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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.
***
___ with dementia, chronic urinary retention ___ BPH s/p
indwelling Foley, chronic hematuria who originally presented to
___ from home with acute delirium and weakness, found to
have hemodynamically unstable GI bleed and septic shock,
respiratory failure requiring intubation, ultimately in 4
pressor shock and passed away this admission.
#MIXED SHOCK COMPLICATED BY #DIC:
Over hospital course, patient remained in mixed shock, with
hemorrhagic component (given melena and presentation with Hgb
___, septic (given gram positive cocci growing on blood
cultures) and cardiogenic with concern for sepsis-induced
Takatsubo cardiomyopathy (given TEE n/f MR/TR, LVEF 20% and
dilated LV and new rise in troponins during hospital course).
For his hemorrhagic component patient received a total 5 U pRBC
in initial resuscitation, and for his septic component he was
treated with IV meropenem and daptomycin. Other sources of
infection were unrevealing: CXR mostly unchanged from baseline
though new, heterogeneous, left infrahilar opacity could be
consistent w PNA: C diff test negative, urine culture negative,
sputum culture invalid sample. Despite these measures, his shock
required increasing doses of four pressors (norepinephrine,
vasopressin, phenylephrine and epinephrine). Steroids were
considered given potential benefit in septic shock, however were
deferred given c/f active GI bleed and poor mucosal protection.
Patient was then intubated given c/f increased work of breathing
and continued to degenerate demonstrating signs of end organ
failure that eventually led to labs n/f low fibrinogen, elevated
D-dimers and ___ together with bleeding from IV sites w c/f DIC
for which he received a total of 2 U FFP (cryoprecipitate not
indicated given his fibrinogen was not below 100). His clinical
status nonetheless continued to deteriorate despite four
pressure support. This was discussed with family and HCP, and
the decision was made to transition from full code to DNR/DNI
status. In order to address pain and discomfort, his ventilator
settings were transitioned to a set respiratory rate and he was
started on propofol and fentanyl. In the afternoon of ___, the
patient passed away due to cardiovascular collapse with family
members at the bedside.
#GI BLEED:
Positive guaiac in ER, likely chronic bleeding with acute
deterioration. No known liver disease or varices, no known
NSAIDS or alcohol use. Unknown last colonoscopy. Resuscitated
with pRBC and fluids. Gastric lavage was negative, so GI did not
conduct EGD. While he continued to have episodic melena, it was
thought that bleeding may have been located further distally in
the GI tract, but that bleeding was contained and prevented from
resulting in further melena due to massive stool burden as
noticed in CT. He was started on PPI and Hgb monitored. The
massive transfusion protocol was activated and he received a
total of 5U PRBC including those received at the outside
hospital.
# AFib with RVR and s/p polymorphic VT:
Irregularly irregular rhythm was first noticed on telemetry,
with c/f sinus tachyarrhytmia on EKG. He was not started on
anticoagulation given c/g active GI bleed, nor started on rate
control given sepsis and pressor support. He later had 8 run
polymorphic VT likely ___ recent ischemia w troponin leak,
followed by Afib with RVR despite pressor support. Cardiology
was consutled and he was received amiodarone bolus followed by
drip to control atrial and ventricular ectopy during hospital
course.
# Transaminitis:
No h/o liver disease, pattern was hepatocellular and thought to
be likely shock liver iso severe shock with ALT/AST rising up to
the thousands and INR peaking at 3.5. He was continued on
pressors for hemodynamic support during hospital course, as
described above.
# Type II MI:
Significant troponin leak which peaked and downtrended, w EKG
n/f inverted T waves in left precordial leads. Likely ___ severe
shock. Low MVO2 was found on VBG and thought to be
multifactorial iso cardiogenic shock and hypovolemic shock as
detailed above. No interventions were pursued given unstable
hemodynamic status iso sepsis, aspirin/heparin were not given
given ongoing c/f GI bleed, statin was not given due to
inability to tolerate PO and subsequent intubation.
# Glucose management
No h/o diabetes, however in setting of stress due to shock,
cortisol levels may have risen and counteracted insulin. He was
started on an insulin regimen during his hospital course.
# Distended abdomen on CT:
Pt has h/o ___ and ? CIPO (chronic intestinal pseudo
obstruction), no h/o UC or Chrons. Given CT c/f colonic
distention, c diff was pursued to rule out c diff induced toxic
megacolon iso concurrent leukocytosis (though patient was not
febrile at any point). C diff testing was negative, and patient
was decompressed through NGT on wall suction iso diagnostic
gastric lavage.
#GOC: as above for mixed shock, patient was initially full code
but had acute decompensation throughout hospital stay.
Ultimately, it was felt the CPR would be ineffective and not
indicated and would likely cause further harm without meaningful
recovery. This was discussed at multiple points, several times a
day on each day of his hospitalization, with multiple family
members, particularly, his HCP ___ (daughter).
Ultimately, as his condition continued to deteriorate, family
felt that shocks and chest compressions would cause more harm
and opted to transition his goals of care to DNR. He did
continue on pressors, antibiotics, and ventilator support,
however, continued to clinical decline with progressive shock,
multiorgan system failure, and he ultimately passed away on
___. His family was at his bedside when he died, and they
expressed appreciation for the care he had received during his
hospitalization.
***. | 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.
***
Hospitalization Summary
The patient presented to the emergency department and was
evaluated by the Hand surgery team. The patient was found to
have infection of the left ___ MCP and was admitted to the Hand
surgery service. The patient was taken to the operating room for
irrigation and debridement, which the patient tolerated well.
For full details of the procedure please see the separately
dictated operative report. The patient was taken from the OR to
the PACU in stable condition and after satisfactory recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to homewas appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT in the left upper extremity. The patient will follow up
with fellow clinic per routine. A thorough discussion was had
with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
***. | HAND OR WRIST PROCEDURES EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ YOF with HIV on HAART (unclear compliance), lung cancer,
prior cocaine induced MI, depression, chronic pain, and
polysubstance abuse with history of withdrawal syndrome, who
presents with multiple complaints
consistent with a withdrawal syndrome from alcohol and opiates.
# Aches, abdominal discomfort, runny nose in context of
# Alcohol and opiate abuse, most consistent with
# Polysubstance withdrawal syndrome:
Her urine and serum toxicology screen were positive for opioids
and cocaine. She was placed on CIWA with PRN Valium and ___
with PRN methadone. She was seen by the ___ RN
and also met with Social Work multiple times. She successfully
completed EtOH and opioid withdrawal with methadone and Valium
PRN. Although patient requested dual diagnosis facility
placement, she was not felt to have any acute psychiatric mood
disorder to warrant placement at a dual diagnosis facility. She
was instead screened for inpatient stabilization units. Social
work performed an exhaustive review, however, only 1 program
(Women's Renewal) accepted her. However, pt reports a prior
unhelpful experience at the particular program and declined to
be discharged to Women's Renewal. As she was medically stable,
she is being discharged to home. Unfortunately, based on her
past history, she is at high risk for relapse.
# Pancytopenia due to
# HIV on HAART
Most recent CD4 204, VL <20 copies (___). Continued home
HAART. Continue Bactrim for PCP ___.
# Lung cancer: She was supposed to have lung resection but owing
to her significant social and compliance issues this has been on
hold. Had already received chemo and XRT at ___.
TRANSITIONAL ISSUES:
1. f/u with PCP
2. f/u with partial program at ___
3. f/u with ___ / ___ for her lung cancer
***. | ALCOHOL DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ w/h/o asthma, testicular cancer (s/p R orchiectomy and
radiation in ___ and two prior episodes of diverticulitis
which were treated with PO cipro in outpatient setting (most
recently ___ years ago), who presented with 3 days ___ reminiscent
of prior diverticulitis episodes, without systemic symptoms. He
presented to ___ urgent care where CT showed acute
diverticulitis with an 8mm intramural abscess and referred to
___ ED where his Tmax was 100 and vital signs were otherwise
stable. He was started on IV cipro + flagyl and IV dilaudid for
pain and observed overnight without improvement thus admitted
for continued monitoring and IV antibiotics. On the medical
floor his condition improved, with resolution of abdominal pain.
On ___ in ___ he was transitioned to PO antibiotics. He
subsequently tolerated regular oral diet and remained afebrile.
acute problems managed during this admission:
# Fever, ___ pain:
# Complicated Diverticulitis:Patient did have previous two
episodes of diverticulitis ___ years ago which were treated in
outpatient setting. Had colonoscopy subsequently which was
reportedly normal per patient. Does have history of pelvic
radiation but no known history of radiation colitis and no
history of GI symptoms or issues at baseline. Presented with
fever, leukocytosis, and ___ pain with imaging
consistent with diverticulitis c/b 8mm intramural abscess
without drainable fluid collection. Reviewed by surgery who
recommended continued conservative management and ___ as
out patient. Managed with IV cipro/flagyl and IVF with
resolution of fever and improvement in abdominal pain. Switched
to PO Abx ___ and tolerated oral diet well.
# Soft tissue/swelling on foot: this developed overnight during
this admission and did not appear like an infection, hematoma or
tumor. Patient does not have history of gout and doesn't look
like a tophus. Possibly a ganglion cyst. No urgent intervention
was deemed necessary.
# Fatty infiltration of liver per CT scan. Patient said this was
previously worked up. Denied heavy alcohol. Patient instructed
to avoid heavy alcohol intake
CHRONIC/STABLE PROBLEMS:
# GERD: continued on home omeprazole
# s/p testiculectomy and radiation for testicular cancer ___,
was followed by oncology subsequently with CT torso's.
Discharged from ___ ___ years ago.
GENERAL/SUPPORTIVE CARE:
# VTE prophylaxis: on heparin subQ during this admission
# Code Status: Full
Transitional issues:
- complete 10 days of abx with PO Augmentin. Last day ___
- post d/c will need colonoscopy and follow up with colorectal
surgery for further discussion about surgical intervention given
young age and 3 episodes of diverticulitis in the past ___ years.
Patient should call Dr. ___ office at ___ tomorrow
morning to arrange for a f/u appointment for within ___ weeks.
- PCP ___ with 1 week of discharge
- PCP to consider ___ for colonoscopy as per above.
- PCP to consider checking LFT's and further ___ for fatty
liver.
- PCP to consider referral to podiatry if swelling on foot does
not resolve completely.
***. | ESOPHAGITIS GASTROENTERISTIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year old man with HTN, hyperlipidemia, and chronic back pain
who presented with 2 days of left leg swelling and tenderness.
This was originally thought to be DVT, as the symptoms of
swelling, pain, and low grade fever was consistent with this
diagnosis (although no clear etiology); however, re-review of
CTV shows compression of vessel with no intraluminal thrombus.
He therefore had MRI of the leg which showed acute tear at the
musculotendinous junction of the medial head of the
gastrocnemius muscle of the right lower extremity and associated
hematoma centered in the medial head of gastrocnemius but
extending into the space between the soleus and gastrocnemius
muscles on the right.
The patient was seen by orthopaedic surgery for his muscle tear.
They recommended conservative management with out-patient follow
up with the ___ clinic. He was placed on Lovenox as he has
high risk of developing DVT ( immobility, compression of the
vein from the hematoma). The hematoma remained stable with no
further bleed. He was asked to stop Lovenox once he is able to
walk. He had no evidence of compartment syndrome. He received ___
who taught him to use walker and ambulate with no weight baring
on the affected limb. He was informed about the symptoms and
signs of DVT, bleeding, and compartment syndrome.
***. | FRACTURE SPRAIN STRAIN AND DISLOCATION EXCEPT FEMUR HIP PELVIS AND THIGH WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient was admitted to the orthopedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
1.)Hypoglycemia, POD#0, PACU->apple juice and D5W IV gtt with
good effect
2.)Nausea/Emesis and persistent hypertension, POD#1, SBP in
180s, max 190s, am PO BP meds not absorbed due to emesis
immediately upon receiving them. Re-administered upon resolution
of nausea/emesis. Continued hypertension with SBP in 180s, found
to be +3.5L received 40mg IV lasix, 10mg IV hydralazine, extra
6.25mg of PO home carvedilol overnight with good effect.
3.)Anxiety, POD# 0&1, very anxious in PACU requiring Ativan,
POD#1 pt continued concern regarding persistent hypertension,
ativan 0.5-1mg IV q6H:prn
4.) Hyperglycemia, POD #1 the patients glucose control ranged
from 250-400. ___ was consulted and insulin regimen was
adjusted accordingly.
5.) Acute post-op anemia with Hgb to 6.8. She received 2 units
of PRBCs on POD#3 and responded nicely.
6.) Acute Kidney Injury, on POD#3 her creatinine spiked to 2.5
from 1.8. This was equivalent to her pre-admission creatinine
however this remained stable following blood transfusion and
oral fluids with serial labs.
Otherwise, pain was initially controlled with a PCA followed by
a transition to oral pain medications on POD#1. The patient
received Lovenox for DVT prophylaxis starting on the morning of
POD#1. The foley was removed on POD#1 and the patient was
voiding independently thereafter. The surgical dressing was
changed on POD#2 and the surgical incision was found to be clean
and intact without erythema or abnormal drainage. The patient
was seen daily by physical therapy. Labs were checked throughout
the hospital course and repleted accordingly. At the time of
discharge the patient was tolerating a regular diet and feeling
well. The patient was afebrile with stable vital signs. The
patient's hematocrit was acceptable and pain was adequately
controlled on an oral regimen. The operative extremity was
neurovascularly intact and the wound was benign.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity.
Ms ___ is discharged to rehab in stable condition.
***. | MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is a ___ year old man with history of HTN, PVD and
colonic adenomas who presented status post-colonoscopy with
witnessed emesis, new O2 requirement, fever, finding of large
left lung opacity.
#ASPIRATION PNEUMONITIS/PNEUMONIA: Diagnosis made from history
of emesis while sedated and subsequent hypoxia, fever and
radiographic consolidation. Patient looked well upon arrival the
floor, but was watched overnight because of oxygen saturations
in the low ___ at rest. He was not started on
antibiotics because he had been afebrile since admission and had
only spiked one fever prior to admission, and this was thought
to be caused from aspiration pneumonitis. However, he then
spiked to 100.9 on the evening of ___. Repeat blood cultures
were sent and he was started on levoquin 750 mg po daily to
complete a 5 day treatment course for pneumonia. Despite the one
fever, he was doing well and oxygen saturations were improved.
He was discharged with the po course of levoquin.
#HTN: SBPs 130s-150s while in the hospital. Continued home
amlodipine and losartan.
- C/w amlodipine and losartan
#PVD: Continued home aspirin and statin while in the hospital.
- C/w ASA81 and simvastatin
TRANSITIONAL ISSUES:
# Patient vomited after reportedly being NPO for over 1 day and
vomitus had particulates in it per colonoscopy team, recommend
eval for cause.
#F/u colonoscopy results
# CODE STATUS: Full
# CONTACT: ___ (wife) ___
***. | RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Pt was admitted to ___ on a conditional voluntary basis.
She aclimated to the milieu readily, maintained behavorial
control and was an active participant in her treatment planning.
In regards to her psychiatric issues, the pt appeared dysphoric
and hopeless about her housing situation. She was maintained on
all outpt medications except for risperidone, which pt did not
want to continue. There did not appear to be any negative
sequelae to this discontinuation.
A neuro consult was ordered at the request of the pts outpt
psychiatrist to evaluate the pt for wernicke's encephalopathy.
The neuro workup was negative for such encephalopathy and the
pts thiamine was WNL at 208.
The pt agreed, for the first time in my history of working with
her, to allow her sister to be contacted. A family meeting was
held for the purpose of identifying, concretely, how the pt's
family could be supportive and this objective was obtained.
The pts outpt team was also active in her dispo planning and
arranged for the pt to be transferred to the ___ and
continue with the DBT partial hospital program.
***. | 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.
***
#Legal: ___
#Safety: Patient remained in good behavioral throughout
hospitalization; he remained on 15minute checks (the least
restrictive monitoring interval).
#Psychiatric:
Upon admission, patient reported non-compliance with psychiatric
medications for past two weeks, believes them to be ineffective.
Per report, combination of VPA and venlafaxine have been
effective combination in the past, but outside psychiatrist
hesitant to increase venlafaxine dose above 75mg given previous
reports of mania at 150mg. Patient reports that SNRI helpful,
but treaters conflicted about inducing mania. Discussed trial of
duloxetine as alternative SNRI to use in conjunction with VPA;
explained the risks, benefits, and side effects of this
medication, he tolerated ___t duloxetine 90 mg he
developed acute agitation, restlessness, which given time course
(within hour of new dose) and resolution when dose was reduced,
was more c/w akathisia than manic switch. His mood was
progressively brighter. He initially expressed thoughts of death
"its passive suicidality, I just want to sit around", but this
resolved by his second week of hospitalization, and he had no Si
by time of dc, was forward looking. Of note he was hesitant to
actively participate in d/c planning in week 1, but by week 2,
and after investigating how d/c would change if he participated
more actively, he became more involved, and secured return to
his prior living situation (confirmed with roommates).
Etiologically, Mr. ___ low mood and suicidality, appear a
combination of subtherapeutic medication, MJ use to "numb
feelings" - contributing to passivity/mood, situational
stressors, isolation. It is notable that he responded actively
to frank but supportive discussion of how d/c plan would be less
than optimal if he does not actively participate.
He continues precontemplative re: mj use. Team processed a
referral to ___, but prior to acceptance, he expressed
that he could not follow through with this treatment. Discussed
stages of changes w/ patient; recommended ongoing engagement in
stages of change discussion.
Team communicated with treaters, Dr. ___ and
Dr. ___, who were in agreement w/ plan for
increased services (___ secured, contact in d/c sheet), VPA
therapeutic, on duloxetine 60 mg (2 week supply of medications
secured at free care clinic; communicated with mom who confirmed
she sent insurance card to pt.'s residence 2 w.a.). Followup
appointments w/ PCP, ___, psychiatrist, endocrinologist
arranged.
Overall, On discharge, mood was bright and reactive. Thought
process was linear and concrete. Thought content devoid of
suicidal ideation and thoughts of self-harm. Also denies
thoughts of harming stepfather. No abnormal perceptions or
beliefs noted or endorsed. Insight and judgment was
significantly improvd. He was rational in his thinking and had
no evidence of psychosis
#Medical
-Type 1 DM: Since his most recent discharge from Deac4, patient
was seen at ___ for DKA. Patient reported difficulty obtaining
and administering his insulin regimen, both due financial and
situational stressors. Per report from collateral, patient had
resumed using marijuana, which likely contributed to his
ambivalence medication compliance. Blood sugars labile on
admission, going from peak in 400s to nadir of 47. Consulted
___ for input on insulin regimen while admitted. Obtained A1c
which was noted to be 10.0. Also liased with outpatient ___
providers about ongoing care. See below in collateral section.
-Addison's Disease: Continued on home fludrocortisone Acetate
0.2 mg PO QD and prednisone 10 mg PO QD. Patient reported
interrupted compliance over the past few weeks due to
social/economic stressors. Explained to patient that acute
cessation of prednisone could exacerbate mood symptoms. Obtained
TSH and AM cortisol: TSH 0.55 and AM Cortsol 2.31.
Seizure Disorder: Continued patient on home divalproex ___
QAM and 1500mg QHS for seizure disorder. Patient reported
interrupted compliance over the past two weeks due to
social/economic stressors. Obtained VPA level which was 64.
GERD: Continued patient on home pantoprazole 24mg Q24hrs
Social/Milieu:
Patient maintained good behavioral control on the unit and
interacted appropriately with peers. Attended occupational
therapy groups and was respectful with staff.
Collateral: Dr. ___:
Reports
that patient had appointment with her on ___ where he came with
his "backpack full of medications, gave them to [her] and said,
'here. I don't need any of these anymore. I'm donating them to
science. I'm going to go to the hospital, and I'll probably be
there for a while.'" She explains that patient had contacted her
several times after his most recent discharge from Deac4.
Explains his interview for new job was thwarted by DKA. To
complicate matters, patient's main support/roommate will be
moving out of country soon, so he will no longer be able to live
in his apartment. This roommate was paying Mr ___ share of
the rent (and, incidentally, was supplying him with marijuana).
