedure, near
patient's reported baseline. Etiology of afib unclear per EP
outpatient notes. Continued home apixaban. Initially held home
propranolol iso bradycardia and per EP did not resume as pt with
NSR HR 50-60s.
CHRONIC ISSUES:
================
#OSA
Not re-evaluated since bypass surgery, which was remote.
Monitored O2 overnight, no desaturations noted.
#Anxiety: Held home propranolol iso bradycardia.
#hx spinal fusion c/b low back pain: Continued Tylenol and home
oxy BID:PRN
#CODE: FC confirmed
#CONTACT/HCP: Wife
___ on ___:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Moderate
3. Propranolol 80 mg PO BID
***. | PERCUTANEOUS INTRACARDIAC PROCEDURES 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.
***
___ with stage III pancreatic adenocarcinoma diagnosed in ___ admitted with acute cholecystitis.
# Acute cholecystitis: Patient had evidence of air in the gall
bladder and gall bladder wall thickening on outside hospital CT
and RUQ U/S. Surgery and GI were consulted, patient preference
was to avoid surgical intervention and her fever and abdominal
pain resolved with with antibiotics. She recieved Zosyn
initially at OSH. On arrival to ___, she was started on IV
CTX/flagyl, transitioned to PO cipro/flagyl briefly, but IV
antibiotics were then restarted due to n/v and low grade fever.
Augmentin was considered for empiric monotherapy, but patient
has h/o PCN (rash several years ago, no h/o anaphylaxis). She
was ultimately transitioned to PO cefpodoxime/flagyl to complete
2 week course. She was prescribed prn antiemetic and scheduled
for follow up with her PCP.
# Pancreatic cancer: Locally advanced pancreatic adenocarcinoma,
recent imaging showed increase in size of pancreatic mass.
Patient expressed desire to avoid chemotherapy and surgical
intervention. She reports dietary changes (low sugar diet) are
her chosen intervention
# IDDM: Patient was continued on her home regimen of glargine
and sliding scale humalog.
***. | 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.
***
___ ___ female with a history of multiple sclerosis
(wheelchair bound, left hemiparesis), systemic lupus
erythematous, chronic thrombocytopenia, neurogenic bladder with
chronic foley catheter, breast cancer, hypertension, refractory
trigeminal neuralgia s/p occipital craniotomy with microvascular
decompression complicated by ___ cranial nerve ___
palsies with diplopia and right facial droop, who presented with
confusion, decreased responsiveness, and aphasia.
#Toxic metabolic encephalopathy:
#Multiple Sclerosis:
#Complicated Urinary Tract Infection, catheter associated
#Functional Quadriplegia
On admission, patient was completely mute and unable to speak.
CTA head/neck were negative for an acute stroke. Brain MRI did
not show any changes to suggest a multiple sclerosis flare. She
was found to have a UTI and was treated with ceftriaxone with
subsequent complete resolution of her symptoms. The symptoms of
confusion and aphasia were thought to be related to the UTI
triggered encephalopathy. Urine culture showed klebsiella and
proteus, both sensitive to ceftriaxone not sensitive to Cipro or
Bactrim. She received 4 days of ceftriaxone, and was
transitioned to cefpodoxime on discharge for an additional 6
days to complete a total 10 day course of antibiotics (day 1=
___ day 10= ___. Her foley catheter was changed during
this admission.
#Neurogenic bladder with foley:
#Secondarily progressive, advanced Multiple sclerosis (followed
by Dr. ___ for ___: Continued home
amantadine, baclofen, lorazepam, tropsium, and oxcarbazepine.
#Elevated lactate:
Patient was noted to have elevated lactate that did not improve
with IVF. Patient was not septic and had stable vital signs,
with no fever or chills. There is no history of alcohol abuse or
malnutrition to suggest thiamine deficiency. LFT and creatinine
were within normal limits. She was monitored clinically.
#Hyponatremia
The hyponatremia was initially thought to be hypovolemia due to
poor PO intake, but did not improve with NS. Sodium resolved
without further intervention.
#Thrombocytopenia: Chronic. Trended down during the hospital
stay.
#GERD: Continued home omeprazole and ranitidine.
#HTN: Continued home amlodipine, losartan
.
#SLE: Continued home hydroxychloroquine.
#Depression/anxiety: Continued home sertraline.
#Home medications: Continued home ascorbic acid, calcium
carbonate, miconazole, magnesium oxide.