Since patient has no source of income, other roommates asked him
to move out. With regard to patient's mother, she reneged on her
agreement to provide him with a flex-spending card so he could
pay for his medications. As such, he has no money to pay for
either his medical or psychiatric medications.
# Risk Assessment:
Upon initial evaluation, the patient was felt to be at elevated
risk for harm to self and harm to others given chronic risk
factors of gender, chronic mental illness, chronic medical
illness, prior hospitalizations, and modifiable risk factors
including homelessness, lack unemployment, social isolation,
lack of adherence to psychiatric medications, insufficient
social supports, current SI, hopelessness, worthlessness, and
low mood. Protective factors include having
psychiatric and medical treaters, lack of family or personal
history of suicide, lack of history of violent behaviors, and
willingness to seek help.
These were mitigated by working to identify a psychopharm
regimen that the patietn would be willing to comply with through
time, providing support and stabilization that lead to the
resolution of his acute symptoms of suicidal and aggressive
thoughts, by increasing his supports (facilitating communication
w/ roommates; DMh care now confirmed - pt. to followup) and
continuing to coordinate with outpatient mental health
providers, working to coordinate his medical care, providing him
with a supply of his medications, supporting him developing
motivation for sobriety, and providing psychoeducation about
chronic patterns of inconsistency. In consideration of
aforementioned risk factors and mitigating interventions,
patient is appropriate for discharge and outpatient level of
care.
***. | PSYCHOSES |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr ___ is a ___ male with a history of atrial
fibrillation on systemic anticoagulation, s/p PPM placement iso
AV nodal disease, COPD with home oxygen requirement, ESRD on HD
(TTS), severe aortic stenosis, who presented from his nursing
home because of a dislodged dialysis catheter.
ACUTE ISSUES:
=============
#Dislodged HD catheter
#ESRD on HD (TThSat)
This is patient's second presentation for dislodged HD catheter
within the past several months, unclear why he is having this
difficulty. Patient without signs/symptoms of infection. No
obvious signs of skin or tissue breakdown around the site. Blood
cultures were negative. Patient had replacement of HD line with
___ on ___. Patient received hemodialysis on ___ after line
placement, in keeping with his routine schedule. Of note,
patient was found to be several kilograms above his dry weight
but insisted on terminating HD prematurely before reaching goal
fluid removal. He was continued on home sevelamer and
nephrocaps.
#Hypotension
Patient's SBPs have been in the low 100s over the past weeks
prior to admission, subsequently falling to ___ prior to
transfer to ED. Hypotension likely ___ decreased cardiac output
in the setting of severe aortic stenosis. Patient did not have
any signs/symptoms of infection/sepsis. Patient received 500cc
IVF in ED. His blood pressure was stable at his baseline of low
100s through the rest of admission. His home metoprolol was held
in setting of hypotension.
#Elevated BNP
#Heart failure with reduced ejection fraction (LVEF 30%) -
Patient has a known history of severe cardiomyopathy,
multifactorial in etiology. NT-proBNP was elevated this
admission higher than previous values, although this is in the
setting of ESRD. Chest x-ray revealed mild pulmonary vascular
congestion and trace pleural effusions. Patient did not have any
increase in his oxygen requirement above baseline or subjective
dyspnea. He had some fluid removal through hemodialysis. His
home metoprolol was held in the setting of soft blood pressures.
CHRONIC PROBLEMS:
=================
#Troponinemia, stable
Troponin .15 with MB 3 on admission, stable on repeat in the
setting of ESRD. No acute ischemic changes on ECG. Very unlikely
to represent ACS.
#Severe aortic stenosis (low flow low gradient)
Patient was last evaluated in cardiology clinic ___ (Dr.
___. There was some discussion of referral for TAVR
evaluation should patient have limited exercise tolerance
related to his valvular disease. Given his deconditioning and
multiple medical comorbidities, however, additional workup for
TAVR including coronary angiography was deemed likely futile.
#Atrial fibrillation
Home metoprolol was held in the setting of hypotension. Home
warfarin was held for replacement of his HD catheter.
#Presumed CAD
Continued home atorvastatin
#COPD
Stable through admission. Continued home inhalers, 2L O2
supplementation by nasal cannula as needed.
#Macrocytic anemia
Hemoglobin was stable and at baseline throughout admission.
#T2DM
Maintained on insulin sliding scale
#Dyslipidemia
Continued home atorvastatin
#GERD
Continued home famotidine
#Depression
Continued home fluoxetine
TRANSITIONAL ISSUES:
====================
[ ] At hemodialysis session on ___, patient was noted to be
several kilograms above his dry weight. Patient insisted on
terminating his HD session prematurely despite not at goal
volume removal. He may need additional fluid removal at next HD
session
[ ] Patient should have INR next checked on ___
***. | OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Patient is a ___ yo male with h/o HTN who presented with
hypertensive emergency in setting of medication non-adherence.
.
# Hypertensive emergency: The patient presented with a BP of
196/143, which occurred in the setting medication non-adherence
for the past year. The patient also experienced a headache and
was found to have ARF (though unknown baseline). Based on
history, exam and radiographic findings, we suspected that this
was fairly long-standing in nature; thus, we aimed to lower
patient's SBP initially to 160. Other etiologies for
hypertension were considered, and the patient's Renal U/S with
Doppler was negative for Renal Artery Stenosis, TSH was normal,
and the patient did not have proteinuria. It was thought that
the patient most likely had poorly controlled essential
hypertension. He was started on Amlodipine 5 mg and Labetalol
during this hospitalization, and his blood pressure decreased to
140-160/90-110.
.
# Coronary Artery Disease: The patient had an elevated CK and
Trop on this admission, but he did not endorse any chest pain
prior to or during this hospital stay. The patient's CK-MB was
also normal, which does not support a cardiac etiology for these
elevated markers. The patient most likely had mild demand
ischemia in the setting of hypertensive emergency. He was
monitored on telemetry and he was started on ___ 325 mg daily,
and he did not have any acute events during this admission.
.
# Congestive Heart Failure: The patient has cardiomegaly on CXR
and by exam, likely due to longstanding HTN. He endorsed
increasing dyspnea on exertion and occasional PND, though a BNP
at OSH was within normal limits. The patient had a TTE, which
demonstrated diastolic dysfunction, and severe symmetric LVH.
The patient was started on Labetalol and Norvasc, and he was
scheduled for a follow up appointment with Dr. ___ at ___
___.
.
# Tachycardia: The patient remained persistently tachycardic on
this admission. He was given IV fluids on admission, as the
tachycardia was thought to be secondary to dehydration. This,
however, did not lower his pulse and the patient remained
tachycardic to the low 100s. The patient was monitored on
telemetry during this admission, and he is scheduled to follow
up with his outpatient cardiologist on discharge.
.
# Acute Renal failure: The patient presented to OSH with Cr of
2.0, though his baseline is unknown. His Cr continued to
increase during this admission to a peak of 3.4. Nephrology was
consulted, and it was thought that the patient most likely had
hypertensive nephropathy in the setting of hypertensive
emergency and long-standing hypertension. The patient was given
gentle IV fluids, and he continued to have good urine output.
The patient's creatinine decreased to 2.2 by the time of
discharge.
.
# Elevated CK: The patient presented with CK of 910. The
etiology of this elevated CK is unclear, but it was thought to
be related to demand ischemia in setting of severe hypertension.
The patient was given IV fluids throughout this admission, and
his CK decreased to 388 by the time of discharge.
.
#. Code: Full
***. | HYPERTENSION WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr ___ was admitted to the neurosurgical service started on
Decadron and Keppra for seizure prophylaxis medications. He had
a CT of the chest which showed Several small lung nodules which
are not particularly suspicious for metastatic disease and each
is also very unlikely to represent a primary malignancy.
However, particularly given concern for malignancy, a followup
chest CT in three months is recommended.
Further brain imaging showed an irregularly contrast enhancing
lesion extending
into the splenium from the left and also into the atrium with
intraventricular growth. In order to achieve a definitive
histological diagnosis, a serial stereotactic biopsy was
indicated. The patient was informed about the findings and
about all the diagnostic and therapeutic options and agreed to a
stereotactic biopsy on ___ preliminary finding indicate a GBM.
Neurologically the patient remained intact, his incision was
clean and dry. He ambulated without difficulty and tolerated a
regular diet.
He was not able to be seen by Neuro-Onc or Radiation oncology
due to the ___ holiday he will be seen at the ___ on
___.
***. | NERVOUS SYSTEM NEOPLASMS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Patient admitted to Dr. ___ service on ___
for dysphagia, intolerance of foods and nausea/vomiting. Patient
kept NPO. TPN continued to provide nutrition. Nausea controlled
by anti-emetics. Patient's pain controlled with IV narcotics.
Home medications were switched to oral suspensions or chushed
formulations. Pt was discharged home on ___ with home TPN.
***. | 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.
***
Postoperatively Mr. ___ was admitted to the plastic surgery
hand service. He was started on a heparin drip, aspirin and
continued on antibiotics. There was concern for buildup of dried
blood and so the splint dressing was removed and he was dressed
with xeroform. There was concern for venous congestion so he was
started on leech therapy with improvement in venous congestion
of the long finger. The flap and finger remained viable and
without evidence of infection so he was discharged.
***. | SKIN GRAFTS FOR INJURIES 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.
***
___ woman with ___ diabetes with history
of necrotizing fasciitis and diabetic foot ulcers presenting
with osteomyelitis of the R foot s/p debridement by podiatry and
MICU stay, now transferred to the floor for further medical
management.
.
.
#Osteomyelitis/Diabetic foot infection with ___
organism: Her foot infection raises concern for ___
organisms such as C. perfringens. Broad coverage including MRSA,
PSA, and ___ organisms. Vanc/zosyn/clinda started ___, d/c clinda on ___. S/p debridements by podiatry
___ after which infection was noted to be present and
leukocystosis persisting. Patient was taken for BKA ___,
closure ___. WBC decreased significantly after BKA,
antibiotics (zosyn switched to clinda [see below]) were
discontinued on ___, wound healing well without any ___
complications to date.
.
.
#Acute on chronic renal failure: Resolved. Known Stage 4 CKD: Cr
of 3.2 on adm. Baseline Cr ~2.7. Renal US negative for
structural lesion. Renal cosulted throughout admission for
fluctuating renal function due to ___ and ___ thought to be
___ AIN which resolved with discontinuation of zosyn.
Upon discharge, Cr 2.8, back to baseline. Per renal, continue to
monitor renal function weekly.
.
.
#Metabolic Acidosis/uncontrolled DM: ___ followed patient and
adjusted insulin as needed throughout hospital course. Patient
refused to eat diabetic diet and eventually with Psychiatry's
recommendation liberalized her diet so as to ensure her
adherence to other medications and encourage PO intake which was
minimal. Upon discharge, on significantly reduced amounts of
insulin (10 units qHS + sliding scale) due to decreased PO
intake. Continue to encourage PO intake.
.
.
#RUQ/abdominal pain: LFTs within normal limits except for mild
elevated alkaline phosphatase is stable. Abd soft, nondistended,
and pt has regular BMs - unlikely obstruction. UA negative,
culture negative. Patient had stoppped OCPs on admission and
began to have withdrawal bleed with severe abdominal pain. Pain
and symptoms improved with initiation of OCPs. Recommend
returning to home OCP (___) when current cycle is
complete.
.
.
#Asthma: controlled, asymptomatic. continued home Flovent,
albuterol.
.
.
#HTN: Hypertensive, asymptomatic. Labetolol 600mg TID,
amlodipine 10mg daily. Uptitrate labetolol as needed for
improved control. Consider initiation of ___ medication if
persistently hypertensive.
.
.
#ANEMIA: Microcytic, and likely anemia of chronic disease, with
component of kidney disease. Iron studies normal ___ ___. Hcts
were monitored and required transfusion ___ but stabilized.
.
.
# Psych: Initially patient refused to partake ___ most parts of
her care including medications, vital signs and psychiatry was
consulted. There is concern for chronic cognitive delay and
resultant inability to fully appreciate her condition. However
later ___ admission began to participate and was adherent to
treatment plan and engaged with physical therapy and other
caregivers. ___ mother was integral part of good
communication with patient.
.
.
.
# CONSULTS: this hospitalization:
- vascular -outpatient followup
- renal -outpatient followup
- ___ -outpatient followup
- psychiatry -signed off
- nutrition -continue to monitor
- ___ -___ rehab for ___ ___
- podiatry - signed off
Transitional Issues:
- please monitor renal function weekly
- uptitrate BP medications as needed
- continue to monitor UOP
- encourage PO intake and monitor blood glucose
- titrate insulin as needed
- CODE: Full code, confirmed
- Mother ___ followup
- SW support
- PCP followup
- ___ at ___ followup
- Vascular followup
***. | AMPUTATION OF LOWER LIMB FOR ENDOCRINE NUTRITIONAL AND METABOLIC DISORDERS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
*** is a ___ yo woman with T1DM, mild cognitive
impairment, disordered eating, HTN, and repeated hypoglycemic
episodes who presents with a new severe episode of hypoglycemia
leading to a fall with head-strike and is admitted for insulin
titration, ultimately discharged to a psychiatric facility for
further stabilization.
ACUTE ISSUES:
# Type 1 DM w/ hypoglycemia unawareness
# Disordered eating
Patient was admitted due to severe hypoglycemic episodes (BG 30)
with fall and head strike. Her cognitive impairment and
disordered eating (including eating only fruit/protein/veg and
no carbs) likely contribute to the frequency of her hypoglycemic
episodes. She fixates on rare hyperglycemia, with inappropriate
lack of concern about severe hypoglycemia. ___ following and
notes pts fixation on BG levels continues at the hospital and
likely worsening iso decreased personal control over DM
management. She continues to compulsively check BGs and compare
her monitor to finger stick values. Her insight seems
increasingly impaired. Evaluated by psychiatry who feels that
patient does not have capacity and has limited understanding of
the risks associated with hypoglylcemia. On discharge, her
insulin regimen is glargine 7u with breakfast and 3u at dinner,
Humalog 1u:20g ___ to be given post intake, HOLD IF NOT EATING /
RESTRICITING has been typically receiving 2u, Humalog HISS 1u:50
for BG > 150 TID AC, and > 200 at HS for correction. She was
started on Thiamine and MV with minerals after evaluation by
nutrition. She was medically stabilized on this regimen.
However, given concerns for ability to control sugars as
outpatient due to mental illness, patient was discharged to
inpatient psychiatric hospital.
# Mild cognitive impairment
Neuropsych outpatient found decreased ability with fluency and
word-finding. Head CT showed prominence of ventricles and sulci
suggestive of involutional changes slightly advanced for age. SW
evaluated patient and noted that patient has family history of
ALS which has presented atypically in the past with cognitive
decline, for which patient is concerned this is a possible
etiology of her symptoms. She was evaluated by neurology to
determine if there was a neurological deficit contributing to
her poor decision making, though they did not recommend any
additional imaging and recommended follow up with her cognitive
neurologist Dr. ___ discharge.
# Fall with head strike
In the setting of severe hypoglycemia. No focal neurologic
abnormalities. CTH w/o contrast shows no evidence of infarction,
acute hemorrhage, edema, or mass. Prominence of the ventricles
and sulci suggestive of involutional changes, slightly advanced
for age. There is no evidence of acute fracture.
# Code status
The patient stated on interview in the ED that she wants to be
DNR/DNI because she is "severely depressed." Per PCP, has never
mentioned this. Psychiatry discussed this decision with her and
she admitted to having not thought about it until the day of
admission. The patient agreed to defer this decision until there
could be discussion with family and medical providers. When
readdressed the patient and family decided for full code.
# Depression
No thoughts of hurting self or SI but desire for extreme
hypoglycemia suggests otherwise. She has expressed suicidal
ideation in the past. She was maintained on her home Citalopram
and was evaluated by psychiatry. Psychiatry felt that her mental
illness might be contributing to her inability to control her
blood glucose as an outpatient, prompting inpatient psychiatric
hospitalization following medical stabilization.
# Rhabdomyolysis
# Transaminitis
Most likely traumatic due to fall and iso hypoglycemia and
staying on ground for approx. 3 hrs. It was mild ___, she has
no preexisting renal disease, and no evidence of myoglobinuria.
CK and transaminases normalized.
CHRONIC ISSUES:
# Hypertension: Continued on home Valsartan
Transitional Issues:
===============
[] Cognitive neurology follow up with Dr. ___
[] F/U with outpatient ___ provider ___ continued
insulin management
[] Continue psychiatric evaluation and therapy
[] New Medications:
Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
Glucose Gel 15 g PO PRN hypoglycemia protocol
Thiamine 100 mg PO/NG DAILY
[]Stopped medications:
HumaLOG U-100 Insulin (insulin lispro) 100 unit/mL subcutaneous
QACHS
Ibuprofen 600 mg PO QHS:PRN Pain - Mild
Tresiba FlexTouch U-100 (insulin degludec) 100 unit/mL (3 mL)
subcutaneous BID
[]Changed medications:
Multivitamins W/minerals 1 TAB PO/NG DAILY
___ is clinically stable for discharge today. On the
day of discharge, greater than 30 minutes were spent on the
planning, coordination, and communication of the discharge.
***. | DIABETES WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
1. Pancreatic cyst s/p ERCP with fevers: Brushing obtained;
pathology was non-diagnostic. Patient was for the most part
pain free, but with occasional episodes of discomfort. She was
initially kept patient NPO, continue IVF, ADAT in the morning,
and, given sphincterotomy, CBC was followed and was stable. She
was therefore discharged in good condition.
2. HTN: Continued Verapamil; held Lasix while NPO and receiving
IV fluids; held Benicar as it was not on hospital formulary, and
re-started at discharge.
3. Asthma/OSA: Continue CPAP, Advair, Albuterol, Flonase.
4. Hyperlipidemia: Continued Zetia. Patient currently off of
Aspirin; would re-start at discretion of PCP.
***. | DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year old female with stage IIIB gastric cancer with
peritoneal metastases s/p total gastrectomy, recent gastric
outlet obstruction s/p PEJ now admitted with distension,
abdominal pain and pain at PEJ insertion site. Imaging
consistent with SBO (clinically partial SBO), new ascites and
colitis.
# Colitis causing SBO: CT abdomen showed colitis and obstruction
secondary to colitis. Patient was placed on cipro and flagyl for
colitis on admission. Patient was having multiple bowel
movement without blood. Stool studies were sent and C. Diff was
negative. Patient was initiated on TPN. Clinical exam of the
abdomen was trended with improvement during hospitalization.
Tube feeds were trailed at low rate x24hrs and advanced. Tube
feeds were advanced to target rate and TPN was discontinued.
Antibiotics were continued and patient was started on clears by
mouth. Patient was tolerating diet and tube feeds with multiple
bowel movements prior to discharge. She was started on ammonium
with improvement in symptoms and discharged on this regimen PRN.
# Spontaneous bacterial peritonitis: patient had large volume
ascites as seen on CT abdomen. Paracentesis was performed for
diagnostic and therapeutic value. Labs on fluid showed 845 WBCs
with 67% PMNs. Patient was converted from cipro to ceftriaxone
and continued on flagyl for 5 days. Abdominal exam was trended
and fluid wave was minimal at the time of discharge. Patient was
setup for outpatient follow up with her hematologist prior to
discharge.
# Cellulitis: patient had erythema, tenderness, and purulent
discharge at time of admission around PEJ tube. Only superficial
involvement of the cellulitis was seen on CT. Patient was
initiated on Vancomycin at admission, having previously been on
cephalexin since ___. Wound culture showed mixed bacteria
without growth of staph or pseuodomonas. Patient's site
improved with proper wound care, including a wound care consult.
Antibiotics were discontinued prior to discharge and patient's
symptoms and signs of celluitis were improved at the time of
discharge.
# Hepatitis B: this is a chronic issue that is followed by the
patient's hematologist. The patient continued on her entecavir
while admitted and is setup for follow up as above with
hematology.
# Gastric Cancer: patient is s/p total gastrectomy and currently
on ramicurimab. Patient is followed by her outpatient
oncologist, Dr. ___ admitted the patient from her
clinic for this hospitalization.