***TRANSITIONAL ISSUES:***
- Continue cefpodoxime 200 mg BID until ___
- Stopped Nitrofurantoin (Macrodantin), please discuss chronic
antibiotic for UTI prophylaxis
- Follow up with urology for possible suprapubic catheter
placement
- Please repeat CBC within a week to monitor for platelets, she
has worsening of her chronic thrombocytopenia
- She was noted to have a skin tear in the abdominal fold, the
husband was instructed to keep it dry and use and ointment;
please monitor to ensure resolution
#CODE: Full (confirmed)
#CONTACT: ___
___: husband
Phone number: ___
***. | OTHER KIDNEY AND URINARY TRACT 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.
***
Ms. ___ is an ___ y/o F with a PMHx of depression and
recent lymphocytic meningitis complicated by elevated ICP who
presented to the ___ ED on ___ with complaints of
subacute onset of headache and decreased exercise tolerance as
well as neck pain. In the ED Ms. ___ was evaluated by
neurology who recommended MRI head and LP. LP was attempted but
unsuccessful in the ED. MRI head w/ and w/o contrast
demonstrated narrowing of both transverse sinuses possibly
suggestive of pseudotumor cerebri. ECG was also performed to
evaluate complaints of decreased exercise tolerance, this
returned normal. CXR normal. Ms. ___ was admitted for
further evaluation.
Upon reaching the medical floor, Ms. ___ headache had
resolved. She denied any shortness of breath or neck pain at
that time. Due to failure of LP in the ED and resolution of
headache while admitted, LP was not pursued. Extensive lab work
up was performed to evaluate for etiology of headaches
including: serum ___, anti-DS DNA, ___,
anti-phospholipid, RF, Anti-Ro, Anti-La, Anti-cardiolipin, ANCA,
C3, C4, ACE. Echocardiogram was performed to further rule out
cardiac origin of reported decreased exercise tolerance. This
returned showing low-normal EF (51%) and was otherwise normal.
Laboratory testing return showing increased ___ other studies
returned within normal limits. Ms. ___ was informed that
some of the labs will take over a week to return and was
instructed to follow up these results with her PCP. A LP was
recommended to evaluate opening pressure and presence of
continued pleocytosis, however patient declined. Ms. ___
___ neck pain was intermittent and managed with hot packs,
she declined other therapy for this including oral analgesia..
Therefore she was discharged on Diamox 1000mg BID to continue
outpatient and follow up with Neurology and Neuro-ophthalmology.
Due to report of decreased exercise tolerance, ECG and CXR
performed and were normal. Echo showed low normal EF of 51%
which is low for someone her age and we recommend she follows up
with her PCP for monitoring and referral if needed.
***. | HEADACHES WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year old female admitted to the acute care service with lower
abominal pain. Upon admission, she was made NPO, given
intravenous fluids, and underwent radiographic imaging of the
abdomen demonstrating a pelvic abscess. She was started on
intravenous antibiotics.
On HD #2, she underwent placement of an ___ drain into the rigth
sided pelvic collection. She drained a small amount of fluid.
A culture was obtained which showed no micro-organisms, rare
yeast. The drain was discontinued on HD # 4. Her vital signs
are stable and she is afebrile. Her white blood cell count is
9.9.
She has been started on a regular diet with no complaints of
nausea or vomiting.
She is preparing for discharge home with follow up with the
___ service in 2 weeks. She will complete her week
course of oral antibiotics.
***. | 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.
***
Pt admitted postop on ___ from rearfoot fusion. Pt tolerated
procedure well (see op note for details). Pt was given
perioperative dose of Vanco b/c of her MRSA history. Given Pt's
PMH, including chronic pain issues ___ her Ethlers-Danlos, a
spinal and epidural catheter were placed preop and Acute pain
service would follow postop. At the recommendations of APS, Pt
was resumed on all of her home meds but started on higher dose
of home oxycodone. POD1, epidural cathether was stopped and
started Oxycontin 20mg BID, Oxycodone (___) for breakthrough,
Toradol x 2 doses PRN with adequate control. Pt seen and
cleared by ___ for ___ LLE. Dsg changed on POD3. All incisions
c/d/i with minimal swelling. BK cast was placed and Pt was
discharged home on POD4 to f/u with Dr. ___ in 10 days.
***. | LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP FOOT AND FEMUR WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
#Osteo/abscesses: After throrough workup and review of outside
imaging studies, no clear source of infection was identified.
Patient underewent ___ drainage of his infection; at time
of discharge culture had not identified a causative organism.
Although patient experienced back pain, he did not have any No
focal neurologic deficits. All blood and tissue cultures are
negative to date.
Patient was initially treated with IV vancomycin and Unasyn,
which was transitioned to Vanc 1gm BID and Ceftriaxone 2mg
daily, with plan to treat for 6 week course
Patient will need to follow up with ID as an outpatient, and
will need weekly labs.
#DM: During admission patient kept on sliding scale insulin,
with plan to transition to oral metformin once home.
#HTN, HLD: Stable. we continued atenolol and simvastatin per
home regimen.
#GERD: We Continued omeprazole.
***. | OSTEOMYELITIS 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. ___ presented electively on ___ for an ACDF of C4-5. Her
intraoperative course was uneventful, please refer to the
intraoperative note for further details. She was extubated in
the OR, an she was placed in a hard cervical. She was
transferred to the PACU for close monitoring. Once she was
stabilized she was transferred to the neurosurgical floor for
continued management.