TRANSITIONAL ISSUES:
- LIVER FOLLOWUP ARRANGED GIVEN NEW ASCITES AND KNOWN HBV
- IRRITATION AROUND J TUBE SITE IMPROVED AT ___; PATIENT HOWEVER
HAS PAIN AT SITE OF J TUBE
***. | ESOPHAGITIS GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
*** y/o M with PMHx of Afib on Coumadin, AS s/p TAVR, CAD s/p
PCI, DVT s/p IVC filter, as well as recurrent GI bleeding, who
presented to OSH with a recurrent GI bleed.
# GI BLEEDING / ACUTE BLOOD LOSS ANEMIA: Received 4 units of
pRBCs. He underwent push enteroscopy with APC of small
angiodysplasias in the stomach and proximal jejunum. He denied
any further episodes of GI bleeding. H/H initially downtrended
after procedure but then stabilized / improved. Anticoagualtion
management discussed below.
# AFIB / DVT: Given his CHADS score as well as his history of
DVT (although he does have IVC filter), he is someone that
should ideally be anticoagulated. However, this is his ___ GIB
in the past year. Cardiology evaluated him to weigh risks /
benefits of a/c. Ultimate recommendation was to stop ASA and
restart coumadin 5 days after stopping ASA, with goal INR range
of ___. On metoprolol and diltiazem for rate control. A
watchman device was considered but not felt to be optimal due to
the dual antiplatelet therapy requirement and his IVV filter.
Should his GI bleeding recur then he will likely need to be
taken off Coumadin and changed back to ASA only.
#Orthostatic hypotension: Noted on the day of discharge and the
day prior to discharge. Was worse in the morning and improved in
the afternoon. The patient noted lightheadedness when this
occurred in the morning. This is most likely multifactorial,
with potential contributions from his alpha blocker, diuretic,
CCB, and BB, and potentially underlying dysautonomia. I
discussed at length with the patient the potential benefit to
remaining in house an additional 24 hours for titration of these
medications but he was adamant about returning home. For now
will discontinue torsemide since he appears euvolemic or
slightly dry and the hypotension occurred in the morning after
his torsemide dose. He will continue monitoring BPs and weights
closely at home. ___ also consider changing alpha blocker in the
future. In addition to ___ he has several closely involved
children and notes that he can stay with them if needed. This
was also discussed extensively with patient's son prior to
discharge, who felt the family would be capable of providing
close support and monitoring at home.
# HYPERNATREMIA: Likely from free water deficit due to being NPO
while at ___ and continuously getting diuresis with
torsemide and furosemide IV per discharge summary. Resolved.
# CKD III: Cr at baseline.
# CAD: S/p PCI in ___ and ___. Mild CP noted after EGD, which
did not recur. Tn mildly elevated but stable.
# CHRONIC DIASTOLIC HEART FAILURE: Was on home torsemide, which
was discontinued for now due to his orthostatic hypotension.
# HYPOTHYROIDISM: On levothyroxine.
# BPH: On finasteride and terazosin.
# GERD: On PPI.
# BORDERLINE DM: Glucose elevated on chem panel. FSBS
100's-220's.
# Constipation: no BMs for several days, patient has discharged
with laxative prescription. As per above he was not amenable to
staying in the hospital
============================================================
Transitional issues:
(1) patient to call ___ on ___ to arrange for PCP and
cardiology appointments
- current plan is Coumadin starting ___, but no aspirin. will
need close monitoring for recurrent GI bleeding, and should this
occur will likely need to have Coumadin stopped and may consider
restarting aspirin
(2) home with ___, close monitoring of INR after restarting
Coumadin on ___
(3) BMP and CBC to be drawn by ___ on ___ for PCP ___
(4) Recommend continued close monitoring of volume status and
BPs/orthostatics. ___ consider discontinuation of terazosin if
continued orthostasis. ___ consider restarting torsemide if
becomes hypervolemic.
(5) Consider checking A1C as outpatient
(6) consider whether to remove IVC filter in the future
============================================================
>30 minutes spent in patient care and coordination of discharge
on ___
***. | MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is a ___ year-old woman with a PMH of decompensated
alcoholic cirrhosis (SBP, ascites, HE), non-variceal UGIB, s/p
RNYGB, prior J-tube, G-tube for enteral feedings, abdominal wall
abscess and EC fistula at prior J-tube insertion site who
presented with
abdominal pain, lower extremity edema, and
anxiety/tremulousness. She was treated for alcohol withdrawal
and underwent imaging which showed no active abdominal
infection.
#Abdominal pain
#Enterocutaneous fistula
Patient presented with diffuse abdominal pain most tender over
RUQ and additionally near wound site. Cholelithiasis on CT
ab/pelvis without cholecystitis. Labs not consistent with
alcoholic hepatitis. Patient empirically started on ceftriaxone
in ED due to concern of infection of enterocutaneous fistula. CT
abdomen with no drainable abscess and ceftriaxone was stopped. A
RUQUS was performed due to cholelithiasis and was without
concerning findings. She received occasional oxycodone for pain.
# Volume Overload
# Lower extremity edema
Patient 246.3 lbs on admission up from 224.2 lbs on discharge in
___ with lower extremity edema. She had not been taking home
torsemide/ spironolactone in setting of eviction. She was
resumed on home torsemide/spironolactone an diuresed well. She
was discharged on Torsemide 60 mg, Spironolactone 50mg daily.
#Alcohol use disorder
#Alcohol withdrawal
Patient denies recent alcohol use though son presented to floor
and informed nursing staff that she has been drinking
excessively daily. Unknown true last use. On presentation she
was tachycardic, anxious, tremulous and with CIWA score > 18
clinically c/w diagnsosis of alcohol withdrawal. She was
maintained on CIWA scale with Ativan which was stopped with
resolution of signs of withdrawal. Thiamine continued. She was
seen by social work.
# EtOH Cirrhosis
# Coagulopathy
# Thrombocytopenia
EtOH cirrhosis complicated by hepatic encephalopathy, SBP, and
ascites. Followed by Dr. ___ B cirrhosis. MELD 13
on admission No sign of hepatic encephalopathy this admission,
she was continued on lactulose 30mL TID and rifaximin 550 BID.
No history of varices in past last EGD ___ with portal
hypertensive gastropathy. Small ascites this admission not
amenable to tap. She was continued on torsemide 60mg and
spironolactone 50 mg. No history of SBP in past.
#Nutrition
Patient s/p Roux-en-y. Previously on tube feeds.
- Continued Thiamine, multivitamins
CHRONIC ISSUES:
===============
# Acute on Chronic Macrocytic Anemia
- at baseline
# Epileptiform seizures
Continued home Keppra 1000 mg PO BID which pt not recently
taking.
# GERD
Continued home omeprazole 40 mg daily.
TRANSITIONAL ISSUES:
====================
[] Please follow up repeat labs in one week, complete metabolic
panel after resuming home diuretics.
[] Continue to assess for signs of volume overload, adjust
diuretics as needed.
[] Please evaluate abdominal enterocutaneous fistula site for
signs of erythema
Full Code
HCP: Mother, Father, ___ ___
***. | 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.
***SSESSMENT & PLAN:
=====================
___ female with history of ETOH cirrhosis c/b ascites,
SBP and hepatic encephalopathy, h/o morbid obesity s/p gastric
bypass, prior alcoholic hepatitis, prior PICC-associated DVT,
who presented with upper extremity swelling, found to have PE
and RLE DVT. Course c/b volume overload with ongoing active
diuresis and malnutrition s/p post pyloric dobhoff placement and
initiation of tube feeds. She was seen by Psychiatry, who
recommended inpatient psychiatric hospitalization for management
of eating disorder/OCD-related malnutrition. She was discharged
from the Medicine service to the inpatient Psychiatry floor.
ACTIVE PROBLEMS:
================
#PE/DVT
Patient presented with upper extremity swelling and dyspnea,
found to have bilateral PE's and RLE DVT thought to be secondary
to prothrombotic state in cirrhosis. Otherwise patient without
other clear inciting factors (no recent travel or immobilization
or surgery). At the time of presentation, patient was HDS and
had negative trop, BNP 353. RUQ U/S on ___ was without e/o
liver mass, making HCC less likely. TTE performed ___ was
without concerning findings; however, the study was limited due
to patient declining the study. Patient was initiated on
apixaban at a loading dose of 10 mg PO BID and transitioned to
maintenance dose of 5 mg PO BID. Patient was monitored on
telemetry with persistent tachycardia noted that worsened with
movement, but no additional events. Dopplers for lower extremity
pulses demonstrated equal ___ pulses in bilateral lower
extremities. Compression stockings were encouraged.
#Malnutrition
Patient presented with albumin 1.2. Nutrition was consulted with
concern for severe malnourishment and recommendation for tube
feeds. NJ tube was placed under endoscopic guidance on ___
without complications, and tube feeds were initiated. The NJ
tube unfortunately clogged on ___ and ___, requiring
replacement under endoscopic guidance in both cases. Psychiatry
was consulted per patient request. Per Psychiatry, etiology of
malnourishment thought to be partly psychiatric in nature with
OCD-like component and eating disorder NOS with limited ability
to take PO's in the community. Psychiatry strongly recommended
inpatient psychiatric hospitalization. She was started on
Lexapro and uptitrated to Lexapro 15mg daily. Patient is willing
to continue tube feeding to maintain nutrition and thus was not
deemed necessary for ___ placement. She was discharged to
the ___ inpatient psychiatry unit.
#ETOH cirrhosis
___ B. Cirrhosis has been c/b SBP, HE, and ascites in the
past with no evidence of esophageal varices on EGD x3 during
this hospitalization. RUQ ultrasound showed moderate ascites,
but she was non-distended on exam, so paracentesis was deferred.
She was continued on home Lasix and spironolactone with
intermittent boluses of IV Lasix for ___ edema with midodrine and
albumin due to mild hypotension with diuresis. She was
discharged on PO Lasix 40mg daily and spironolactone 50mg daily.
She was additionally continued on lactulose 45mL TID titrated to
goal of ___ bowel movements/day and ciprofloxacin 500mg daily
for SBP prophylaxis.
#Sinus tachycardia, mild
Etiology likely ___ advanced cirrhosis and malnourished state.
EKG on ___ with sinus tach and no other concerning findings,
QTc 425. Chronic issue since at least ___. Remains
asymptomatic.
#Asymptomatic pyuria
Admission UA showed moderate leuks and few bacteria with 1
epithelial cell. Patient denied urinary symptoms, and
antibiotics were deferred.
CHRONIC PROBLEMS:
=================
#Mood disorder
Psychiatry was consulted per patient request with concern for
possible eating disorder or low appetite secondary to
depression. Per Psychiatry, malnutrition likely related to
depression and anxiety. Patient should continue on Adderall and
Lexapro 15mg qHS. Please continue to monitor QTc's.
#H/o opioid use disorder
- continued home suboxone
#Housing concerns
Social Work consulted; please continue to provide resources as
needed.
TRANSITIONAL ISSUES:
==================
[] Please continue to monitor blood pressures as patient remains
on diuretics (lasix and spironolactone).
[] Please continue to monitor tube feed and PO intake.
[] Please continue to work with the patient to address any
housing concerns.
[] Please continue to monitor QTc intervals while on
QTc-prolonging medications.
Tube feeding orders per Nutrition:
Continuous tubefeeding: Start ___ Osmolite 1.5 Cal; Full
strength
Tube Type: ___ post-pyloric (ppft); Placement confirmed.
Starting rate:55 ml/hr; Advance rate by 10 ml q6h Goal rate:75
ml/hr
Cycle?: Yes Cycle start:1800 Cycle end:0800
Residual Check: Not indicated for tube type
Flush w/ 30 mL water Per standard
Free water amount: 50 mL; Free water frequency:Q6H
***. | PULMONARY EMBOLISM WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
This is a ___ gentleman with a pmhx. significant for
HIV, HCV, GI bleed in ___, and DM who is admitted after
injecting himself with sudafed for LUE cellulitis and DVT.
.
# LEFT UPPER EXTREMITY CELLULITIS: Patient injected himself with
sudafed while intoxicated. He was initially covered with
vancomycin, cefepime, and flagyl. He remained afebrile and
white count stabilized, thus he was transitioned to PO
doxycycline and keflex for total 7 day course (Last day of
antibiotics ___. The area of erythema had receeded and
resolved by the time of discharge.
.
# LUE DVT: Patient with DVT in left upper extremity. He was
started on lovenox twice a day and will likely continue on
lovenox for a total 6 week course, to be dictated by his PCP.
.
# ETOH USE: Patient admits that his last drink 24 hours prior to
admission. On admission, he did exhibit signs of alcohol
withdrawl. He was placed on a CIWA scale with valium 10 mg
every 3 hours for CIWA scores > 10. By the time of discharge,
patient was scoring on CIWA ___, reprting mostly anxiety,
sweats, and nausea, especially upon waking up in the AM. On
discharge, was taken off CIWA scale due to low scores and valium
was discontinued. He will be discharged with follow-up tomorrow
at the ___ Program.
.
# HIV: Continued home medications.
.
# DEPRESSION/ANXIETY/INSOMNIA: Continued venlaflaxine, ambien
for insomnia. Patient had previously been taking klonopin 2 mg
twice a day for acute anxiety. Continued klonopin at this dose.
.
# HYPERLIPIDEMIA: Continued atorvastatin
.
# HYPERTENSION: Continued home medications
.
# CHRONIC PAIN: Continued gabapentin
***. | CELLULITIS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
MEDICAL COURSE:
___ y/o female admitted on ___ to ___ following a fall
found to be in A fib with RVR and low normal pressures, admitted
to ___ for definitive care of AFib, found to have
significantly decreased EF, 3-vessel CAD and severe AS.
Diagnoses:
# Systolic Congestive Heart Failure: Apparently just diagnosed
at the outside hospital that she was transferred from. BNP of
2,134. EF on repeat Echo here significantly decreased EF at
___. She was also clinically in CHF with peripheral edema,
crackles on lung exam, overloaded CXR and DOE. During her stay
she was gently diuresed but diuresis was difficult at times
because occasionally her pressures drop and/or her Cr would bump
up a bit. For this reason she was gently but steadily diuresed
with spironolactone and IV Lasix. On the days prior to planned
surgery she was almost euvolemic (peripheral edema better, still
with some bibasilar rales). At that time she was down about 6
Kilos since admission.
# Aortic Stenosis: Pt had known AS but Cardiac cath showed that
this has continued to worsen. Valve gradient of 35 mm Hg.
Valve area estimated 0.6 cm2 on cath. AS is severe. Will
likely need AVR if she can tolerate the procedure. NTG was held
during her stay as she was very preload dependent. Cardiac
surgery saw and evaluated the patient and decided that aortic
valve replacement was the best option for her at this time.
# Coronary Artery Disease: Ruled out for MI at outside hospital.
Patient has strong risk factor history. Cath showed 3 vessel
disease most appropriate for CABG. For this reason they decided
to plan CABG at the same time as AVR.
# Afib: Pt was admitted in atrial fibrillation. Report from the
OSH was that his was new and she may need to be cardioverted.
Upon further chart biopsy we found out she has been in atrial
fibrillation for a long time and that cardioversion was not the
best option at this time. Initially her beta blockade was
titrated up for rate control. Because there was concern that
her beta blockade may be contributing to decreased cardiac
output her beta blockade was titrated down and digoxin was
started. She has been adequately rate controlled on Metoprolol
and Digoxin since that time. As far as her anticoagulation she
was admitted on Dabigatran and this medication was continued
throughout her admission.
# Transamnitis: Exact etiology unknown but likely caused by
hepatic congestion ___ poor forward flow. LFT's were trended
during this admission and trended back down nicely. She did not
have any RUQ tenderness or signs of systemic infection during
her stay. Given the rise in her LFT's her methimazole and
Statin were held for a period of time but restarted when her
LFT's had come back down.
# Cough: Pt complained of cough on admission. Etiology unclear.
___ have been related to her CHF. No white count. Afebrile.
Cxr w/o failure or PNA. This symptom resolved after several
days.
# Hypotension: SBP to the 90's per report on admission. Pt was
not hypotensive at all during this admission.
# Fall: Initial presenting complain to OSH. Unclear etiology
but sounds Mechanical vs. syncope. Unclear story. Sounds like
she may have been on a lot of sedative medications. Syncopal
etiology concerning for AS. Sedative medications minimized
during her stay.
# Type II Diabetes Mellitus: Home medications were held during
this admission and her glucose was adequately controlled with
sliding scale insulin.
# Hyperthyroidism. Patient has history of hyperthyroidism with
a goiter. TSH within normal limits. Thyroid function tests
were rechecked later in admission because we were holding her
methimazole for a few days. These tests showed...
# Depression: Patient did not complain of symptoms during her
stay. She was maintained on her home citalopram.
# RCC s/p radiation in ___: Not addressed during this admission.
# 7 mm pancreatic head cyst: Not addressed during this
admission.
# Hip Pain: No fractures per report. Pt was given acetaminophen
as needed for pain.
# Right Foot Cellulitis: Reportedly diagnosed as an outpatient.
Treated with Keflex for unknown duration at OSH. Patient does
not appear to have cellulitis at this time. No antibiotics
given during this stay.
SURGICAL COURSE:
On ___ Mrs. ___ was brought to the operating room where
she underwent an aortic valve replacement and coronary artery
bypass graft x 3. Please see operative note for surgical
details. Following surgery she was transferred to the CVICU for
invasive monitoring in stable condition. Within 24 hours she was
weaned from sedation, awoke neurologically intact and extubated.
She did require pressor/inotrope support initially and these
medications were weaned off on post-op day one. On
post-operative day one she was started on beta-blockers and
diuretics and diuresed towards her pre-op weight. Post-op she
remained in atrial fibrillation (history of) and later in
post-op course (day 4) was started back on Dabigatran. Later on
this day she was transferred to the step-down unit for further
care. Chest tubes and epicardial pacing wires were removed per
protocol. During her post-op course she worked with physical
therapy for strength and mobility. She continued to make steady
progress without complications and on post-op day five she was
discharged to rehab facility with the appropriate medications
and follow-up appointments.
***. | CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient was brought to the Operating Room on ___ where
the patient underwent Redo, TVR(___ ___ epic) RV epicardial
Lead placement with Dr. ___. Also, the right ventricular lead
was removed from the right ventricle to allow for the proper
seeding of the valve and the end of the lead was loosely tacked
to the thick part of the arterial wall, very superficially to
enable removal if needed. Prevena placed to optimize wound
healing.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight. The
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication.
She underwent extraction of RV lead on ___ which she
tolerated well. PPM interrogated post-op. The patient was
evaluated by the Physical Therapy service for assistance with
strength and mobility. By the time of discharge on POD 6 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
home in good condition with appropriate follow up instructions.
***. | CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT 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.
***
OVERDOSE/SUICIDE ATTEMPT/DEPRESSION/ANXIETY: possible suicide
attempt, his mood disorder is unstable and required 1:1 sitter
and psychiatry was consulted. Given his mood disorder
(depression, anxiety) as well as substance abuse and possible
suicide attempt the consulting psychiatrist filled out a ___ form and recommended inpatient psychiatric admission. All of
the patient's psychotropic medications were held with a plan of
re-initiation of a new regimen inpt psych.
ETOH ABUSE: The patient was started on valium prn for CIWA > 10
for ETOH withdrawal but showed no significant signs of ETOH
withdrawal. He was given thiamine and folate.
ASPIRATION: likely aspiration in the setting of self extubation.
No fever and no cough so likely uncomplicated aspiration
without pneumonia.
***. | POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mrs. ___ was admitted following her cardiac cath on ___
which revealed no coronary artery disease. Upon admission she
underwent routine pre-operative work-up. On ___ she was brought
to the operating room where she underwent an aortic valve
replacement. Please see operative note for surgical details.
Following surgery she was transferred to the CVICU for invasive
monitoring in stable condition. Later this day she was weaned
from sedation, awoke neurologically intact and extubated.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable on Nitro gtt only. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. The nitro gtt was weaned off. He first
night post-op she developed slow afib associated with 4.5 sec
pause requiring VVI pacing at times, and Lopressor was
discontinued. She was seen by the EP department who recommended
no nodal agents and decreased pacemaker back-up and continued to
evaluate. She was started on Coumadin for her afib. Her INR
quickly uptrended and it was held for ___ hours in order to
remove epicardial wires safely. Her baseline creatinine is 1.0
and it peaked at 1.8 post-operatively. Lasix was adjusted but
eventually dc'd ___ to back rash and elevated creatinine.