On ___, the patient was doing very well. There were no events
over night. Her pain was well controlled and her neurologic
exam was stable. She tolerated a PO diet, voided, and ambualted
in the halls. She was discharged to home with follow up
instructions.
***. | CERVICAL SPINAL FUSION WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year old male with history of systolic CHF with CAD s/p CABG,
stage III-IV CKD ___nd paranoid schizophrenia,
presents from his group home with generalized weakness and upper
respiratory symptoms, with concern for pneumonia.
# Sepsis- Patient initially presented with and fever (temp of
100.8) and leukocytosis (14.1) on ___ with presumed pulmonary
source of infection given his respiratory symptoms, hypoxemia
and abnormal CXR. He was started treatment empirically on
levofloxacin 750mg Q48 hours for community acquired pneumonia.
On the day of admission, patient had several episodes of
hypotension (nadir to 98/40) with intermittent episodes of
fever. Treated with IV bolus fluids and blood pressure was
responsive to fluids. The patient had some intermittent fevers
initially, but upon discharge he was afebrile. While he was
hypotensive, his home antihypertensive medications were held.
By the end of his hospitalization, however, the patient was
restarted on his home doses of lasix and metoprolol. All blood
and urine cultures are negative to date, making a pulmonary
source most likely.
# Community Acquired pneumonia: The patient was noted to have
opacity at the left lower base, and was also noted to have a new
hypoxemia requiring a 3L O2 requirement. He was started on
levofloxacin 750 mg q48h (renally dosed) for treatment of
community acquired PNA. The patient was sent to rehab to
complete a total of 7 day course. The patient was also started
on albuterol nebs PRN. He was weaned off his O2 during the
course of the hospitalization; upon discharge, the patient was
breathing comfortably on room air. He was discharged with PRB
nebs.
# Chronic systolic CHF (EF 35-40% on echo ___: The patient
did not have any signs of volume overload on exam. The patient's
metoprolol and furosemide were initially held in the setting of
his relative hypotension, but once his pressures improved, he
was started on his home medications. Of note, the patient is
not currently on an ACE or ___. Consider starting one of these
medications as an outpatient to maximize his medication regimen
for his heart failure.
# CAD s/p CABG and stent: The patient was continued on his
aspirin and Plavix while in patient. As mentioned above, his
metoprolol was initially held in the setting of low blood
pressures; this was restarted prior to discharge. Patient not
currently on ACE-I as outpatient and would recommend initation
of ACE-I as outpatient with PCP.
# Hyperlipidemia: The patient was on simvastatin at home. This
was stopped and he was started on pravastatin, as the use of
simvastatin and gemfiborzil is contraindicated by FDA
recommendations; continued gemfibrozil.
# CKD stage III-IV: The patient's creat remained at baseline.
He was continued on calcitriol and vitamin D supplementation.
# Paranoid schizophrenia: Stable with no mood symptoms.
Continued with risperidone and sertraline
# Hypertension: The patient's Lasix and metoprolol were
initially held given relative hypotension. Upon discharge, his
pressures had recovered and the patient was restarted on his
lasix and metoprolol.
# Insulin Dependent diabetes- The patients home dose of 70/30
insulin was increased from 10 units in the AM and 16 units in
the ___ to 18 units in the AM and 12 units in the evening with a
humalog insulin slididng scale. The patient still has some
elevated FSBGs and his insulin regimen will need to be titrated
as an outpatient for optimal glycemic control.
# Hypothyroidism: The patient was continued on his home
levothyroxine.
Transitional Issues:
- The patient will need to take one more dose of Levofloxacin
tomorrow ___.
- The patient's simvastatin was stopped and he was started on
pravastatin.
- Gabapentin was renally dosed while in house; please continue
to renally dose this medication as the patient's renal function
changes.
- Please monitor the patient's blood pressures.
- Would consider starting an ACE ___ as an outpatient for the
patient's systolic CHF.
- Please check fingersticks, as the patient's insuling regimen
was changed slightly during this admission
***. | SIMPLE PNEUMONIA AND PLEURISY WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ was admitted for altered mental status. In the ED
she was noted to have a UTI which was treated with antibiotics.
Her hospital course, by problem, follows below.
.
#Altered mental status - In the ED, CXR revealed stable findings
from previous and a UA consistent with UTI. Patient was treated
with azithromycin and ciprofloxacin and the etiology of her
mental status changes was thought to be sequelae from the UTI.
Upon transfer to the floor, a more clear story of her changed
mental status emerged and, given a supratherapeutic INR, there
was concern for ICH. The patient underwent a CT scan which was
reassuring that there was no intracranial hemorrhage. Given the
absence of ICH and the subtlety of neurological findings, the
etiology of her changed mental status was thought to be due to
UTI and the neurologic findings were suspected to be her
baseline (collatoral information from family confirmed some
neuro findings). While seizure with post-ictal state could not
be fully excluded, the patient remained without subsequent
episodes while in the hospital. Her mental status had returned
to her baseline per patient's son by hospital day 2. The
patient's Namenda, Mirtazapine, Citalopram, Keppra, and Aricept
were continued throughout her stay.
.
#UTI - the patient was initially treated with ceftriaxone in the
emergency department based on culture data from a ___ UTI.
Cultures were sent from the floor and revealed no growth but as
they were sent after antibiotic dosing, antibiotics were
continued. The patient was transitioned to PO cefpodoxime on HD3
and should continue this for a total of 7 days of antibiotics.
.
#EKG Changes - EKG changes and mental status was initially
concerning for a possible new ACS. However,the patient had two
sets of negative troponins and an absence of sxs which was
reassuring for acute cardiac event. A repeat EKG showed
resolution of some t wave flattening that was seen previously.
.
#Possible pneumonia - Given absence of cough or other
respiratory sxs and stable cxr azithromycin was discontinued
upon transfer to the floor.
.
#Supratherapeutic INR - the patients INR was 3.6 at the time of
presentation. This was reported to be due to dietary variation
in the patient. Coumadin was redosed daily based on INR checks.
The patient should continue taking coumadin as described with
regular INR checks.
.
#Dispo - ___ evaluated the patient and determined that she would
benefit from ___ rehabilitation.
***. | KIDNEY AND URINARY TRACT INFECTIONS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year-old male with hx of metastatic gastric cancer, s/p
multiple abdominal surgeries, and s/p intra-abdominal chemo/XRT
who presented to the ED after his G-tube fell out and was
admitted with sepsis, likely from intra-abdominal source.
.
# Hypotension/Sepsis: The patient presented to the ED with frank
pus extravastating from his G-tube site and hypotension. CT
abd/pelvis revealed an intra-abdominal rim-enhancing fluid
collection. Based upon abdominal imaging and clinical picture,
he was diagnosed with sepsis. Early goal therapy was initiated.
He was covered with broad spectrum antibiotics (vanc, cefepime,
flagyl) in addition to anti-fungal therapy with micafungin since
he had been receiving TPN. He required pressure support with
leveophed, which was eventually weaned. CT body and ___ were
consulted for potential drain(s) replacement, and a new G-tube.
He would have required multiple procedures and general
anesthesia. After a goals of care discussion with his wife, he
was made DNR/DNI with treatment goals for symptom and sepsis
management. He was transferred to the floor in stable condition.
Blood culture from ___ was positive for lactobacillus.
Surveillance blood cultures drawn after that time were negative.
The patient was closely followed by the Infectious Disease
consult team, and antibiotic/antifungal coverage was gradually
narrowed. He remained hemodynamically stable, but did have
several spikes in temperature to as high as 101.5 while on the
floor. The most likely source for his fever was felt to be
persistent intra-abdominal infection, with limited antibiotic
penetrance into abdominal fluid collection. The patient again
declined any surgical or ___ drainage of the fluid
collection, as his goal was to be discharged home with hospice
care. He was discharged home on ceftriaxone, and per ID he will
need to be on this antibiotic indefinitely. He was afebrile at
the time of discharge, hemodynamically stable, and feeling well.
He was instructed to take acetaminophen as needed for
pain/fever, but advised not to take more than 4g of
acetaminophen per day.
.
#. Metastatic gastric cancer: The patient had been on hospice
previously, however per oncology and surgery providers who know
him, consistency in goals of care has been difficult. At time of
discharge, the patient was again to receive hospice care at
home. He is not currently receiving chemotherapy. He will
continue to use a dilaudid PCA for pain control, and will
receive IVFs through his portacath. He will no longer receive
TPN at home, but is able to tolerate a clear liquid diet. He
will continue to take prochlorperazine as needed for nausea.
.
# Anemia: Patient's baseline HCT prior to admission was in mid
20___. There was no evidence of acute bleeding during his
hospital course. He was transfused one unit PRBCs while in the
ICU. His HCT remained stable, around ___, while he was on the
medical oncology floor. He had some episodes of tachycardia,
but otherwise remained hemodynamically stable.
***. | 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.
***
___ y/o F with GERD and delayed gastric emptying, presenting with
___ days of abdominal pain, nausea, and vomiting.
.
# Abd pain/diarrhea: Appeared consistent with viral syndrome,
possibly secondary to history of potentially undercooked meat, 1
hr prior to onset of symptoms. CT abdomen was mainly notable for
abnormal appearance of hepatic vasculature, reported as possibly
consistent with vasculitis. LFTs were normal, but lipase was
somewhat elevated. There was no radiographic evidence of
pancreatitis. Her symptoms were all improving by the time she
arrived on the floor. She was continued on her home omeprazole
and metocloproamide. On the day of discharge, she was tolerating
a regular diet without significant pain or nausea. Her primary
gastroenterologist was contacted and the patient was discharged
with follow up with her outpatient GI provider.