Creatinine has remained 1.7-1.8. Avoiding nephrotoxic agents,
voiding adequate urine. Her renal function will need to be
monitored closely while at rehab. The patient transferred
without incident to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. Her SVH site
appeared reddened but has improved in appearance, pettechiae
noted only, without signs of infection. By the time of
discharge on POD 7 the patient was ambulating with assistance,
her wounds were healing and pain was controlled with oral
analgesics. The patient was discharged Life Care of ___ 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.
***
Mr. ___ is a ___ year old male with a history of NASH
cirrhosis and ascites, with a recent admission on ___ for
diuretic-refractory ascites and discharged with a plan for
weekly therapeutic paracenteses, who now presents with further
ascites, hyperkalemia and ___.
ACTIVE ISSUES:
==============
# Acute kidney injury
Patient presented with creatinine to 2.4 above recent discharge
value of 1.2. He was given an albumin challenge for two days
with minimal improvement in his creatinine, initially thought to
indicate hepatorenal syndrome; he was subsequently started on
octreotide and midodrine. His creatinine slowly began to improve
and the midodrine and octreotide were discontinued. He was
treated with albumin daily. His home diuretics were held and he
was instructed to hold his home diuretics until he follows up
with his hepatologist as an outpatient.
# NASH cirrhosis complicated by refractory ascites
# Dyspnea
Patient has history of cirrhosis and large volume ascites,
recently found to be refractory to diuretics. He presented after
a large-volume paracentiesis that was complicated by acute
kidney injury (see above). He then developed worsening dyspnea
that improved after therapeutic paracentesis on ___ and ___.
Fluid counts were initially concerning for peritonitis so the
patient was started on ceftriaxone. Antibiotics were
subsequently discontinued after repeat fluid counts were
reassuring.
# Atrial fibrillation
Patient has a history of atrial fibrillation well controlled
with sotalol. His home sotalol was held on admission in the
setting of his acute kidney injury. On ___, patient was
triggered for atrial fibrillation with rapid ventricular
response with heart rates 160-180. He was treated with IV
metoprolol, oral metoprolol, and albumin with subsequent
improvement in his heart rate. His home rivaroxaban was
initially held in the setting of his acute kidney injury, but he
was re-started on apixiban 5mg BID on ___. On discharge his
heart rates were stable in the ___ and ___ and he was on
metoprolol 25mg QID. We consolidated his short acting metoprolol
to 1005mg XL once daily on the day of discharge.
# Anemia
Patient has macrocytic anemia at baseline, but presented with
worsening anemia. He had no evidence of active bleeding and
stool guiac was negative. His anemia was thought to be
dilutional in the setting of receiving an albumin challenge (see
above). He received a blood transfusion on ___ and on the day
of discharge on ___ and his hemoglobin was subsequently
stable.
# Hyperkalemia
Patient presented with hyperkalemia in the setting of new ___
(see above). He had no EKG changes on admission and was managed
in MICU with albuterol nebulizers, insulin, dextrose, lasix, and
kayexalate. On the floor, he was treated with lactulose and his
potassium subsequently normalized. His home diuretics were held.
# Hyponatremia
Patient presented with low sodium, thought to be in the setting
of low circulating volume. His sodium improved after albumin
administration.
# Coagulopathy
Patient presented with worsening coagulopathy thought to be in
the setting of worsening synthetic function. His MELD score is
26. He had no evidence of active bleeding and his labs were
monitored daily.
CHRONIC/STABLE ISSUES:
=======================
# NIDDM
Home metformin and glipizide was held and patient was treated
with insulin sliding scale.
# HLD
Continued home atorvastatin and aspirin 81mg
TRANSITIONAL ISSUES:
====================
[ ] New medications: Metoprolol XL 100mg Succinate once daily,
Apixiban 5mg PO BID, lactulose 15ml as needed to ensure ___
bowel movements per day
[ ] Held medications: Sotalol 120mg PO BID, Rivaroxaban 20mg PO
daily
[ ] Held Diuretics: spironolactone and furosemide and discharged
off of all diuretics
[ ] Patient will need outpatient paracentesis once weekly by ___.
Order has been placed.
[ ] Noted to have RLL lung nodule measured 1.6 cm on imaging.
Recommend f/u with PCP to discuss further imaging with CT chest
Follow up with Dr. ___ in ___ weeks (scheduled, see above)
***. | CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ yo woman w/Afib and history of recent right temporo-parietal
infarct presenting with seizure. The seizure reportedly started
in her left arm, and then generalized, requiring a large amount
of Ativan to finally break. In that context she was intubated
for airway protection, and transferred to ___. As she had a
history of a stroke in ___, and had recently been restarted
on Coumadin, there was some concern that she may have developed
hemorrhagic conversion of her prior stroke, however she had a
head CT with no sign of hemorrhage. She was started on keppra
for prevention of further seizures. She was successfully
extubated on ___, and after extensive discussion with her
family it was confirmed that her wishes were to be DNR/DNI.
Later that evening she developed increasing respiratory
distress, and a repeat chest x-ray showed near collapse of her
left lung, which was suspected to be due to mucous plugging. At
this time she also became febrile and hypotensive, and was
started on broad spectrum antibiotics. The option of a
bronchoscopy was discussed with the family, however after
extended discussion, it was decided that the patient's wishes at
this time would be to not undergo any further aggressive
intervention, and she was made CMO. She was transferred to the
floor, and passed away on ___ with her family at the bedside.
***. | SEIZURES WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is a ___ year old male with no significant past
medical history who presented with fever, chest pain, and
unintentional weight loss. Ultimately was found to have
bilateral hilar lymphadenopathy on imaging of unknown etiology.
# Bilateral hilar lymphadenopathy: Patient presented with fever,
bilateral hilar lymphadenopathy, chest pain and unintentional
weight loss concerning for sarcoidosis vs. infection vs.
lymphoma. Clinical suspicion for tuberculosis was low at the
time of presentation. Patient underwent an endobronchial
ultrasound on ___ and preliminary results showed noncaseating
granulomas, concerning for sarcoidosis vs. infection. Suspicion
for lymphoma was low based on preliminary results, however
pathology reports were not final at time of discharge.
Histoplasma urinary antigen was negative. Acid fast bacilli
stains were negative x 2 with culture pending. PPD was negative.
HIV antibody was negative. ACE, Blastomycosis antibody, and
Histoplasma antibody were pending at discharge. Patient has
close follow-up with his primary care doctor at which point
final pathology reports and pending labs should be reviewed. He
also has follow up with Pulmonology. His fevers and chills
resolved prior to discharge.
# Chest pain: thought to be due to enlarged hilar lymph nodes
encroaching on his pericardium. His ECG on admission was normal.
Cardiac biomarkers were negative. CTA chest was negative for
pulmonary embolus or dissection. His chest pain was managed with
PO opioids and completely resolved prior to discharge.
# Flank rash: Pruritic rash appeared on the patient's left flank
briefly with chills, most likely due to miliaria. Other
etiologies included drug eruption v. contact dermatitis. Rash
improved with sarna lotion and TAC cream BID.
# Anemia: The patient was found to have a normocytic anemia with
hemoglobin 12.9 which was stable throughout his admission.
Although iron studies were not performed, this was thought to be
due to anemia of chronic inflammation.
TRANSITIONAL ISSUES
- Lymph node biopsy results were pending at the time of
discharge. These will need to be followed up.
- ACE level pending at time of discharge
- Serum histoplasma and blastomycosis serologies pending
- Recommend considering TTE and cardiac MRI for sarcoid work-up
if this is ultimately diagnosed, and given chest pain
- Follow up acid fast bacilli culture
***. | OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
*** yo M w/ no CAD but diastolic CHF, hx of afib s/p AVR and
aortic aneurysm dissection, s/p Liver/Kidney transplant ___ and
variceal bleeding now presents from OSH for an evaluation of
dyspnea on exertion.
.
# CP/DOE. This is a new phenomenon for him and is associated
with exertion. Most likely explanation for this man is chest
pressure/SOB due to tachycardia in setting of known dCHF and
impaired filling causing worsening LV wall stress resulting in
chest pressure. This is consistent with his normal C.Cath in
___. THe ECG changes are likely related to rate related
conduction delay. However, he has HTN/HL and hx of CKD s/p
transplant. The fact that he is having sx at rates of 120
suggests that there may be some CAD, likely small/distal dz. He
is sx free at this time. TTE suggested no wall motion
abnormalities with diastolic dysfunction and small left
ventricular cavity. His cardiac enzymes were normal. He was
started on metoprolol succinate for rate control. Will obtain
stress echo as outpatient with Dr. ___ work-up of possible
CAD.
.
# PUMP: chronic dCHF, did not appear to be in acute heart
failure. His losartan was continued, and metoprolol was started.
Lasix was discontinued.
.
# s/p Liver/Renal transplant. No evidence of ascites on exam.
Continued tacrolimus. His tacrolimus level was found to be
slightly low at 3.8 and it was suggested that he follow up with
transplant. LFTs and synthetic function labs were not
substantially elevated.
.
# Pancreatitis. Resolving. Was not an active issue. His lipase
and amylase were trending down.
.
PROPHYLAXIS:
-DVT ppx with hep. SC.
-Pain management with Tylenol prn
-Bowel regimen with Senna/colace
.
CODE: confirmed full
Transitional issues:
-Diastolic dysfunction: Has very small left ventricular cavity
seen on TTE, and may have LVOT obstruction at higher rates -
this is the likely mechanism for his dyspnea on exertion. He
was started on metoprolol. His lasix was discontinued and he
was instructed to stop taking it.
-HTN: He was started on metoprolol and losartan was continued
***. | HEART FAILURE AND SHOCK WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ who presented ___ for elective C4 corpectomy and C3-5
anterior fusion. Please see separate operative report by Dr.
___ more information.
#Cervical Stenosis w/Myelopathy
Now s/p corpectomy/ACDF. The patient was under close
surveillance with Q4H neuro-checks. The surgical drain was
removed on ___ without issue or complication and post pull
x-rays demonstrate no residual catheter. The patient's foley
catheter was removed and he was voiding without issue.
#Mobility
___ evaluated the patient and recommended rehab placement.
***. | 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.
***
Ms. ___ presented to the ___ emergency department on
___ via transfer from ___. She
suffered a right open tib/fib fracture and a left ankle
fracture. She was admitted, consented, and prepped for surgery.
Later that day she was taken to the operating room and
underwent an I&D with IM nail to her right tibia and an ORIF of
her left ankle fracture. She tolerated the procedure well, was
extubated, and then transferred to the recovery room. In the
recovery room she was noted to have two episodes of sinus
tachycardia to 150's which resolved with esmolol. She was
transferred to the floor for further care. On ___ she was
transfused with a total of 4 units of packed red blood cells due
to acute blood loss anemia. She was seen by physical therapy to
improve her strength and mobility. On ___ she became sinus
tachycardic to 140's with SBP in 120's without ST changes on
EKG. She received IVF and Lopressor 2.5mg IV push with return
to normal HR. Medicine consult evaluated her tachycardia as
secondary to poor PO hydration. On ___, she was discharged
to rehabilitation facility in stable condition.
***. | 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.
***
SUMMARY:
___ is a ___ yo M with dementia (unknown type), major
depressive disorder, primary hyperaldosteronism, and HTN who was
brought to the ED from ___ (where he was
living) due to agitation and functional decline.
HOSPITAL COURSE BY PROBLEM:
# Severe dementia (unknown type) with behavioral disturbance
He was sent to the ED by his nursing home due to behavioral
disturbance. Overnight in the ED he had episodes of agitation
requiring IM Haldol. He was seen by Psychiatry who recommended
starting Depakote and trazodone and continuing his other home
psych meds (sertraline, olanzapine). He was placed on a ___ given his inability to care for himself and episodes of
agitation. He was admitted to medicine for placement in a
___ ___ facility as his living facility refused to
take him back due to aggressive behavior.
After his admission to medicine, he was calm and cooperative,
though intermittently restless (making his bed over and over,
pacing) and impulsive (would occasionally wander out of his
room). Psychiatry titrated the newly started Depakote and
trazodone. The patient's behaviors stabilized and he was calm
and cooperative as above. ___ was removed.
Later in the hospitalization, he had recurrence of
impulsivity and psych was reconsulted. Valproic acid was
increased from 75 to 100 mg QHS. A valproic acid level can be
checked at ___. He was cooperative and redirectable on the day
of discharge.
# ___
Cr on admission was 1.6 from baseline ~1.1. Urine Na was <20;
most likely this was prerenal ___. His Cr improved to baseline
after he was given IV fluids and encouraged to drink. His home
lisinopril and eplerenone were initially held in the setting of
___.
# Primary hypertension
# Primary hyperaldosteronism
# Hypernatremia
His home home hydralazine, nifedipine were continued. As above
his home lisinopril and eplerenone were initially held due to
___. Ultimately lisinopril was withheld. Eplerenone was held
until the date of discharge. He had elevated Na which will
respond to the eplernone - which would address the
hyperaldosteronism related hypernatremia.
# HLD
Held home atorvastatin while in house to decrease pill burden;
resumed on discharge.
>30 minutes spent on complex discharge
***. | ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
A/P: ___ with ESRD on HD, HTN, DM2, PAD, CMML, diastolic
dysfunction presented with pleural effusion. Decompensated in
setting of SVT during dialysis, now resolved.
.
On the day of admission, while at HD, the pt became very
tachycardic (SVT to the 150s, ? atrial flutter) and had
associated chest pain radiating to the jaw and diaphroesis. His
tachycardia converted back to sinus rhythm.
.
He underwent thoracentesis ___. Results were consistent with an
exudative pleural effusion. Repeat chest CT demonstrated
persistent pleural effusion, and a CTA on the day of transfer to
the ICU demonstrated significant interval increase in pleural
effusion with almost complete atelectasis of the RLL.
.
Upon transfer to the ICU, the pt did not have any complaints
other than some mild wheezing. He denied chest or jaw pain,
shortness of breath, diaphroesis or nausea.
.
#Pleural effusion: Was found to be exudative by Light's
criteria. Ddx included PE, TB, malignancy, parapneumonic
effusion, hemothorax. There was no evidence of PE on CTA. He had
a significant travel history, but reports a negative PPD in the
past. This, coupled with the lack of cavitary lesion(s) on CT,
makes TB unlikely. There was no pneumonic infiltrate, no fever
and no white count to suggest an underlying pneumonia. His Hct
has been stable, although the fluid did reaccumulate so fast
that a hemothorax ___ a complication of the initial
thoracentesis. Given his significant smoking hx, malignancy is
high on the differential. Exactly why the effusion reaccumulated
so quickly is unclear, although it does suggest a possible
hemothorax.
IP performed thoracentesis with chest tube placement and
obtained 1.5L of red/blood-like fluid he was then taken to the
OR one day later for VATs.
While in the ICU he became hypotensive to ___'s requiring 3L of
IVF and also was noticed to have a HCT to 24 for which he was
transfused 2 units PRBCs. He was started on vanc/zosyn for broad
coverage but this was discontinued after his BP stabilized and
there was no evidence of infection. In addition CXR showed
possible recumulation of fluid in the R.lung field.
His vitals stabilized and he was transferred to the medical
floor where he remained on 2l nc. He had his chest tube removed
without inciddent and a follow up CXR did not show
reaccumulation.
Wet read on his pathology from VATS showed reactive
histiocytosis, fibrinous changes, no evidence of CMML
involvement or pulmonary/mesothelial malignancy.
.
#hypotension-pt was hypotensive to ___'s one night in ICU after
HD and after OR procedures. Etiology likely secondary to
hypovolemia. Other possibilities included infection/sepsis
and/or med effect from OR. He was temporarily on broad spectrum
antibiotics but they were discontinued after his cultures were
negative.
He was given midodrine prior to HD and did well. He continued
to be normotensive for the duration of his hospitalization.
.
#atrial flutter: Pt had chest discomfort, jaw pain when HD
began, HR increased to SVT at 150s (likely atrial flutter). SVT
broke spontaneously, and pt's sxs improved with SL nitro and
morphine. Blood pressure was stable throughout. That his sxs
appear to correlate with his atrial flutter would suggest demand
ischemia. There are no ischemic changes on EKG, and his cardiac
enzymes are at his baseline. A primary coronary process such as
plaque rupture is unlikely, and I suspect that his sxs were
related to his rate.
.
#NSVT-pt had a 40 beat run of NSVT, asymptomatic,
hemodynamically stable. EKG was done with no ischemic changes.
His lytes were closely monitored and aggressively repleted. He
had an echo to look for wall motion abnormalities, which showed
an EF of >55%, no new wall motion abnormalities.
This dc summary will be faxed to his PCP and will need to have
cards follow up
.
# ESRD: Has not been able to undergo adequate HD sessions due to
atypical CP and then hypotension recently. He started receiving
midodrine prior to HD and tolerated HD well. He was continued
Nephrocaps, sevelamer, calcium acetate
-needs one unit of PRBCs and iron studies as per renal on day of
discharge
.
# DM2: He was continued NPH at reduced dose (10 qhs) and sliding
scale.
.
# CMML: not active, unlikely to cause pleural effusion
.
# RLS: continued ropinirole 0.25 bid
.
# FEN/Lytes: Diabetic, cardiac, renal diet replete lytes prn
.
# Prophylaxis: Heparin SC 5000 tid, on home PPI, bowel reg
.
# Code status: FULL CODE
*********
On day of discharge pt's WBC 16, had been fluctuating during
hospitalization, possibly due to CMML.
.
.
***. | 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.
***
___ G2P0 with hx epilepsy, Anticardiolipin antibody admitted
at 26+2 weeks after an episode of epistaxis and a witnessed
seizure. Her seizure was typical for her and resolved with 1mg
of Ativan. Neurology was consulted and followed her closely. She
had a normal neurological exam and a negative head CT. They did
not recommend any AED's and recommended that she followup with
her epileptologist. (See consult note in OMR for details). She
was admitted to the antepartum service for observation. She was
normotensive and without any evidence of preeclampsia by
negative labs and 24 hour urine. Fetal testing was reassuring.
She was not contracting. Ultrasound on ___ revealed a breech
fetus, BPP ___, normal AFI, and EFW 1245g(84%). MFM was
consulted and recommended discontinuing the aspirin, recheck EFW
in 4 weeks, and weekly ATU testing beginning at 32 weeks. In
addition, iron studies and iron supplementation was recommended
given her anemia. She was discharged home on ___ in stable
condition.
***. | OTHER ANTEPARTUM DIAGNOSES WITH MEDICAL COMPLICATIONS |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient presented to the emergency department and was
evaluated by the hand surgery team. The patient was found to
have near complete amputation of the left thumb at the level of
the IP joint status post saw injury and was admitted to the hand
surgery service. The patient was taken to the operating room on
___ for open reduction internal fixation, with extensor
pollicis longus and flexor pollicis longus repair, as well as
repair of the radial digital nerve with allograft, and
revascularization of the radial digital artery via vein graft to
the left thumb, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing to the left hand, and will be discharged on
aspirin 162 mg daily for 4 weeks for DVT prophylaxis. The
patient will follow up in the Hand Fellow's Clinic per routine.
A thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
***. | HAND PROCEDURES FOR INJURIES |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Assessment/Plan:
Pt is a ___ y.o female with h.o metastatic colon cancer with
known metastasis to the liver, depression, who presented with
weakness and was found to have cholangitis and enterococcal and
strep viridans sepsis.
.
#Sepsis-due to polymicrobial bacteremia (VRE, strep viridans)
and due to cholangitis/biliary obstruction. Pt was found to have
fever, RUQ pain, transaminitis and bile duct obstruction. She
was started on cipro and flagyl upon admission as well as IV
vanco given her recent instrumentation/ERCP at OSH 1 month ago
with stent pull. Pt underwent an ERCP on ___ finding biliary pus
and a large obstructing stone that could not be removed. A
plastic stent was placed. Pt will need a repeat ERCP in ___ for stent extraction. The day of pt's
ERCP, she developed severe sepsis and required many liters of
IVF. She was transferred to the ICU after the ERCP for further
monitoring. In the ICU, pt received continued aggressive IVFs.