.
# Iron deficiency anemia: Limited OSH records indicate patient's
Hct was in low 30's earlier this ___. Denies menorrhagia or
BRBPR. Reports colonoscopy in recent years--does not recall any
abnormalities. Was guaiac negative in ED. Hct remained stable
during the hospitalization.
.
# GERD: Continued home PPI
.
# Gastroparesis: Continued home Reglan
.
# ETOH: Pt reports 3 drinks/day. Family member reports that
patient may be under-reporting. No history of withdrawal
symptoms or hospitalizations for etoh abuse. No signs of
withdrawal during this hospitalization. Last drink was six days
prior to admission. She was monitored with a CIWA scale, and was
counseled regarding her excessive etoh use and its effect on her
chronic gastrointestinal issues.
.
# Tobacco abuse: Was treated with nicotine patch
.
# CODE: Full code for duration of hospitalization
***. | SYNCOPE AND COLLAPSE |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Patient was admitted to the Transplant Surgery Service following
a diagnostic laparoscopic converted to open segment VIII liver
resection and cholecystectomy ___ for a liver nodule
concerning for HCC in segment VIII. Please see separate
operative dictation for details of this procedure.
Postoperatively, he was taken to the PACU where he remained
stable, and was subsequently transferred to the floor.
Early on POD 1 he was febrile to 102, so urine cultures and
blood cultures were sent and a CXR was performed that showed a
right lower lung consolidation likely representing a combination
of pleural effusion and atelectasis, but infectious process in
the right lower lobe could not be excluded. Urine output
decreased and IV fluid boluses were given with good response.
Hematocrit was checked and was stable at 32.6. Urine
electrolytes were checked and FeNa was calculated to be 0% and
FeUrea was calculated at 21.4%.
Diet was advanced to clears. Early on POD 2, he was again
febrile to 102 and tachy to 112. Urine and blood cultures were
sent, and a stat liver duplex was performed that showed a normal
doppler assessment of the hepatic vasculature, trace perihepatic
fluid at the dome, and in ___'s pouch. A small right pleural
effusion, and a coarsened liver echotexture consistent with
known cirrhosis was also noted. CXR was repeated and showed
substantial interval increase in the right pleural effusion that
was concerning for intra-abdominal process, and a left mid-lower
lung opacity most likely reflecting lingular atelectasis that
was unchanged since the prior study. In the late afternoon on
POD 2, he was febrile again to 102.4 and was tachycardic to 116.
A CT Torso was done to evaluate for an intra-abdominal or
intra-thoracic process causing the patient to have his ongoing
SIRS picture. The CT showed no intra-abdominal abnormality to
explain fevers, lobar atelectasis of the RLL with moderate
effusion and non-specific colonic wall thickening. A pulmonary
consult was obtained and recommendations were to continue
incentive spirometry and oob/ambulate. IV Vancomyin and Zosyn
were started on ___ and continued thru ___.
On postop day 4, abdomen was less distended and diet was
advanced to regular. Foley was removed and he was able to
urinate. JP drain output increased to 1455cc. Serum sodium was
136. IV fluid hydration was stopped. He remained afebrile. JP
drain fluid was sent for cell count with WBC of 1825 and poly
18. Vanco and Zosyn were switched to Ceftriaxone on postop day 6
(on ___. JP drain output continued to increase to as high as 2
liters per day. He was given Albumin 12.5 grams a couple times.
Serum albumin was 2.6. LFTs decreased from postop elevation and
stabilized. Given high JP output, a liver duplex was done on
postop day 7 to evaluate for portal vein thrombus. Duplex
demonstrated patent hepatic vasculature and trace ascites.
On postop day 10, fluid was sent from the JP for cell count
demonstrating 6900 with 11 polys. The JP drain was removed and
diuretics started (Aldactone 50mg qd, Lasix 20mg qd). Incision
and old JP drain site remained clean and dry. Abdomen was mildly
distended. Weight was 79.8 on ___. preop weight from ___ was
87.6 and 81.66 on postop day 0.
He was passing flatus and had BMs on postop day 4 and 8. Colace,
senna and MiraLax were administered. Pain was initially managed
with morphine iv which was changed to Oxycodone on postop day 4
when he was tolerating a diet.
On postop day 11, vital signs were stable. He felt well enough
to go home. Pain was controlled with Oxycodone. He instructed to
decrease oxycodone to prevent constipation. He was averaging
10mg every 4 hours the day prior to discharge. All blood and
urine cultures were finalized as negative from ___ and ___. Upon
discharge, IV Ceftriaxone was discontinued and Ciprofloxacin
started. He was to take 500mg bid for one week then decrease to
500 mg daily for SBP prophylaxis. Follow up with set for ___.
He was instructed to have labs draw just prior to this visit.
***. | PANCREAS LIVER AND SHUNT PROCEDURES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ y/o M with PMHx of cholelithiasis, who presented with RUQ
pain, imaging showing cholelithiasis and CBD dilation, lab work
c/w cholestasis.