Her BP improved and she was then transferred back to the medical
floor. Initial BCX from the periphery grew strep viridans and
another BCX in the setting of hypotension grew VRE from the port
sample. AFter this, the ID service was consulted. The final ID
recommendation was to place pt on IV daptomycin during admission
and switch to linezolid to complete a 2 week total course for
bacteremia (600mg linezolid BID), 11 more days after discharge.
Port/line infection was considered. However, only 1 blood
culture from the line was positive with subsequent cultures
negative and prior cx's negative. It was not recommended that
the patient have her line/port removed at this time unless
subsequent cultures return positive. Pt will be treated with
cipro/flagyl for 10 days for cholangitis. TTE did not show
endocarditis. LFTs improved as did jaundice.
-would recommend weekly cbc, lfts, chem 7 while on linezolid and
given recent cholangits.
MONITOR CLOSELY FOR SEROTONIN SYNDROME WHILE ___ IS ON LINEZOLID
AND SSRI
.
#biliary obstruction/obstructive jaundice/transaminitis-Pt with
known liver mets and history of cholangitis/cholelithiasis. Pt
presented this admission with sepsis and cholangitis. The
physicians at ___ had been recommending that the patient undergo
consultation with Dr. ___ at ___ for consideration of CCY
and ?hepatic metastasis resection. MRCP was performed showing
progression of hepatic metastasis as well as cholelithiasis and
biliary sludge. The patient was discussed at hepatobiliary
surgical conference. The team will likely be performing a CCY in
the outpatient setting after treatment for
cholangitis/bacteremia. The appointment has been set up with Dr.
___. Pt will need a repeat ERCP in 1 month's time
for stent extraction at ___.
.
#metastatic colon cancer-s/p resection, urostomy, ileostomy-Pt
is no longer on chemo x 6 months. MRCP and U/S revealed the
presence of hepatic metastasis. Pt should follow up with her
outpatient oncologist for further care.
.
#Urinary tract infection-Pt treated with ciprofloxacin.
.
#non-gap metabolic acidosis-resolved
.
#anemia, normocytic-no current suggestion of active bleeding.
Anemia worsened after agressive IVF. HCT upon discharge 24.3. No
signs of active bleeding during admission.
.
#seizure d/o-continued keppra.
.
#depression/anxiety-continued venlafaxine/clonazepam. Social
work was consulted.
PLEASE MONITOR FOR SEROTONIN SYNDROME WHILE ___ IS ON AN SSRI
.
#FEN-regular low fat
.
#ppx-hep SC TID
.
#access-PIV
.
#communication-letter sent to PCP, ERCP ___
HCP ___
.
#code-full, discussed with pt and HCP
***. | 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 an ___ yo woman with stage IIIb lung cancer along
with dCHF, hypertension, and ?COPD who presents to the ED with
several days of cough, shortness of breath, and fever found to
have health care associated pneumonia.
ACTIVE ISSUES
#. HCAP: Given acute onset and concurrent fever, acute
respiratory infection appears most likely, despite relatively
unremarkable CXR. Flu swab was negative. She was treated
empirically for HCAP with vanc, cefipeme, and azithromycin. She
completed a 5 day course of azithromycin. Antibiotics were
narrowed to cefpodoxime for which she should complete a 7 day
course (last dose ___. She was also put on standing nebs given
hx of COPD. Patient was weaned off of 4L NC to RA successfully
after increasing frequency of pleurx drainage from daily to
twice daily. She was discharged home with oxygen given mild
desaturation with ambulation.
# Intermittent substernal pain with epigastric pain: Troponins
mildly elevated in the setting of infection. EKG with no ST-T
wave changes. Substernal chest pain was thought to be related to
GERD. Symptoms improved after initiation of H2 blocker and
Maalox/Diphenhydramine/Lidocaine prn.
CHRONIC ISSUES
# Hx of lung cancer: Stage IIIb diagnosed ___. S/p palliative
XRT and palliative carboplatin (AUC 2) and paclitaxel (50 mg/m2)
x4. Recent hospital course was complicated by recurrent right
sided pleural effusion, negative cytology, and s/p pleurX
placement. Pleurex was maintained and drainage had no evidence
of infection. She should drain pleurex twice daily since she was
noticed to desat with only once daily drainage.
#COPD: Patient with reported history of emphysema. PFT's in ___
with FEV1 97% predicted. Patient does take advair at home.
Patient was continued on home advair and put on standing
nebulizers while hospitalized.
# Hx of stroke: Known right sided residual weakness. Continued
home ___, pravastatin.
# Diastolic heart failure: No known CAD per chart review. Last
TTE in ___ unremarkable. Appears euvolemic to dry.
Continued home metoprolol and amlodipine.
# Hypertension: Continued home amlodpine and metoprolol. Held
HCTZ while hospitalized. Consider restarting in near future
# Dyslipidemia: Continued home pravastatin.
TRANSITIONAL ISSUES
# Complete 7 day course of cefpodoxime (last dose ___
# Patient was started on ranitidine for symptoms of sore throat,
epigastric pain, and intermittent chest pain
# Consider restarting HCTZ in the outpatient setting if blood
pressures are stable
# Discharged with home oxygen
# Patient should drain pleurx BID to prevent desaturation.
CODE: DNR/DNI
EMERGENCY CONTACT: Daughter ___ ___
***. | 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.
*** yo ___ speaking F with a PMH of dCHF (EF 60% in
___ w/ recurrent HF admissions, multifactorial hypoxia (O2
dependent with a history of poor adherence to home O2),
pulmonary hypertension, obesity hypoventilation syndrome and OSA
presenting with dyspnea and hypoxemia.
.
>> Active issues:
# Hypoxemic respiratory failure: Secondary to ___ exacerbation,
with some possible component of lower respiratory tract
infection. The patient presented with fever to 102, elevated
WBC, sore throat and cough concerning for a viral infectious
process. Viral illness may have been trigger for ___
exacerbation. She required Bi-PAP respiratory support
intermittently. Diuresis was complicated by acute renal failure,
which was unresponsive to diuretics. A temporary dialysis
catheter was placed on ___. Three liters of ultrafiltrate was
removed, with significant symptomatic relief. Standing albuterol
and ipratropium nebs were provided. She continued her inhaled
dose of fluticasone. The patient was continued on her home
medications of metoprolol, nifedipine, doxazonsin and low dose
aspirin. Blood cultures and rapid respiratory viral
culture/screen were negative. Pt was 8L negative for FICU stay
and pt subsequently transferred to the floor on 5L NC. Pt's
renal function improved and she was responsive to IV lasix and
then autodiursed further. Pt restarted on home lasix 80 PO BID
on ___. Pt total > 10L neg for LOS. Pt weaned from 5L NC to
___ NC which was home level.
.
# Acute renal failure: The patient developed rapidly progressing
ARF on HD #2. Nephrology was consulted and initially recommended
high dose diuretics to which the patient was unresponsive. The
ARF was likely secondary to contrast induced nephropathy
(contrast received for CT abd/pelvis) and possibly some
component of cardiorenal syndrome. The patient required
ultrafiltration on ___. Urine output improved on ___, and
became responsive to furosemide. The patient was provided a
renal diet and sevelamer/calcium acetate. Cr peaked at 5.5 and
normalized on ___. HD line was removed ___. Phos binders were
stopped as phos normalized.
.
# LLQ/groin pain: Pt with LLQ/groin pain since early ___ prior
to admission. She saw her PCP the day before admission. This
pain was also present in ___ as well per pt reports. She is a
poor historian but reports the pain is in her L groin region,
crampy, worse with urination, walking. She had a negative CT
abd. UA/ucx negative x2. She was put on simethicone. This pain
is longstanding and not related to acute intraab process or UTI
based on imaging and microbiology workup during this admission.
Etiology remains unclear.
.
>> Chronic issues:
# DMII: Uncontrolled, most recent A1C 8.1. She was continued on
her home does of NPH and provided SS Humalog.
.
# OSA: CPAP at night
.
# HTN: Continued doxazosin, nifedipine; home ___ held for ___.
.
# Hyperlipidemia: Stable. The patient was continued on
atorvastatin.
.
# Glaucoma: Stable. The patient was continued on her home eye
drops.
.
# Chronic neuropathic pain: Stable. Gabapentin was continued.
.
>> Transitional issues:
- Full code
- Please note CT abd showed fluid in endometrium and recommend
pelvic U/S follow-up in the OP setting.
- Please restart hose losartan 100mg if SBP persistenly >
130-140.
- Please continue home supplemental O2 (___) for goal sats
88-94%.
- Please monitor daily wts. Wt on ___: 195lb
***. | HEART FAILURE AND SHOCK WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient tolerated the procedure without intra-operative
complications. Please refer to the operative note for full
operative detail. The patient was extubated in the OR and
transferred to the PACU in stable condition. The patient
initially recovered in the PACU before being transferred to the
floor in stable condition. Her pain was well controlled on
parental narcotics. Her diet was slowly advanced on POD 0 and
on day of discharge she was tolerating a regular diet. Exam
upon d/c was unremarkable. The remainder of the hospital course
was relatively unremarkable, and pt was discharged in stable
condition, ambulating and voiding independently, and with
adequate pain control. Pt was given explicit instructions to
follow-up in clinic with Dr. ___ PCP ___ ___ days.
Pt was given detailed discharge instruction outlining wound
care, activity, diet, follow up and the appropriate medication
scripts.
***. | OTHER EAR NOSE MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ yo female with a complicated medical history including
schizophrenia and tardive dyskinesia that p/w altered mental
status, fevers to 102.8, hypernatremia (160) in the context of
decreased po intake and dramatically reduced functional status
over the past several months with three prior admissions for
same in the past two months.
*Fever/Altered Mental Status
Patient has presented with similar symptoms three times in the
past two months and an extensive work-up (as documented
previously) has been unremarkable. During this admission
patient was found to have a positive UA (proteus mirabilis) and
a sodium level up to 160 on the day of admission. These were
felt to be the primary etiologies of her fevers and AMS.
Patient was treated with antibiotics (initially ceftriaxone and
flagyl and then switched to po ciprofloxacin) and her sodium
level was brought within a normal range (see below) and her
fevers and mental status changes resolved. By the second day of
admission the patient was speaking (which she was not doing on
the day of admission) and by the ___ day of admission she was
speaking in almost complete sentences and responding to
commands. Patient's home At___ was held in the context of
altered mental status, and we will recommend that she not
receive it when she returns to the ___. Given
previous concerns about syphillis, RPR was checked an was
negative. CK was checked given risk factors for NMS (but no
recent antipsychotics) and this was similarly WNL.
*Hypernatremia
On admission, patient's free water deficit was approx. ___ L.
This was most likely due to poor po intake in the setting of a
fever and decreased ability of patient to access free water on
her own. There was no evidence of drugs causing this or an
osmotic dieuresis. We started her on fluids and corrected her
sodium slowly over several days to a normal sodium of 140. As
patient's sodium corrected, her mental status improved
dramatically. She was off fluid >48 hours at the time of
discharge and taking good PO intake.
*Acute Renal Failure
Patient's baseline creatinine is 0.6. On admission she was
found to have a creatinine of 1.2 and a FeNA of 0.1% suggesting
a pre-renal etiology of her elevated creatinine. Creatinine
improved with fluids over a few days to patient's baseline.
* Schizophrenia
Will recommend an outpatient psychiatric consult once patient
returns to ___.
* FEN
Speech and swallow recommended that patient be allowed to have
thin liquids and pureed foods with 1:1 supervision. Patient's
po intake was good during the last few days of her admission.
She will be discharged with instructions to receive water
frequently.
***. | 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.
***
Mr. ___ was transferred from OSH after receiving IV tpA for
acute onset of nonfluent aphasia. Upon arrival here, he was
noted to have a nonfluent aphasia and mild right hemiparesis. He
was initially admitted to the ICU for monitoring s/p tPA. He
clinically remained stable. He had MRI which not only showed the
expected L MCA stroke (he had an acute left fronto-temporal
stroke), but also an acute right cerebellar stroke. He was also
noted to have multiple old infarcts. There was no flow limiting
stenosis or thrombus noted on MRA. He had no documented history
of a. fib, but there was one EKG which looked like a. fib. Given
this and the b/l infarcts noted, he likely has cardioembolic
etiology of his strokes. TTE was performed and did not show any
ASD or PFO, nor any clear cardiac etiology of stroke. Optimally,
he would be anticoagulated for the likely cardioembolic
etiology, but he did have hemorrhagic transformation s/p tPA of
the left frontal stroke and an old left occipital stroke. He is
also noted to have microbleeds on his MRI, likely indicating
amyloid angiopathy. Given the risk of hemorrhage with oral
anticoagulation in amyloid angiiopathy, the decision was made to
not proceed with Coumadin, but rather use Aspirin for secondary
stroke prevention. He was on this prior to admission, but this
has been held with the hemorrhagic transformation. Repeat CT
scans have been stable (there was question of a slight increase
in right frontal hemorrhage on one repeat CT scan, so this was
again repeated prior to discharge and was stable) and the plan
is to restart Aspirin on ___. He was continued on
Simvasatin for secondary stroke prevention. His lipid panel and
HbA1c were checked (please see results in results section of
summary). His HbA1C was checked and is elevated; alterations to
his diabetes medication should be considered. Given his strokes,
we have advised that he hold off on Erythropoietin until he is
seen in follow-up with Dr. ___. His Trental was also held and
restarting this medication should be discussed in follow-up as
well.
***. | 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 ___ yo woman with a history of polysubstance use
disorder including heroin, crack cocaine and alcohol including
prior alcohol withdrawal seizures, also with a history of PTSD
with multiple psychiatric hospitalizations for suicidal ideation
who presented initially to the ED intoxicated and with suicidal
ideation but later developed severe alcohol withdrawal in the
emergency department.
# Polysubstance abuse complicated by,
# Severe acute alcohol withdrawal
# Opiate Withdrawal
Patient has a long standing history of polysubstance abuse
including crack cocaine, heroin and alcohol. She has a prior
history of alcohol withdrawal seizures. While observed in the ED
she developed severe alcohol withdrawal though without seizures,
RR peaked in the ___ and HRs in 140s with severe tremulousness
and diaphoresis. While in the ED she required a total of 270mg
Diazepam until her withdrawal was reasonably treated. Initially
on arrival to the floor, she was somnolent and difficult to
arouse, potentially related to over treatment in the ED. She
then awoke and was again tachycardic, tachypneic, and tremulous
and was thus transferred to the ICU for phenobarbital treatment
and monitoring. She received 600mg IV phenobarbital and
transferred to the floor in stable condition. Upon return to the
floor, she was in opiate withdrawal, complaining of diffuse
myalgias, diarrhea, and anxiety. This was managed
symptomatically and conservatively. She then wished to leave AMA
and wanted to present to an outpatient ___ facility. She had a
desire to participate in a long term treatment program. The
risks of leaving, including death from respiratory depression if
she engaged in any significant opiate or alcohol abuse while on
phenobarbital were explained. She understood these risks and was
deemed to have capacity to make the decision to leave AMA.
# PTSD
# Suicidal ideations
Evaluated by psychiatry in the ED; their recommendations
indicated the patient did not meet section 12a criteria. BEST
called to evaluate for DDART/EATS for voluntary substance use
treatment, but patient had desire to go to limited places and
wanted to self-refer. She was continued on Seroquel. Ultimately,
suicidal ideation resolved and on discharge, she had no such
ideations.
# Diabetes Mellitus, Type II complicated by
# Neuropathy
# Hypertension
Continued home Lisinopril and Gabapentin
#S/P Unwitnessed Fall
XR of chest, CT head negative. X-ray of foot was not completed
prior to transfer.
# Hepatitis C:
Hep C Ab positive during last admission. Needs outpatient
Hepatology f/u for possible liver biopsy and Hep C treatment
though she remains high risk of missing appointemnts.
# Thyroid Nodule
CTA during last admission revealed stable 4 cm exophytic thyroid
nodule. Patient was evaluated by Endocrine team during a prior
admissoin who recommended ultrasound-guided FNA as an
outpatient.
> 30 minutes were spent on discharge care, planning, and
coordination.
TRANSITIONAL ISSUES:
- Needs ultrasound-guided FNA as an outpatient for thyroid
nodule
- Needs outpatient hepatology follow-up for possible liver
biopsy and Hep C treatment
- Hep B vaccine series (received dose in ___
***. | ALCOHOL DRUG ABUSE OR DEPENDENCE LEFT AMA |
What is the most likely Medicare Severity Diagnosis Related Group (MS-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 brought to the operating room on ___ and
underwent EVAR with left hypogastric embolization. The
procedure was without complications.She was closely monitored in
the PACU and then transferred to the floor in stable condition
where she remained hemodynamically stable. He was given a
regular diet and he is fully ambulatory. He was discharged home
on POD # 1 in stable
condition. Follow-up has been arranged with VASCULAR SURGERY
on ___ at 1:30 ___ With ___, MD
___
Building: ___ (___ ___ Floor
Campus: ___ Parking: ___
He was also asked to call ___ to schedule for his CT
arteriography 10 days before his appointment.
***. | AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON W/O MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
TRANSITIONAL ISSUES:
====================
[ ]Last day of abx was ___. Patient can continue PO Vancomyin
until ___ for C diff prophylaxis.
[ ]Losartan and Metoprolol held on discharge to minimize pill
burden
[ ]Continued apixaban for portal vein thrombosis but can discuss
discontinuing.
[ ]Patient's home tramadol replaced with oxycodone. Her pain was
well controlled on oxycodone 5mg q6h:PRN and she will be
discharged with it.
#HCP/Contact: ___ (friend and HCP) ___
daughter ___ (may release health information to her)
___
#Code: DNR/DNI
BRIEF HOSPITAL COURSE:
======================
The patient is a ___ y/o woman with a history of bladder cancer
s/p BCG/interferon (___), stage I colon adenocarcinoma s/p
surgical excision (___), and stage IIB pancreatic
adenocarcinoma s/p whipple (___), recent PVT on apixaban, now
on palliative treatment.
She was admitted for GNR klebsiella sepsis, treated with two
weeks of IV Ceftriaxone with improvement, though with uptrending
obstructive biliary labs which did not improve despite PTBC
placement, ultimately attributed to progression of malignancy.
Given this, the patient was discharge home with home hospice
services.
ACTIVE/ACUTE ISSUES:
====================
# Malignant biliary obstruction:
# Cholangitis/transamintits:
Malignant biliary tract obstruction s/p ___ L biliary and ___ R
biliary drain placement, capped ___. Total bilirubin continued
to rise, and PTBDs were upsized to 10 ___ on ___. Despite
this, her total bilirubin continued to be elevated, and
ultimately this was thought to be secondary to progression of
malignancy rather than an intervenable blockage. As such, a
family meeting was held on ___, and the decision was made to
DC drains and DC home on hospice.
# Klebsiella bacteremia
BCx and UCx growing pansensitive Klebsiella. Negative BCx from
___ onward. The patient was on broad spectrum antibiotics
initially, but was eventually narrowed to Ceftriaxone
monotherapy with return of sensitivities, and completed a full
14 day course from first negative blood cultures on ___. She
had fever after PTBD upsizing, thus antibiotics were continued
for an additional 48 hours until BCx returned negative. Her
antibiotic course was as follows:
- Zosyn ___ - ___ narrowed to ceftriaxone (___)
# QTc prolongation:
EKG with QTc 507 on admission; ___ polypharmacy Zofran and
escitalopram. QTC 455 on ___.
# DMII:
Home glargine 12U QAM and 10U QPM. Adjusted to 12u glargine qAM
after some adjustments in house for hyperglycemia initially.
# Portal vein thrombosis: Apixaban was held for PTBD drain
placement, but restarted thereafter and continued.
CHRONIC/STABLE ISSUES:
======================
# Recurrent C. diff infection (resolved): The patient was on PO
Vancomycin while on antibiotics as above, and was discharged
with the plan to continue PO Vancomycin for one week following
the last day of abx for prophylaxis.