# Bile Duct Obstruction, Cholelithiasis: S/p sphincterotomy with
stone extraction. T.bili downtrended after procedure. However,
pt continued to have ongoing RUQ pain, worse after meals.
Surgery was consulted for consideration of inpatient CCY;
however, they felt that risk of having to convert to open
procedure was too high. ___ was consulted for perc chole
placement however a follow up RUQ U/S here revealed a contracted
gallbladder and multiple stones - making a perc chole
technically difficult.
Patient was thus admitted under acute care surgery, and it was
decided to take patient to the OR to perform lap chole on ___.
Patient tolerated the procedure well. On POD1, patient started
to pass gas. Patient was tolerating regular diet. Patient denies
nausea/vomiting/fever/chills. On POD2, patient denies abdominal
pain.
Patient was found to be ready for discharge. Patient will
follow-up with acute care clinic in 2 weeks.
***. | LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
This is a ___ with history of HIV on ART (CD4>500, VL 100s) and
rheumatoid arthritis on etanercept (discontinued in ___
who presented with rash.
#Hypersensitivity rash
Initially presented with concern for disseminated zoster. The
patient was briefly on IV acyclovir. She was evaluated by both
dermatology and ID who felt that rash was NOT consistent with
Zoster. Dermatology raised the concern for scabies and the
patient was treated with permethin x1. She underwent skin biopsy
with preliminary report showing no evidence of scabies and was
consistent with a hypersensitivity reaction. She was started on
triamcinolone and feoxfandine for symptomatic treatment. Final
biopsy is pending on discharge.
#HIV, asymptomatic
ON ART, no changes made
- consider outpatient hepatitis serologies, RPR and treatment
for latent TB
#Rheumatoid arthritis
- continue outpatient follow up
Transitional issues:
- Please remove sutures in 2 weeks
- Consider outpatient hepatitis B/C serologies and quantaferon
gold
- Would consider treatment for latent TB
- Biopsy results are pending on discharge
***. | ALLERGIC REACTIONS 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 lady with NSCLC metastatic to CNS (s/p ___ and to
paraspinal region who presented with uncontrolled back/right
thorax pain in setting of RUL/paraspinal mass invading into
right ___ to 8th ribs.
# Small bowel obstruction:
Hospital course was complicated by SBO. NGT was placed early am
of ___ and obstruction resolved by ___. NGT now removed and
she
is tolerating full diet well. The patient did complain of some
possible vomiting later it the hospitalization but it appeared
to just be thick secretions and was evaluated by speech therapy
who concurred and did not see any signs of aspiration.
# Constipaton: Patient with large stool burden noted on CT scan.
In setting of increasing opioid regimen will need to pursue
aggressive bowel regimen. We used daily miralax, colace, senna
and bisacodyl.
#Acute neoplasia related pain
#Right paraspinal muscular involvement
#Right pathological rib fractures: Pain was not controlled with
oxycodone at home but initially responded fairly well to
equivalent doses or oral hydromorphone. Started MS contin on
___ with good effect in addition to dilaudid ___ mg as needed.
Oral analgesics were held in setting of SBO, but were resumed
upon resolution. Radiation oncology deferred radiation treatment
given large treament area, possible side effects, and patient
preference.
# Falls: Several falls at home over the last few months. Last
was about a month ago. Some may have been medication induced.
Otherwise due to fatigue, weakness and pain. She remains quite
debilitated and will require SNF discharge for safety and
continued rehabilitation.
#Cancer cachexia:
#Severe malnutrition: Loss >15 lbs in <1 month. We continued
dexamethasone 1mg daily and nutrition was consulted.
#Metastatic NSCLC: Recurrence known since MR in ___,
with biopsy on ___. No metastatic disease on CT abdomen. We
continued levetiracetam for ppx given CNS disease. Current not a
candidate for systemic treatment due to poor performance status
and need for rehab. In preparation for possible use of
pemetrexed in the future., she received 1000mcg B12 SQ on ___
and we started 1mg folate daily. A brain MRI was done for
evaluate of prior metastatic disease as she had missed several
outpatient appointments. She will follow up with her neuro
oncologist and primary oncologist as an outpatient.
# Bacteruria: Initial UA on ___ grew alpha hemolytic bacteria.
She had no symptoms and repeat UA on ___ was clean. She was not
treated with antibiotics.
#HTN: Her home amlodipine and benazepril were initially held. We
resumed amlodipine 5mg daily after SBO resolved. She was
persistently hypertensive, so captopril was added (as benazepril
is non-formulary). She did have hypertensive urgency the night
of ___. A head CT was done and unchanged and her blood pressure
improved without intervention. Her home regimen was restarted on
discharge.
#Code Status: DNAR/DNI. A prior MOLST could not be found so a
new one was filled out with the patient on discharge.
Greater than 30 minutes spent discharge planning.
***. | PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
*** yo F with h/o EtOH cirrhosis c/b portal HTN and bleeding
varices, s/p TIPS (___) and h/o ischemic bowel s/p right
colectomy and ileostomy reversal (___), who recently relapsed
with drinking who presented with upper GI bleed.
#GI BLEED: Ms. ___ was admitted to the MICU where she had an
emergent EGD for suspicion of upper GI bleed. EGD showed a 1cm
non-bleeding marginal ulcer at the site of the gastro-jejunal
anastomasis from her prior Roux-en-Y gastric bypass as the most
likely cause of her GI bleed. Given h/o portal hypertensive
gastropathy and variceal bleeds, she had RUQ abdominal
ultrasound which showed that TIPS was patent with no
ascites/splenomegaly. She received 4 units of blood total, and
her HCT bumped from 20 to 26 following transfusion. She had one
more episode of black stool and large BRBPR while in the MICU on
HD #2, no further episodes after this. She initially received
Octreotide on admission, this was DC'd once lower suspicion for
variceal bleed. EGD showed nonbleeding ulcer at GJ anastomosis
which was likely source of bleed. She was initially on
pantoprazole gtt, later switched to pantoprazole 40mg IV BID and
Carafate susp 2gm BID. She also received 3-day course of
Ceftriaxone for SBP prophylaxis. Her home spironolactone and
Lasix were held in MICU in setting of GI bleed. Heparin
prophylaxis was held in MICU given recent GI bleed. Patient was
then transferred to the floor where her hct remained stable. On
discharge, she will take 3 days of Cipro 500mg BID for SBP
prophylaxis, will continue carafate, increase her home PPI dose
from qd to bid. She will have labs re-checked and faxed to
liver clinic on ___ to assure her hct remains stable.
.
# ALCOHOLIC CIRRHOSIS: The patient's home furosemide,
spironolactone were held in setting of GI bleed. Her lactulose
was held in MICU per her preference.
.
#ALCOHOL WITHDRAWAL: At admission to the MICU, the patient
reported a fear of going into alcohol withdrawal even though her
last drink was just on the morning of her admission. The patient
did not score per CIWA while in MICU, so it was discontinued.
She received her home folate, multivitamins, and thiamine.
Patient was interested in outpt program to stop drinking. Spoke
with social work.
.
#THROMBOCYTOPENIA: The patient's platelet count at admission was
92 and decreased to 58 on ___. The thrombocytopenia could be
secondary to decreased production by a hypocellular bone marrow
as seen in cirrhosis, but is most likely dilutional given the
patient's transfusion with several units of pRBCs.
.
#ACID-BASE DISTURBANCE: The patient had an initial AG of 21. Her
AG metabolic acidosis could be secondary to alcoholic or
starvation ketoacidosis. Based on her initial blood gas, the
patient also had a primary respiratory alkalosis, likely
secondary to hyperventilation from her anxiety. She also had a
primary metabolic alkalosis, likely secondary to volume
contraction alkalosis given her GI bleed. Her AG closed over
the course of her hospitalization.
.
#ANXIETY: Ms. ___ received Lorazepam prn for her anxiety.
.
#RASH: The patient's rash was serpiginous in appearance, most
c/w tinea corporis (with many overlying excoriations). She
received Clotrimazole cream and oral fluconazole for treatment
of her rash. Will need outpatient derm follow up given severity
and chronicity of rash. Wanted to see derm in clinic in
___, provided contact information.
.
#DEPRESSION: The patient was continued on her home gabapentin.
.
#HYPOTHYROIDISM: The patient was continued on her home
levothyroxine sodium.
.
TRANSITIONS OF CARE:
-will have cbc/chem10/coags/LFTs checked on ___ and faxed to
liver clinic
-wil be seen in liver clinic as outpt
-will take Cipro 500mg PO bid x3 days
-changed PPI dosing from qd to bid, will need to be changed back
to qd as outpt
-started carafate, may need to be d/c'ed as outpatient
***. | 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.
***
# BRBPR:
Patient came with reports of BRBPR in setting of suprtherapeutic
INR likely hemorrhoidal. EGD and colonscopy performed that
identified no other source for bleeding per GI. While in the ED,
the patient was given FFP and Vit K with reversal of INR seen
while waiting for colonscopy/EGD. Her Hct was stable throughout
admission with no evidence of any blood in her stools and
otherwise asymptomatic besides occasional abdominal pain (see
below). Pt recommended continue follow-up with GI for future
colonscopy with long prep likely needed in the future. Follow-up
with PCP setup following discharge.
.
# Abdominal pain:
Patient reports chronic pain due to fibromylagia with pain
during admission consistent with her normal pain. No evidence of
obstruction or acute abdomen noted during admission. Infectious
work-up including UA was negative with no vaginal discharge or
leukocytosis. Pain not associated with periods. LFTs normal Last
EGD ___ showed non-erosive gastritis. CTA of pelvis ___ showed
no abdominal pathology but did show adhesions. However, while
prepping for colonoscopy, patient did state improvement in her
abdominal pain so could be a component of chronic constipation.