- Cont PO Vancomycin 125 mg BID for ppx until ___.
# MDD:
- Continued home escitalopram 20 mg QHS and lorazepam 0.5 mg BID
PRN
anxiety/insomnia
# HBV carrier:
- Continued home entecavir 0.5 mg daily
# Afib:
- Has been very well rate controlled off of metoprolol ER 50 mg
so will hold indefinitely on discharge
# HTN:
- BPs well controlled in house so will hold losartan
indefinitely on discharge
***. | 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 pancreatitis: The patients abdominal pain persisted on the
floor. His LFTs were re-checked and his lipase increased from
113-> greater than 600, consistent with acute pancreatitis.
Past triglycerides were normal. CT scan suggested mild
pancreatic inflammation. The case was discussed with ERCP. The
most likely cause was recent moderate EtOH use plus
boxing/trauma. He was strongly urged to avoid both for the time
being. His symptoms did not immediately improve. MRCP was
performed - which revealed mild inflammation, and no other
pathology. He clinically improved with bowel rest and fluids
and his diet was slowly advanced without difficulty.
Triglycerides were checked and were normal, no otc or rx. meds
in pts hx to explain etiology. Boxing and or etoh are
considered the most likely culprit in this case.
See omr note regarding prelim read from radiology about ?
divisum and consideration of ercp - ultimately cancelled as no
divisum of pancreas on final MR interpretation.
***. | DISORDERS OF PANCREAS EXCEPT 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.
***
___ yoM with COPD, CAD p/w increased weakness and productive
cough x 3 days found to have Community Acquired Pneumonia and
Possible mass in Lingula
.
# Community Acquired Pneumonia: Stable, discharged on room air.
The patient initially had endorsed chest discomfort and was
ruled out for MI. CXR revealed a LLL infiltration on and pt was
productive of mild sputum and had leukocytosis. The patient was
treated with Ceftriaxone and Azithromycin while in the hosptial.
.
The patient's CXR showed a 4.5cm lingular mass that was
concerning for neoplasm. Chest CT was performed which showed no
definitive obstructing mass and appeared infectious, however
this consolidation in lingula could represent neoplasm given the
bulging of the contours and its relatively inhomogeneous
appearance. Pulmonary was consulted and reviewed the Chest CT
films. Given that the patient has superimposed pneumonia, it is
difficult to ascertain whether this is truly a neoplasm.
Patient is a former smoker with a 30 pk yr history, no
hemoptysis, weightloss, nightsweats, or LAD on exam.
- Plan will be for outpatient follow up with Dr. ___ in ___
weeks (his office will call to schedule appt)
- Transition to Levaquin 750mg q48hrs to treat for full 14 day
course
- Reimaging per Dr. ___ 1 month
.
# Atrial Fibrillation: The patient was noted to have small burst
of atrial fibrillation on telemetry. On review of old ECGs, it
appears that this has been present on an old ECGs (___).
CHADS2 = 3. At this point, will defer anticoagulation as pt has
a question of a lung mass that needs futher evaluation.
- Continue ASA 325mg daily
- Will communicate to PCP of this finding
.
# CAD: The patient was ruled out for MI, and was continued on
his home medications.
- cont asa 325mg daily; simvastatin 80mg daily; home betablocker
.
# HTN: well controlled
- continued home beta blocker, lisinopril
***. | 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.
***
The patient is a ___ yo man with h/o cirrhosis complicated by
ascites, SMV and portal vein thrombosis, who presents with a two
day history of fever.
.
#) Fever: The patient states that he has had a fever to 102 for
two days prior to admission. He also stated that he has had a
productive cough and diarrhea but denied dysuria and myalgias.
A CXR, urinalysis, and blood cultures were all negative for
infection, and the patient was not found to have any ascites on
abdominal ultrasound for possible SBP. A C. Difficile culture
was sent, which returned positive on the day after admission.
It is likely that this was the source of his fever, though a
concomitant viral infection was also thought to be a likely
etiology.
.
#) C. Difficile: The patient was found to have CDiff on
admission stool cultures. The patient has not been treated for
this in the past, so it was thought to be a new infection, as
the patient had diarrhea on the day of admission. He was
started on Flagyl and was given a prescription on discharge for
a two-week course of this medication. He will follow up in the
liver clinic on ___ regarding this issue.
.
#) Black tarry stools/guaiac positive: The patient was found to
have dark stools, and he was guaiac positive in the ED. The
patient was recently started on iron sulfate, and it is possible
that his stools are now darker as a result. The patient has a
history of portal gastropathy, and he had a recent EGD which did
not show any gastric ulcers. The patient's hematocrit remained
stable during this admission, and he did not have any acute
events.
.
#) EtOH Cirrhosis: The patient has a history of EtOH cirrhosis,
complicated by esophageal varices, portal gastropathy, portal
vein thrombosis, and ascites. He had an abdominal ultrasound on
admission, which did not demonstrate any evidence of ascites.
He was continued on his home doses of Nadolol and Lasix, and he
did not have any acute events during this admission.
.
#) Diabetes: The patient has a history of Type 2 Diabetes, for
which he takes Glyburide daily. he was continued on this
medication, and he was placed on a Humalog insulin sliding scale
for further coverage. He remained stable during this admission.
.
#) Hypertension: The patient has a history of hypertension, for
which he takes Nadolol daily. He was continued on this home
medication, and he remained normotensive throughout this
admission.
.
#) Hypercholesterolemia: The patient has a history of
hyperlipidemia, for which he takes Ezetimibe daily. He was
continued on this medication during this admission.
***. | MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ underwent anterior and posterior colporrhaphies, b/l
sacrospinous suspension. Please see operative note for full
details. She was admitted to the GYN service post-operatively.
By POD1 she was ambulating, tolerating a regular diet,
controlling her pain with oral pain medications. She underwent
UROGYN voiding trial such that after an initial 250 mL of NS was
instilled into her bladder she was able to void ___ mL. She was
discharged home in good condition on POD1 with follow-up.
***. | FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE 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.
***
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left calf compartment syndrome and tibial plateau
fracture and was taken emergently to the operating room on
___ for left calf fasciotomy and external fixation of tibial
plateau fracture. Postoperatively she was admitted to the
orthopedic surgery service. She subsequently underwent several
operations including repeat I&D and vac change on ___,
ex-fix removal, ORIF left tibial plateau fracture, and vac
placement on ___, and left lower extremity lateral wound
split thickness skin graft and medial primary closure with vav
placement over skin graft and incisional vac placement over
medial primary closure.
The patient tolerated the procedure well (for full details
please see the separately dictated operative report). The
patient was taken from the OR to the PACU in stable condition
and after recovery from anesthesia was transferred to the floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. She was transfused
2 units of pRBCs for a HCT of 20.3 on POD2. The patients home
medications were continued throughout this hospitalization. She
was evaluated by psychiatry for medication management with mild
agitation while an inpatient. They recommended limiting
benzodiazepine use in addition to continuing her home
medications. Her platelet count increased to greater than ___ on
___ and hematology was consulted for further evaluation.
Given her lack of signs of an infection this was thought to be
reactive in nature and they recommended following her CBC and
monitoring her clinical status. Her platelets began to trend
down on ___ and she remained afebrile with stable vital
signs and no signs of an infectious process. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is touch down weight bearing in the
left lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.
***. | WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE 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 history of atrial fibrillation (on Coumadin),
multiple TIAs, and metastatic colon cancer was admitted for
confusion. Found to have RML consolidation on CXR and
hyponatremia. She was discharged to home hospice.
1. Poor Speech, Delirium
Patient's symptoms appeared slightly improved upon admission to
the floor compared to when she was first found by her family and
even from our ___ ED evaluation. CT scan showed no acute bleed
and INR was found to be therapuetic. There were no focal
nuerological deficits. Delirium was likely secondary to RML
pnuemonia and hyponatremia. Neurology was consulted and agreed;
they recommended no LP or MRI. The patient's mental status
improved remarkably over the course of several days on empiric
antibiotics and was confirmed to be at or near her baseline by
family members upon discharge.
2. Pnuemonia
RML consolidation was noted on CXR with a leukocytosis. The
patient endorsed a history of cough with mucus. Also had a
small oxygen requirement. The patient was started on IV
ceftriaxone and PO azithromycin for empiric coverage. Urine
Legionella antigen was negative, blood cultures shows no growth
to date. The patient's delirium substantially improved after
only a few days of antibiotics. She completed a 7 day course of
abx.
3. Hyponatremia
Admission sodium was 131; home lasix was held. Sodium initially
trended downward to a nadir of 128 while the patient was given
NS. Was thought to be due to SIADH secondary to pneumonia.
Sodium trended upward on fluid restriction.
4. Atrial fibrillation
This was stable. Home meds were continued, including beta
blocker and digoxin. Coumadin was also restarted after
hemorrhagic stroke/intracranial hemorrhage was ruled out. Coags
were checked daily and the patient's INR remained in therapuetic
range throughout her admission.
5. Metastatic Colon Cancer s/p resection: Stable
Heme/onc was contacted. A family meeting was held which
established the goals of care. The patient and her family
decided that a discharge home with hospice care would be the
best situation for her. Pt is aware she has a terminal illness
but prefers not to discuss too many of the details because she
finds it is not helpful to her emotional well-being. Family and
providers chose to respect her wishes. She is also ___ retired
___, previously very high-functioning and spoke at her
granddaughter's nursing school graduation. Time at home is the
main priority for her. She is clearly DNR/DNI
6. GERD
Stable, was kept on PPI.
7. FEN
The patient was kept on a regular diet.
8. PPX
The patient was anticogulated with coumadin.
DNR/DNI - pt is clear in her wishes. She would like to avoid
future hospitalizations if possible and maximize time at home.
***. | 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.
***
Mr. ___ is a ___ with PMHx notable for NASH cirrhosis
c/b esophageal varices s/p banding, hepatic encephalopathy,
ascites, GAVE, CAD s/p CABG (___), and PCI x2 (___), DMII
who presents with worsening weakness, confusion two days prior
to admission.
# HEPATIC ENCEPHALOPATHY: Mr ___ was admitted with mild
asterixis, confusion, decreased mental status, and inability to
follow commands. This was in the setting of multiple recent
admissions with similar presentation that was successfully
treated with laculose with improvement in mental status. The
most likely exacerbating factor for this admission seems to have
been inadequate lactulose dosing at home given recent
gastroenteritis. Ascitic fluid analysis was not suggestive of
SBP. UA and CXR was not suggestive of infection. Portal vein was
patent on US. He was given lactulose with marked improvement in
mental status. On discharge he should take Lactulose 30mL TID
titrated to 3BM daily and Rifaximin 550 BID.
# FALLS: Multifactorial including ongoing hepatic
encephalopathy, diabetic neuropathy, muscle wasting and
deconditioning. He has had multiple falls at home over the past
month. He was seen by physical therapist who recommended that he
go to rehab to address his deconditioning. Other etiologies of
his falls were considered such as orthostasis (though this was
not seen during hospitalization) or adrenal insufficiency
(though his AM cortisol was within normal limits).
# EOSINOPHILIA: Chronic and asymptomatic. Absolute count 990. Pt
was seen by hemonc and ID. He was found to have strongly
positive strongyloid antibody and was treated with ivermectin
with plan to followup for further evaluation and treatment. He
was treated with ivermectin 15mg bid with f/u in 3 months for
repeat testing. Other etiologies such as adrenal insufficiency
(commonly seen in cirrhotic patient) appear not to be present
given normal AM cortisol).
CHRONIC ISSUES:
========================
# CIRRHOSIS: Due to NASH. C/b ascites, hepatic encephalopathy,
varices s/p banding. MELD Score 9.4 on admission and was stable
during hospitalization.
## VARICES/GAVE: History of varices s/p banding. H&H at baseline
and pt on nadolol and protonix. Last EGD (___) showed Grade
obliterated varices s/p banding. Continued on nadolol 20mg .
## ASCITES: large based on US but same as prior imaging in
___. Pt s/p diagnostic para in ___ with no e/o infection.
No history of SBP but is on prophylaxis given low ascitic
protein 1.1 and prior abnormal kidney function. Continued home
lasix 20mg, spironolactone 75mg, and SBP prophylaxis with cipro
500mg daily.
# Hypothyroidism: Recently diagnosed. PCP recently started him
synthroid 25mcg which pt had not started as of ___. Started
during admission.
# DMII: well controlled. Last A1C in ___ was 6.2. Continued
lantus 6U at bedtime and ISS with humalog
# HTN: pt currently hypertensive which is unusual for patient
with cirrhosis. Continued lisinopril 2.5mg
# CAD: Pt s/p CABG and PCI x2. Not on plavix given h/o
significant GIB and variceal bleed. Continued ASA 81mg, nadolol
and atorvastatin 80mg
# Thrombocytopenia: at baseline and chronic. Due to splenic
sequestration.
# Anemia: Chronic. H&H at baseline. Most likely anemia of
chronic disease and history of GIB.
TRANSITIONAL:
- ensure ID f/u in mid ___ for repeat testing
- followup with Dr. ___ Hepatology as an outpatient
- will need repeat endoscopy.
- please assess wife's ability to care for Mr. ___ at home as
he approaches discharge as PCP has indicated that transition to
assisted living facility may be needed.
# CONTACT: wife ___ ___
***. | DISORDERS OF LIVER EXCEPT MALIGNANCY CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ was admitted for elective Left carotid endarterectomy.
She tolerated the operation well, recovered in the pacu and then
was transfered to the vicu overnight. Her vitals were monitored
closely and she remained on dextran overnight. On POD 1 her lab
values were stable and she was feeling well. She was
neuro-vascularly intact and stable for discharge home. She will
follow up in a month with a carotid duplex.
***. | EXTRACRANIAL PROCEDURES WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient was admitted to the inpatient Neurology Stroke
service for further evaluation and management. The following is
a hospital course by system:
1) Neurologic:
The patient was determined to have multiple small acute
infarcts, in the left centrum semiovale and left frontal
(superior frontal) cortical/subcortical region. CTA, echo, and
carotid duplex were performed and showed (1) status post right
carotid endarterectomy without any evidence of recurrent
stenosis, and (2) a 60-69% left ICA stenosis. This imaging
suggested that the stroke was embolic in nature, arising from
the left internal carotid artery.
Clinically, the patient presented alert and oriented to person,
place and date, but experienced moderate to severe dysarthria w/
decreased language fluency, poor prosody, intact comprehension,
intact naming, and intact repetition. Motor exam remarkable for
slightly weaker finger flexion on L relative to R, ___ toes,
and tandem gait with stumbling. Over the course of a couple of
days, pt's speech became more intelligibile as he started to
slow his rate.
The patient was placed on heparin drip for stroke prophylaxis,
and will be d/c with aggrenox for continued prophylaxis.
2) Fluid/Electrolytes/Nutrition:
The patient was initially kept npo, given moderate to severe
dysarthria. Pt passed swallow evaluation on the first day, and
started PO intake of think liquids and regular solids.
3) ID:
no issues.
4) ___:
After allowing BP to autoregulate for 24 hours, Mr. ___
was placed on metoprolol for hypertension. BP remained remained
relatively high, with systolic blood pressures in 130s-150s.
5) Code: The patient was full code during the hospitalization,
discussed with the patient's daughter (health care proxy).
On hospital day course 6 the patient was transferred to the
Vascular Surgery team.
___ He was taken to the OR by Dr. ___ a L Carotid
Endarterectomy. Tolerated procedure well without complications.
Beta blocker and HCTZ started post-op for BP control. The
patient was transfered to the VICU. A-line and telemetry
monitoring was done overnight.
POD 1 (___) The patient was stable in the VICU overnight. In
the morning a regular, soft dysphagia diet was started, foley
was removed, aline removed and the patient was OOB with nursing.
Medications changed for SBP < 140.
POD 2
Vital signs stable. DC home. ___ set-up for BP checks while at
home. Cleared by ___ for home. Will follow-up with Dr. ___
Dr. ___ as well as speech therapy.
***. | EXTRACRANIAL PROCEDURES WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
*** year old woman w/ h/o recent MVR for severe MR, AF on
coumadin, HTN, and HLD who presents with diarrhea and
dehydration after recent rehab stay.
.
# C. Difficile Diarrhea- Patient presented with several days of
watery diarrhea and abdominal cramping after a recent stay in
rehab after hospitalization from ___ to ___ for MVR. During
her rehab stay was also treated with course of linezolid for VRE
UTI. These factors put her at risk for C. diff, which she tested
positive for during this hospitalization. She was started on
metronidazole with a plan for a 11 day course. Her symptoms
improved and the frequency of her diarrhea decreased. She was
discharged to ___ with her PCP.
.
# Hypotension- Patient presented to PCPs office with SBP in ___.
This improved with IVF hydration and was attributed to
dehydration in the setting of diarrhea, continued use of
diuretics, and poor PO intake. Her anti-hypertensives were held
and she was able to manage her fluid rehydration with oral
intake, maintaining normal blood pressures. She was discharged
off of her HCTZ and lisinopril- these should be restarted in the
outpatient setting on follow up if she returns to her
hypertensive baseline.
.
# ___: Patient presented with creatinine of 1.8 up from baseline
of 0.7. This was attributed to pre-renal azotemia secondary to
dehydration as above. Her creatinine normalized with IVF and
subsequent oral intake of fluids.
.
# AF: Patient developed AF in the MVR post-op setting and was
started on coumadin with a plan for 6 weeks of anticoagulation
per Dr. ___ Dr. ___. Her EKG in the ED was
consistent with AF and INR was 3.4. Her coumadin was held given
her supratherapeutic INR intially and subsequently given that
she was started on metronidazole. She was continued on her home
diltiazem during this hospitalization and monitored on
telemetry- her rhythm converted to sinus soon after admission
and remained in sinus for the remainder of her hospitalization.
She was instructed to restart her 2 mg dose of coumadin after
she completes her antibiotics and come in for PCP ___ and INR
check on ___.
.
# Anxiety/Depression: Patient intially reported a good mood and
denied SI. On further questioning by her PCP she noted passive
SI, without a plan. She did contract to safety. She was
evaluated by psychiatry who felt that this was not an acute
decompensation and that there were no barriers to psychiatric
discharge. She was continued on her home buspirone, sertraline
and mirtazepine. She will benefit from continued structured
programs at the ___, which was discussed with patient.
She is also planning to start volunteering at the ___ as she
has found that helping people has previously given her a sense
of accomplishment and purpose.
.
# Recent fall: Patient reported history suggestive of mechanical
fall, though orthostasis may have played a role. No alarm
features to suggest TIA or more serious etiologies. She had a
small bruise on L frontal area, but was neurologically intact.
Her neurologic exam was monitored and remained intact. She
remained quite mobile on her feet without demonstrating any
signs of high fall risk during this hospitalization.
.
Code: DNR/DNI (discussed with patient)
.
Emergency Contact/HCP: ___ (lawyer): ___
Pending on Discharge:
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
For Follow Up:
Please check electrolytes on follow up visit as Ms. ___
potassium was slightly low on discharge. She was given a dose of
potassium for repletion prior to discharge.
***. | MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with hx gastric bypass in ___ transferred from ___
___ with findings of high grade small bowel obstruction on
CT. The patient was stable on arrival, describing a few day
history of sharp, left-sided abdominal pain with associated
obstipation, nausea, and vomiting. She had an NGT in place and
her exam was nonperitoneal, although a high clinical suspicion
for an internal hernia, the findings of high grade obstruction
on CT, and her history of gastric bypass prompted OR planning
for diagnostic laparoscopy for definitive diagnosis. The patient
was taken to the OR on ___ and underwent an exploratory
laparoscopy, lysis of adhesions,
internal hernia reduction, and mesenteric defect closure. Her
NGT was removed on ___ in the morning. She quickly advanced
from sips to clears to regular throughout the day, was passing a
small amount of flatus and was out of bed ambulating and feeling
well. The patient attempted to leave AMA in the late afternoon,
stressing that she was well, did not require monitoring, pain
medication, or further hospitalization and describing that she
wanted to return to ___ with her husband as soon as possible.