.
*** Chronic Diagnoses ***
.
# PEs - Patient has a history of 2 PEs (one provoked). INR has
been difficult to manage. Patient recieved FFP and Vitamin K as
above with reversal noted. For bridging therapy, heparin drip
was initially started prior to colonoscopy/EGD procedure. After
procedure, patient was started on Lovenox bridge while being
restarted on home Coumadin dosing. Pt instructed to continue
Lovenox shots and follow-up with ___ clinic as arranged for
INR check shortly after discharge.
.
# ___ edema
Unclear etiology, which has been ongoing for several weeks. DDx
includes venous stasis, CHF and DVT. ___ was negative. No
events over the tele. Patient reports schedule for outpatient
holter for palpitations and stress test. Pt sent directly to
cardiology for Holter montior and further work-up as previously
established by cardiology on outpt basis.
.
# Fibromyalgia and chronic pain:
Stable, see above abdominal pain. Continued home oxycodone,
tizanidine, flexeril without complaint.
# Depression/anxiety:
Stable on home seroquel, bupropion, lorazepam
.
# HTN:
Stable on home lisinopril
.
*** Transitional Issues ***
.
- GI recommended repeat colonscopy in the future for further
evaluation because of length of her colon and need for more
adequate prep despite receiving 3L or more of Moviprep prior to
procedure
.
- Patient was counseled numerous times and stated that she could
have her mother or another relative assist who were already
trained to assist her in getting her Lovenox shots. Verbalized
understanding of risk of not having the shots while achieving
therapeutic INR.
.
- Pt set to follow-up with ___ clinic for dose adjustments
and INR check. Pt has issues with compliance while on warfarin,
may benefit from meds like dabigatran where monitoring less but
must weigh risks/benefits.
.
- * Patient had appointment to pick-up Holter for history of
palpitations on day of discharge so patient sent to cardiology
to pick it up.
***. | OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is a ___ year old man with DM type 2, HTN, and a
history of non-healing chronic L heel wound who is transferred
to ___ for ongoing podiatric care, with concern for
osteomyelitis.
ACTIVE ISSUES:
==========================
#Chronic L heel ulcer
#Osteomyelitis
#Strep Viridans acute bloodstream infection: Pt has a history or
non-heeling left heel ulcer which has now been excised multiple
times. He had both clinical (probing to bone) and radiographic
findings of osteomyelitis. Was found to have bacteremia at
___, but with negative cultures since. He underwent bedside
I&D ___ by podiatry, then OR debridement ___. on POD #2, he
had a Bivalve boot placed, which should stay in place at least
until podiatry follow up. Tissue from the OR grew coagulase
negative Staph in small numbers, but given the chronicity of his
ulcer, it was felt reasonable to treat this. His white count and
inflammatory markers were monitored during hospitalization. An
echocardiogram was obtained which did not show any evidence of
vegetation. He will continue on Vancomycin, Ceftriaxone, and
Flagyll, to complete a 6 week course (___). OPAT follow
up at ___ will be arranged.
#Urinary retention. Reportedly pt had acute urinary retention at
___ requiring placement of Foley. This has now resolved and
he is voiding without issue. Denies history of BPH. He was
continued on Tamsulosin, which was started at ___.
#Elbow pain. Pt developed subacute onset R elbow pain associated
with swelling, erythema, and warmth while at ___ which
continued at ___. Low concern for septic joint as he is
afebrile and symptoms seem to improving with minimal
intervention, but this remains on differential given previous
bacteremia. Other possible etiologies include olecranon
bursitis, epicondylitis, crystal deposition disease. Pain and
range of motion improved with no intervention. He refused
ultrasound to evaluate for fluid collection/abscess
# primary HTN
# DM2 with neuropathy
Chronic stable issues during hospitalization
TRANSITIONAL ISSUES:
-To receive 6 week course of Vancomycin, Ceftriaxone, and
Metronidazole (___)
-Antibiotics plan per infectious disease team at ___. All
questions regarding outpatient parenteral antibiotics after
discharge should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
-Labs to be checked weekly: CBC with differential, BUN, Cr, AST,
ALT, Total Bili, ALK PHOS, Vancomycin trough, ESR, CRP
-Stitches will be removed at next appointment with Podiatry.
-Should be non-weight bearing on L foot until Podiatry follow
up, possibly longer.
-Pt had Bivalve boot placed ___. This should remain in place at
least until Podiatry follow up
-Monitor for right elbow pain. Patient had acute right elbow
pain during hospitalization, which self-resolved. If this
returns, however, would consider septic joint.
-Tamsulosin started this hospitalization for acute urinary
retention at ___
# CODE: Full (confirmed with patient)
# CONTACT: Wife, ___, ___
***. | OTHER ENDOCRINE NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC |
Subsets and Splits