I was able to reach the patient prior to her departure and
review appropriate discharge instructions and provide her with a
prescription for pain medication. The patient verbalized
understanding and stated that she would be following up in 2
weeks with her bariatric surgeon in ___ to haver her surgical
incisions looked at. She was provided with the ___ clinic phone
number should she need further follow up with us, and to
facilitate communication between her bariatric surgeon and ACS,
should the need arise.
***. | PERITONEAL ADHESIOLYSIS WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ y/o M with hx of diastolic CHF, HTN, Hep B, Hep C and EtOH
abuse presents L arm tingling and SOB in the conext of
consumption of large quantities of EtOH, most consistent with
worsening of anxiety. Exch of the problems addressed during
this hospitalization are discussed in detail below.
.
Left Arm Tingling: Given multiple prior episodes, we felt that
this was most likely associated with anxiety or musculoskeletal
pain, although ACS was considered as well. On admission, EKG
revealed no acute changes and cardiac enzymes are negative x3.
There were no events on Telemetry. MI was ruled out. We
continued the patient's ASA at 325mg daily. Given the patient's
history of HTN and glucose intolerance and a significant family
hx of cardiac disease, we felt that the patient should undergo
an outpatient stress testing. We discussed this plan with the
patient's PCP ___ arrange for the patient to
undergo this testing in the near future.
Per discussion with PCP ___ ___, fax
___, the patient has an appointment on ___ at
11:30 am.
.
Shortness of Breath: We felt that this SOB is likely
multifactorial, COPD plus fluid overload in the setting of Lasix
non-compliance plus anxiety. The patient remained stable and was
satting well on Room air. Given symptomatic improvement with
administration of klonapin, we felt that anxiety probably played
a prominent role. MI was ruled out as above. There was no
evidence of COPD exacerbation or respiratory infection. We gave
the patient standing Ipratropium nebs, albuterol PRN. We
restarted the patient on outpatient lasix 40 mg PO bid (the dose
was confirmed with PCP).
.
Pedal Edema: this was likely secondary to diastolic CHF as
diagnosed last admission as well as some venous stasis. The
patient was not compliant his lasix despite PCP ___.
We restarted Lasix bid as above. We also re-started Lisinopril
5mg daily.
.
COPD: stable, breathing improved with treatment of his anxiety
and nebulizer. Does not appear to have COPD exaccerbation
requiring abx or steroids.
- standing ipratropium PRN, albuterol PRN
.
ETOH abuse: The patient has a long standing history of EtOH
abuse, just drank 1 quart of brandy, 1 pint of vodka the day of
admission and finished just prior to calling EMS ~10pm. On
presentation to the floor, the patient appeared to be in mild
withdrawal. The patient was monitored for signs of EtOH
withdrawal on CIWA scale and was given Valium 1mg PRN q1hr for
CIWA>10 in addition to standning Klonopin. He received 100mg of
Valium on ___ and another 30mg of valium on ___. We
started the patient on Thiamine, MVI, Folate on admission. The
patient was on fall precautions. The patient was seen by social
work consult for substance abuse. We offered the patient an
admission to ___ facility, but he refused.
.
Epigastric Pain: The patient was complaining of a few episodes
of epigastric pain, which was releaved well with bowel movement,
Maalox/Diphenhydramine/Lidocaine. He was noted to have elevated
lipase on labs with chronic mild abdominal pain. This
presentation was not consistent with acute pancreatitis, but
chronic pancreatitis is possible. Has been diagnosed with
pancreatitis at ___ before.
.
Hepatitis C: US last admission showed fatty infiltration and no
masses, per patient has a hepatologist whom he doesn't follow up
with regularly at ___. The patient needs an outpatient
follow-up.
.
Hypertension: the patient was hypertensive during his EtOh
withdrawal. He was re-started on Lisinopril 5mg daily. We
controlled hypertension with IV Hydralazine 10mg, which the
patient needed once.
.
Anxiety: the patient has been diagnosed with anxiety and has
outpatient follow-up with a psychiatrist. We continued the
patient on klonapin 2 mg daily. The patient received Valium PRN
based on CIWA scale for EtOH withdrawal.
.
Back pain: chronic, but the pain was under control during this
admission.
.
Onychomychosis: The patient was noted to have bilateral
onychomychosis; we recommend outpatient podiatry follow up.
.
The patient received Heparin SQ for DVT prophylaxis during this
admission, Heart Healthy / Low sodium diet. Electrolytes were
repleted PRN.
The patient signed out AMA on ___ at night while being
covered by cross-coverage despite the best efforts to convince
the patient to stay in the hospital until his alcohol withdrawal
is complete.
.
***. | ALCOHOL DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY 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.
***
___ was seen in the ED on ___ status post fall from
unknown height with left humerus fx, 1st rib fx, bilateral
pneumothoraces and a compression fx to the superior and anterior
endplate of T12 and S1 seen on CT
trauma/chest/torso/abdomen/pelvis. Neurological exam was intact.
Patient was admitted to the trauma service. He was deemed to
have non-operative injuries at that point. At that time, due to
his multiple bony injuries, orthopedics/spine was consulted.
They recommended a splint for L humerus fx per ortho, and a TLSO
brace per spine, with daily neurovascular checks of his upper
extremities.
His Cspine was cleared clinically on ___. That day, he was put
on 1:1 observation, and obtained ___ eval for possible
discharge home. He did complain of some ankle pain, and an xray
that day showed soft tissue swelling, without any fracture or
dislocation. A repeat chest xray showed unchanged bilateral
small apical pneumothoracies, with a L apical pneumatocele,
essentially unchanged from his initial chest xray in the ED.
During this time, his oxygen saturation status was unchanged,
and all vital signs were within normal limits.
On ___, he was evaluated and awaited inpatient psychiatry
placement. On ___, he had good rectal tone, his Foley was
discontinued for acute urinary retention, and he had a urinary
void in the pm.
Per ___, his treatment plans were ADLs, functional mobility,
post-concussive
symptoms, one-handed techniques, education re: energy
conservation, cuff and collar, TLSO brace, and WB precautions,
all 1 to 2 times a week for 1 week.
At time of discharge, patient tolerated all PO home medications,
was advanced to and tolerated a regular diet, and voided well
without Foley intervention. He was able to ambulate and all IV
fluids were discontinued. From the standpoint of ACS service, he
is medically cleared for the inpatient psychiatric unit. He will
not need IV, a catheter, or daily laboratory testing at this
time.
***. | OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Patient underwent I&D of his LLE on ___ by ortho and a wound
VAC was placed after eschar/soft tissue was debrided. Plastic
surgery was consulted for assistance with soft tissue coverage
of the patient's LLE. ID consulted when tissue stain showed
Bacillus sp. (not anthracis) and Gram-negative diplococci.
Patient treated with vancomycin IV on surgery/admission,
ceftriaxone IV was added following the latter finding on Gram
stain. The patient underwent several more debridements and VAC
changes and had an IM nail exchange due to the + cultures from
the OR. On ___ her underwent a right anterolateral thigh
myocutaneous flap to left lower leg and a skin graft. He
tolerated the procedure well and was recovered in PACU with
frequent flap checks. Overnight, the Patient's flap appeared to
become more congested between 12am-1am. Vioptix dropped from 47%
to 39% during this time. Upon bedside evaluation, arterial
Doppler signals were strong but the muscle under the skin graft
appeared more dark. Dressings were taken down. Flap appeared to
have developed acute onset venous congestion of uncertain
etiology and patient was taken back for reexploration and flap
salvage. In the OR he had thrombectomy of flap vein and a
redo-venous anastomosis. He was returned to ___ for frequent
flap checks and started on a heparin drip. He recovered well
and was transferred to the floor. His pain was managed with a
combination of IV pain medications including IV morphine,
Tylenol and toradol until patient could tolerate oral pain
medications. He was continued on IV vancomycin and ceftriaxone
per ID. The patient was noted to have right upper arm pain,
swelling tenderness, with PICC in place. Ultrasound revealed a
partially occlusive thrombus within the right brachial vein
along the PICC line. Hematology was consulted and advised to
leave the PICC in place for access and to continue the heparin
drip, as we were doing. Final hematology recs were for a total
of 3 months of anticoagulation for PICC-associated DVT and
switching to rivaroxaban 20mg daily when discharging patient.
On ___, the patient got out of bed and felt pressure in his
right thigh. Upon rounding on him routinely in the afternoon
Dr. ___ he had a very large hematoma that was
expanding. Patient was transfused 2 units of packed red cells
for acute blood loss anemia. The patient was taken back to the
OR where approximately 300cc of bloody clot was evacuated.
Hemostasis was achieved and patient was recovered in PACU and
returned to floor. The rest of his hospital stay was
uneventful. He recovered well and worked with ___ for WBAT on
both lower extremities. The flap remained viable and the donor
site remained flat without hematoma. Patient was transitioned
from heparin drip to rivaroxaban. He was discharged to home on
IV vancomycin and ceftriaxone per ID recs. He had one JP in
place to right thigh.
***. | WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE 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.
***
___ male with h/o atrial flutter/AFib, COPD non-adherent to ___
who presented to outside hospital with chest pain and found in
atrial flutter with HR 110. Negative troponins. He converted to
normal sinus rhythm after receiving 2 doses of Cardizem while at
outside hospital. Case discussed with patient's cardiologist Dr.
___ cared for patient during prior admission in ___
and recommended transfer to ___ for further evaluation. On the
floor, the patient was seen by the Electrophysiology team with
the following plan. Patient remained in sinus rhythm and
respiratory status much improved compared to prior admission. EP
team does not have opening until ___. Patient has sleep study
scheduled for tomorrow. Plan was to monitor overnight on
telemetry to be discharged following day for the sleep study and
then return for elective admission on ___ for ablation. He
was continued on diltiazem 120mg PO daily and ASA 81mg PO daily
on the medical floor. During the night after primary team left,
patient eloped from hospital.
***. | 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.
***
TRANSITIONAL ISSUES:
======================
[] Discharged on 14 day total course of abx with cipro 500 BID
___, last day ___
[] Will need repeat CMP within 1 week of discharge to ensure Cr
continues to trend downward.
[] Please repeat EKG 1 week post discharge for QT monitoring on
cipro.
[] Tacro dose decreased to 4 mg BID since it has been 2 months
since transplant.
[] repeat EKG for QTC monitoring in outpatient clinic after d/c
[] BPs elevated this admission to 150s-170s intermittently (Pt
keeps log at home and reports normal SBPs in the 130s); please
___ ambulatory BPs and adjust anti-hypertensives as necessary.
[] Consider holding Bactrim ppx while pt is on Cipro if okay
with outpatient transplant nephrologist.
DC Cr: 1.1
SUMMARY:
===========
___ PMH ESRD of unknown etiology s/p DDRT ___, subsequent
graft failure now s/p SCD DDRT ___, SCC, HFpEF, pAfib on
apixiban,
diverticulitis w/ multiple complications s/p ex lap who
presented
with fever and found to have GNR bacteremia as well as UTI, ___,
and hyponatremia.
ACTIVE ISSUES
=============
# GNR bacteremia
# UTI with concern for pyelonephritis
Prior UTI in ___ w/ 3 separate urine cultures growing
pseudomonas (sensitive to everything but ciprofloxacin). Started
on cefepime in ED, narrowed to CTX ___ following sensitivities.
Bacteremia
likely secondary to urinary tract infection. Urine growing
E.coli
and BCx growing GNRs with similar sensitivities last positive
___, all cultures after
this NGTD up to ___ on discharge.. ID consulted and recommended
14 day total course of abx with outpatient ciprofloxacin 500 BID
___, last day ___.
# ___:
# ATN:
Baseline Cr 0.7-1.0. Cr 1.5 on admission. Renal U/S shows no
hydronephrosis. Urine lytes c/w prerenal etiology likely iso
infection and recurrent fevers. Urine microscopy showed ATN. s/p
2L NS on admission, another 1L NS ___. Renally dosed
medications and
treated with IVF resuscitation.
# ESRD s/p prior failed transplant:
# SCD DDRT ___:
Etiology of ESRD unknown. Cr 0.6-0.7 at baseline.
2 months after transplant as of this admission; Goal tacro level
around 10.
- PPx: Continue Sulfameth/Trimethoprim SS 1 TAB PO DAILY,
ValACYclovir 500 mg PO BID; Famotidine 20 mg PO BID for GI PPx
- Immunosuppression: Continue Mycophenolate Sodium ___ 360 mg PO
QID, PredniSONE 5 mg PO DAILY, Tacrolimus 4 mg PO Q12H
STABLE/RESOLVED ISSUES
=======================
# Hyponatremia - resolved
Likely hypovolemic hyponatremia in the setting of infection,
decreased PO intake, and insensible losses with fevers. Urine Na
<20 and ATN. s/p several L NS since admission. Na now within
normal range.
CHRONIC ISSUES
==============
# HFpEF:
- Target dry weight 113 lbs.
- Preload: not on home diuretics
- NHBK: Continue Metoprolol Succinate XL 100 mg PO BID
# Paroxysmal A. fib: CHADS-VASc 4.
Continued on apixiban 5 BID, metop succinate 100 BID, amiodarone
200 daily.
# Chronic diarrhea: Continued Diphenoxylate-Atropine 1 TAB PO UP
TO 5X PER DAY, AS NEEDED FOR DIARRHEA
# HLD: Continued Atorvastatin 10 mg PO QPM
# Restless legs syndrome: Continued rOPINIRole ___ mg PO DAILY
- Continue Gabapentin 100 mg PO BID
# Vitamin D deficiency:
- Continue Vitamin D 1000 UNIT PO 3X/WEEK (___)
***. | 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.
***
___ with HTN, anxiety, chronic anemia, HTN, anxiety and BCC s/p
multiple MOHS currently finishing course of treatment for
cellulitis who is admitted with acute kidney injury incidentally
discovered during work-up for a fall.
# Acute kidney injury: Cr elevated to 2.0 from 1.1 in ___.
FeNa is 2.62% but FeUrea is < 35% and patient is on HCTZ. Most
likely pre-renal vs in setting of recent Bactrim use. Patient
was given 1L NS bolus overnight with improvement of Cr to 1.7
# Fall: Sounds mechanical, no indication of syncopal episode.
Fracture ruled out with CT pelvis. Pain well controlled with
standing Tylenol. Baseline ambulation appears to be with rolling
walker, patient noted to be able to transfer on her own in past
notes. Physical therapy evaluated her with plans for continued
outpatient ___ with no acute rehabilitation needs. She will have
24-hour care back at ___.
# Hyponatremia: Patient is clinically euvolemic and is not
thirsty, making hypovolemic hyponatremia less likely. Based on
urine lytes, suspect that hyponatremia was due to inappropriate
ADH secretion due to pain from fall, as the ED documentation
describes significant pain. Will have f/u lytes in 1 week.
# LLE cellulitis: Resolving, after MOHS procedure several months
ago. Completed course of Bactrim/Keflex on ___.
# Anemia: Stable for past nine months, apparently long standing
issue due to "chronic disease" and iron deficiency. Not
currently on iron. H/H stable from hematoma.
TRANSITIONAL ISSUES:
====================
- Recheck CBC/lytes in 1 week
- held losartan/HCTZ in setting of ___ increased amlodipine to
5 mg
- continue home ___
- code: full
- contact: ___ (son) ___
***. | 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.
***
Mr. ___ presented to ___ on ___ and underwent a cardiac
catheterization which demonstrated no flow limiting coronary
artery disease. He was admitted for preadmission testing and
evaluation. He remained hemodynamically stable overnight. He was
taken to the operating room on ___ and underwent aortic
___ replacement. Please see operative note for surgical
details. Following surgery he was transferred to the CVICU for
invasive monitoring in stable condition. Several hours later he
was weaned from sedation, awoke neurologically intact, and
extubated.
Beta blocker was initiated and he was diuresed toward his
preoperative weight. He remained hemodynamically stable and was
transferred to the telemetry floor for further recovery. He
developed atrial fibrillation and was treated with beta blocker
titration and Amiodarone bolus. Warfarin was initiated. He was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 5 he was
ambulating freely, the wound was healing, and pain was
controlled with oral analgesics. He was discharged to ___
___ 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.
***
Trauma consult admitted to general surgery after mechanical
fall. Imaging done in ED:
___ Imaging:
CT head: neg
CT Cspine: neg
CT torso: ? left lat 8th rib fx. obturator internus hematoma no
extrav
CXR: no acute process
L foot XR: no fx
L hand XR: no fx
L hip XR: L sup and inf pubic rami commin fx
Injuries on admit:
? left lat 8th rib fx
L obturator internus hematoma no extrav
L sup and inf pubic rami commin fx
Orthopedic surgery consult for Left superoior and inferior pubic
rami fracture recommended non operative manamgent, full weight
bearing and follow up in 4 weeks.
CT was done to evaluate hematoma and showed no progression and
no extravasation.
Patient remained stable tolerated PO meds and regular diet and
pain was well controlled. She was evaluated by ___ and will
be discharged to rehab facility.
***. | FRACTURES OF HIP AND PELVIS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
PSYCHIATRIC: Ms. ___ initially was admitted on a conditional
voluntary basis to the inpatient psychiatric unit after
presenting to the ED on ___ with c/o worsening depression and
suicidal ideation with plan to overdose on prescription
medications. Initially, she reported continued suicidal
thoughts, but denied intent and plan while she was hospitalized.
On ___, she completed an MMPI, which showed results largely
unchanged from results obtained in ___, during a psychiatric
consult through the pain clinic at that time. The current study
demonstrated a modest ___ peak c/w some depression, anxiety,
and somatic complaints. There was also a ___ trough c/w
cluster B traits. There is also a mildly-elevated paranoia
scale and anxiety/obsessive-compulsive scale on MMPI. The
patient's dose of Effexor was increased to 375mg per day.
During the course of her hospitalization she began to report an
improved mood, decreased suicidal thoughts and then denied
suicidal thougthts, intent, or plan. She exhibited some
hair-pulling and eyebrow-picking behavior. She rarely
participated in groups, claiming that they were mostly "silly",
and preferred to focus on her own knitting. However, she did
interact with other patients on the floor, and even reported
helping other pts with their problems.
On day of discharge, a family meeting was arranged, and the
events of ___ hospital stay were reviewed. Continuation with
an outpatient partial program was strongly recommended, but pt
refused participation because she worries that if she does not
return to work soon, that she would be fired, as she did from
her last job. Both her husband, ___, and her
psychiatrist, Dr. ___, agreed that an outpatient
partial program would be important in her recovery process.
However, she continued to refuse to comply with recommendations
from her treatment team. Since pt was no longer endorsing
suicidal ideation and no longer required hospital-level of care,
she was discharged at her request with the explicit knowledge
that outpatient partial program participation is strongly
recommended.
.
MEDICAL: On admission, Ms. ___ reported no somatic complaints.
Her laboratory studies, including basic electrolytes, CBC,
coagulation studies, TSH, and urinalaysis were all unremarkable.
Urine and serum tox screens were only positive for
benzodiazepines, consistent with her Xanax use. Discharge
summary obtained from her ___ admission in ___ was attained,
demonstrating no significant laboratory findings, normal head
CT, and normal EEG. During her stay, she did complain of some
worsening of her chronic LBP, which was treated with
acetaminophen. She was discharged with her husband in stable
condition.
***. | 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.
***
___ year old female with h/o solitary right kidney, ESRD on HD,
h/o low grade noninvasive bladder CA s/p multiple surgeries who
initially presented to ___ with dyspnea found to have a
pericardial effusion with tamponade physiology on bedside ECHO.
ACUTE ISSUES
============
#Pericardial effusion/Tamponade:
Likely secondary to uremic pericarditis given that pt missed
dialysis. Pericardiocentesis was performed with removal of 470cc
of serosanguinous fluid. Pericardial pressure 15->2. Drain
removed ___. No bacterial growth. Cytology negative for
malignancy. No further evidence of tamponade physiology over
course of admission.
#Urinary Tract Infection:
Pt was initially asymptomatic, and initial urine culture had no
growth. However, on ___ pt developed suprapubic tenderness and
dysuria, so she was started on cefpodoxime. Urine culture was
pending on discharge. The patient explained that her most recent
prophylactic cipro prescription was mistakenly for 150mg instead
of 500mg. She was instructed to finish a 7 day course of the
cefpodoxime, and resume her 500mg of cipro on ___ after HD.
#Anemia: Hemoglobin 7.4 from baseline of 11 with no evidence of
acute blood loss. In some individuals, uremic pericarditis may
be associated w/ worsening anemia ___ inflammation and EPO
resistance. Pt was transfused for Hgb<7, and received a total of
1 U PRBC over the course of her admission. Hemolysis labs were
wnl. Iron studies showed ferritin>1000.
Our nephrologists have contacted home dialysis unit to ensure
appropriate outpatient regimen.
#Transaminitis: Mild with no acute hepatic pathology on RUQ u/s.
___ have been due to volume overload/congestive hepatopathy.
Hepatitis serologies showed non-immunity to hep B, Hep C viral
load of 6, and Hep A Ab positive. Given Hep C viral load and
mild transaminitis there should be outpatient Liver/Hepatology
follow up.
CHRONIC ISSUES:
===============
#ESRD: Continued home sevelamer and vitamin D, and pt was
continued on her home ___ dialysis schedule.
#HTN: Held then restarted home amlodipine
#GERD: continued home PPI
#Anxiety: lorazepam qhs prn
#Depression: continued home fluoxetine
TRANSITIONAL ISSUES
===================
- Not immune to Hep B
- Positive Hep C Viral load (6) w/mild transaminitis. Will need
outpatient ___ follow up
- repeat TTE in 3 weeks
- pt was discharged with 7 day course of cefpodoxime for UTI,
scheduled to be taken after HD and to thus finish on ___. She
should resume her prophylactic cipro 500mg on ___ after HD.
However, she should discuss with her outpatient providers
whether cipro is the most appropriate prophylactic regimen given
its new blackbox warning. Additionally, pt claims that her most
recent cipro prescription was for 150mg instead of 500mg, which
could help explain why she developed a UTI. Please write a new
prescription if this is the case.
- Anemia - RENAL will speak directly w/ outpt HD to make sure
she is being treated appropriately and ask them to remind her to
present for dialysis
-Discharge Weight: 55.3kg (just post HD on ___
***. | OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ is an ___ with a hx of HTN, HLD who presented s/p
mechanical fall on ___ and was found to have R posterior rib
9&10 fractures. She was initially admitted to the surgery
service for management of pain and was transferred to the
Medicine team for continued pain control and control of
hypertension
# Hypertension:
Patient's blood pressure was poorly controlled in the outpatient
setting with recent uptitration of her anti-HTN regimen. In the
setting of pain, her blood pressure was further increased. On
presentation, her BP was found to be 220/110. Her hospital
course was also complicated by poorly controlled HTN with BP
range: 132/55-250/90. She initially received home dose valsartan
120mg and required PO (50mg) and IV hydralazine (___). On
___, patient was started on amlodipine 5mg po qd, and valsartan
was increased to 320mg po. She received diltiazem 60mg po x 1.
She was later transitioned to Valsartan 320mg and Labetalol
(uptitrated to 400mg po bid). Amlodipine 5mg was added.
Given difficulties in BP control, she underwent renal artery US
for evaluation of secondary cause of HTN. There was no evidence
of hyperthyroidism, no evidence of infection or ischemia to
account for sx, no intracranial processes to explain HTN as
neuro exam is wnl. Renin/Aldosterone were pending at time of
discharge.
# Delerium:
Patient developed hypoactive delerium during the
hospitalization. Causes included hospitalization, pain and
pain/sedating meds. There was no evidence of infection. Delerium
resolved spontaneoulsy.
# Bacteruria - multiple colonies
Pt reports occasional dysuria and had + UA but organisms
appeared to be contaminant. NSG reported sample may not have
been clean. She recevied Bactrim 500mg DS BID (___) x 1d.
# Pain Control/Rib Fx:
Pain control was achieved with tylenol, tramadol, oxycodone prn
and morphine prn. There was no evidence of pneumothorax, no
crepitus on exam. Patient continued to use incentive spirometry.
# Leukocytosis
Please see labs section. UA negative on ___ and no resp sx.
Likely ___ stress response in setting of rib fx. Resolved
spontaneously.
#Depression: The pt with hx of depression and has a depressed
mood during the hospitalization. Continued Bupropion to 75 mg
qam and citalopram 20mg po qd.
# Hypothyroidism: TSH was found to be elevated. Levothyroxine
was increased to 100mcg po qd.
# Neuropathic ___ pain
Pt complained ___ L>R. This limited her mobility.
Low-dose gabapentin was inititated for management of this pain.
TRANSITIONAL ISSUES:
# CODE: DNR/DNI
# CONTACT: Daughter (___) ___
- Please note: patient was incidentally noted to have a "8 mm
focal outpouching of the infrarenal abdominal aorta, consistent
with a chronic, partially thrombosed aneurysm or
pseudoaneurysm."
- Please rechech TSH and free T4 in outpatient setting
(levothyroxine increased in inpatient setting given elevated
TSH)
- Please continue to titrate anti-hypertensive regimen; consider
increasing amlodipine to 10mg and continued management of pain
and anxiety.
- If blood pressure control remains difficult, please consider
continued evelauation for secondary causes (i.e. urine
metanephrines).
- Consider down titration of blood pressure medication if blood
pressure trends down with improvement in symptoms of pain and
anxiety.
- Consider initiation aspirin 81mg daily for primary prevention.
***. | OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient presented to the emergency department and was
evaluated by the Acute Care Surgery team. The patient was found
to have penetrating abdominal wound, small
bowel enterotomy x2 and was admitted to the Acute Care Surgery
Service. The patient was taken to the operating room on ___
for an exploratory laparotomy + small bowel resection, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications. The patient was given ___ antibiotics
and anticoagulation per routine. The patient initially had an
NGT in place- this was discontinued ___ after he had return
of bowel function. His diet was then sequentially advanced to a
regular diet, which the patient tolerated well. The ___
hospital course was remarkable for a fever of 101.7 on ___. The
patient underwent a fever workup and the likely cause was deemed
to be atelectasis. Incentive spirometry was encouraged and the
patient had no other febrile episodes. Social work was consulted
and deemed that the patient had a safe environment to return
home to. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient
will follow up with Dr. ___ on ___ 2:40PM A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
***. | MAJOR 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.
***
___ with h/o MDS ___ MUD HSCT x 2 ___ and ___ c/b
transplant rejection and graft failure c/b GVHD of the lungs,
gut, and skin, ___ recent prolonged hospital courses
___ and ___ for PNAs who initially
presented to clinic with hypoxia and tachycardia found to have
PNA c/b hypercarbic respiratory failure and shock requiring
intubation and MICU admission. Had bronch and BAL w/ cx growing
pseudomonas, aspergillus, and CMV pos. Also influenza A
positive. Treated with broad spectrum antibiotics and given on
prednisone at baseline for GVHD, was given stress dose steroids
for shock. He improved and steroids titrated down to baseline
30mg daily. He was able to be successfully extubated on ___ and
called out from the ICU on ___ when stable on RA. Treated with
cefepime (x14 day course), posaconazole, IV ganciclovir and
Tamiflu x28 days. Patient clinically improved on cefepime, ___,
ganciclovir, and Tamiflu. On ___ He was found to have a
detectable CMV viral load, and negative flu swab. Patient was
seen by ID and transitioned to PO ciprofloxacin 500mg bid, and
PO valgancyclovir 900 BID to be continued until neg CMV Vl. He
will also continue on Zithro MWF 3x/wk, posaconazole 300mg qd,
atovaquone 1500mg qd, and was transitioned to monthly IVIG
infusions, per ID recs, who will f/u with in clinic. His pulm
status improved to stable on 2L, per pulm there was no need for
bronchoscopy currently as all airways were open, and was DC'd to
pulmonary rehab.
.
>> ACTIVE ISSUES:
# Hypoxic and Hypercarbic Respiratory Failure: Patient was found
to have respiratory failure, and likely has multifocal process.
Patient has previous GVHD in his lungs, bronchiectasis, and
BOOP, as well as previous history of E. coli PNA, pseudomonas
multifocal PNA, sternotrophomonas PNA, and aspergillus PNA. Upon
admission, patient's CTA was negative for PE, however showed
multiple bilateral upper lobe opacities consistent with
infectious etiology. Patient underwent endotracheal intubation,
was placed on higher dose steroids given concern for his prior
GVHD, and placed on broad spectrum antibiotics including
vancomycin, cefepime, levofloxacin, and continued azithromycin
and posaconazole. Patient underwent bronchoscopy remarkable for
pseudomonas in sputum, and galactomannan positive titer in BAL.
Patient extubated to high flow NC. Patient also found to be
influenza H1N1 positive, and was started on Tamiflu. Patient
continued on therapy, and ID consulted given persistence of
aspergillus in BAL which would be concerning for worsening
breakthrough infection despite posaconazole and recommended
continued therapy with f/u posconazole level and examination of
resistance patterns. Ganciclovir also added to regimen for
possibility of CMV pneumonitis. Plan was for 14 day course of
cefipeme until ___ for presumed pseudomonas and 28 day course
for Tamiflu (day 1: ___ with continued droplet
precautions for those 28 days. He was also continued on
monteleukast, duonebs MDI, flovent, azithromycin for BOOP. He
continued to improve, hypoxia resolved and he was transfered to
the floor. Evaluated by speech and swallow without concern for
aspiration.
On the floor, patient clinically improved on cefepime, ___,
ganciclovir, and Tamiflu. CMV viral load on ___ was negative.
Ganciclovir was d/c'd and patient was started on acyclovir ppx.
On ___ repeat CMV viral load was detectable so his acyclovir
was changed to PO valgancyclovir 900 bid to transition to 900 qd
once CMV VL neg. Patient was seen by ID who also recommended to
transition him from IV cefepime to PO ciprofloxacin. Patient is
now clinically stable on this regimen. Final Abx regimen
includes: atovaquone, cipro, valganciclovir, posaconaszole,
azithro
# Septic Shock: Patient initially found to be in shock likely
___ to septic shock, and also in the setting of adrenal
insufficiency. Patient was started on increased steroids given
shock, and patient's lactate normalized during stay in the ICU.
.
# MDS ___ MUD x 2 c/b graft failure and GVHD of the lungs, gut,
and skin: Patient was continued on prednisone as above, and was
continued on prophylaxis with acyclovir, atovaquone,
posaconazole given prior history of aspergillus with adjustments
per above. Patient was also continued on urosidiol for gut GVHD.
.
# Sinus Tachycardia: Chronic tachycardia for past few months,
with baseline rates in 100s-120s. This is thought likely
compensatory for poor lung reserve. Patient's home diltiazem was
held initially in the setting of hypotension, and this was then
restarted.
.
# History of Aspergillus PNA: Patient was continued on
posaconazole as an inpatient. Repeat galactomannan titer similar
to previous 2 months ago. ID consulted given question of whether
tracking titers would be appropriate to measure response to
therapy. ID recommended to continue the posaconazole. The
patient became stable and clinically improved. Patient remained
stable on posaconazole.
.
# Hypogammaglobulinemia: Patient was given dose of IVIG, with
immunoglobulin panel done as an outpatient. Patient was
continued on IVIG dosing qweekly, then adjusted to 3x/wk and
finally to 1x/month per ID, currently on treatment dose of
Valganciclovir
.
# Anemia: Patient was also found to be acutely anemic ___ with
h/h 5.7/___.9 for which he was transfused 2 units prbcs. Patient
remained hemodynamically stable and h/h remained stable the
remainder of hospitalization. CTA abd/pelvis showed
spontaneously hyperdense material noted within the cecum and
proximal ascending colon concerning for recent bleed if there
had been no recent
oral contrast administration (we have no record of recent oral
contrast administration at this institution); no active
extravasation. Patient never had melanotic stools or
hematochezia, during hospitalization, however, and patient was
ultimately not thought to have had a GI bleed. H/H remained
stable.
.
# Depression/Anxiety: On the floor the patient appeared to have
a persistent depressed affect with little motivation to get out
of bed or do his ___ exercises. Psychiatry was consulted to
evaluate for depressed mood in the setting of overall decline in
the ___ medical condition with likely terminal illness.
They recommended to continue the patient's mirtazapine and
olanzapine. They also recommended to increase the patient's
Ritalin dose to 7.5 mg and start him on Lexapro. The patient
clinically improved on this regimen with notable increases in
his alertness and improvements in his mood.
TRANSITIONAL ISSUES
====================
- incidental finding: found to have questionable enhancing
nodule at the interpolar region of the right kidney may
represent an proteinaceous or hemorrhagic cyst, evaluation with
dedicated ultrasound is recommended.
- plan to follow-up with Dr. ___ on ___
- ID f/u with Dr ___ on ___
- Pulm f/u with Dr ___ on ___. Per pulm, may benefit from
Chest ___ vest
- will need Non-con CT Chest before pulm f/u apt on ___ to
evaluate for interval change of Pneumonia
- will next need IVIG on ___, was previously 3x/wk but will now
be Qmonthly. Valganciclovir 900mg BID started and acyclovir DC'd
as with detectable CMV, to be downtitrated to 900mg qd once
undetectable. Per ID, will need weekly CMV VL in addition to
regularly scheduled CBC, LFTs, electrolytes while on ABx
- adjusted psych meds as pt was depressed over admission
- if having signs of fluid overload can give 40mg IV Lasix
- NEW HOME MEDICATIONS:
--Zithro 250mg MWF 3x/wk
--Cipro 500mg BID
--Valganciclovir 900mg BID (to be taken until CMV negative and
then titrate down to 900mg qd)
--Senna/Colace for constipation
--Escitalopram 10mg qd
- HOME MEDICATIONS STOPPED:
--Levaquin 750mg qd
--Acyclovir 400 tid
- MEDICATION CHANGES:
--Ritalin 2.5 qd now 7.5 bid
--MS ___ 15 BID now 30 BID
--Olanzapine ___ QAM/QPM now ___
# CODE: Presumed Full
# EMERGENCY CONTACT: Name of health care proxy: ___
Relationship: partner
Phone number: ___
***. | SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
PATIENT:
Mr ___ is a ___ year old male with a history of HIV and dual
diagnosis of depression/EtOH abuse with multiple admissions in
the past for alcoholdetox presents to the ED for treatment of
alcohol withdrawal.
.
.
ACUTE ISSUES
# Alcohol withdrawal: Patient admitted and placed on a CIWA
scale. At maximum, patient scored 14 on the scale and received
10mg diazepam for each score > 10. Started on thiamine, folate,
and a multivitamin and his home keppra was continued. Despite
having a history of delerium tremens and alcohol withdrawal
seizures, Mr ___ remained without significant autonomic
instability and had no seizures while hospitalized. By day 3 of
his hospitalization, he was scoring 1s consistently on the CIWA
scale. Social work was consulted to help with placement for
after-hospital care and resources to help with alcohol
cessation.
.
.
CHRONIC ISSUES
# Fatty liver disease: Transaminases elevated in alcoholic
pattern at admission His LFTs had been higher in the past,
although he had some borderline evidence of synthetic
dysfunction.
.
# Depresion: Patient did not endorse active suicidal ideation or
thoughts of delf harm while hospitalized. He did however, report
significant financial and housing difficulties which led to not
taking his medications and to drinking from 1wk prior to
admission. He was reportedly in danger of being evicted from his
housing. Social work was consulted for assistance in these
matters. Home sertraline continued.
.
# Pancytopenia: Stable from prior. Patient's platelets notably
fluctuated considerably, which was also consistent with past
admissions. Felt to be realted to his HIV. There were no signs
of active bleeding.
.
# HIV: Patient had not taken his HAART medications in the 6 days
preceding his admission. HAART medications were restarted once
hospitalized.
.
.
TRANSITIONAL ISSUES:
# Patient to complete outpatient alcohol detox program
# Please draw platelets at PCP ___ to trend
# Please follow pancytopenia and LFTs in the outpatient setting
to monitor for signs of cirrhosis
# Code: Full (confirmed with patient)
# Contact: ___ (mother) ___
***. | 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.
***
___ yoM with h/o metastatic sarcoma to lungs and metastatic
medullary thyroid carcinoma who presented with acute PE.
# Acute pulmonary embolus: He was incidentally found to have
acute PE on routine CT chest. PE was segmental in right lower
lobe. He endorsed mild DOE but no other symptoms and remained
hemodynamically stable. He was started on lovenox. He had
lower extremity ultrasounds that were negative for DVT. He does
have a port in place and given that this could in theory
contribute to development of thromboembolism and he no longer
needs his port for chemotherapy, it was arranged for him to have
his port removed as an outpatient. He should continue lovenox
until this occurs (tentatively planned for ___ but definite
date being arranged). He will hold his dose of lovenox the night
prior to and morning of his port removal. After this procedure,
he can be bridged to coumadin with goal INR ___. He was
referred to the ___ clinic for management of his
coumadin and his PCP was updated. Would recommend referral to
our ___ clinic to decide appropriate duration of therapy
as not clear if this was provoked, and if it was provoked due to
prior h/o surgeries, it is not likely reversible.
# History of metastatic sarcoma to the lungs, in remission for ___
years: No evidence of recurrence on recent CT. He was seen by
his primary oncologist Dr. ___ admission.
# History of metastatic thyroid cancer, in remission for ___
years: Continued synthroid
# HTN: Stable, continued on chlorthalidone and losartan
# DM2: Controlled without complications, controlled with diet
and metformin
# Hyperlipidemia: Home statin
TRANSITIONAL ISSUES:
- Discharged on Lovenox
- WIll have port removal in next several weeks, being arranged
by ___
- After port removal, can bridge to coumadin. Referral to ___
___ clinic done.
- Recommend referral to ___ clinic to assess duration of
therapy
***. | PULMONARY EMBOLISM WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
ASSESSMENT & PLAN: ___ h/o HTN/HLD, h/o Urosepsis and E.coli
bacteremia, R renal artery occlusion/R renal atrophy presenting
with wt loss, early satiety, loose stools who presents with a
new finding of a pancreatic mass and is now s/p ERCP.
# Pancreatic mass:
# Liver mets
# Diarrhea
Ms. ___ presented with weakness, weight loss, early
satiety, loose stools. Abdominal CT scan showed 4.1 cm
pancreatic head lesion which caused CBD dilation. There was
also associated duodenal constriction (proximal) and SMV
occlusion. There was also evidence of multiple liver metastases
(largest 3.3 cm). Blood tests revealed elevated CEA which was
most c/f pancreatic CA. ___ was pending. She underwent ERCP
with sphincterotomy where a plastic CBD stent placed. It was a
difficult access (stricture in ___ duodenum), and as a result,
EUS guided biopsy of pancreatic mass was unable to be performed
. A brush biopsy was sent, returning as adenocarcinoma. For
further work-up and to assess condition of the liver masses, an
U/S guided biopsy of the liver masses were performed. Pathology
is presently pending. Chest CT for staging purposes showed no
evidence of metastases. The oncology service was made aware and
will follow up with these results and to provide f/u
appointments once the path is finalized. At the time of
discharge, ___, VIP are pending. Patient and family are
well aware of diagnosis and likely poor prognosis (may favor
more palliation). Ms. ___ husband passed away from
pancreatic cancer - and thus there is a good awareness of the
trajectory. Palliative care was also involved and provided
additional information. She will follow up with her PCP and
___, both appointments to be scheduled.
# Hypokalemia/Hypomagnisemia:
This was related to poor PO intake and diarrhea. PPI may also be
contributing. Electrolytes were repleted and were continued to
be normal through the hospital stay.
# Diarrhea.
Checked VIP, stool C.diff PCR. C. diff PCR was negative, VIP
was pending. Diarrhea was improved at time of discharge.
# Rash
# Pruritus: patient placed on sarna lotion. Patient will follow
up further with PCP if it does not resolve with control of
pruritus and less scratching of lesion.
# h/o UTI:
# h/o EColi bacteremia
h/o multiple episodes of UTI/sepsis. In retrospect, possibility
that E. coli bacteremia may be secondary to a biliary process.
Patient had a mildly positive UA at ___. Urine culture
was negative. PCP is planning to coordinate outpatient follow-up
with Urology.
# Encephalopathy:
Has had a significant decline in mental status since THR in
___. She has received B12 supplementation and has been
evaluated by neurology. TSH recently was within normal limits.
Malignancy may be contributing. ___ evaluated patient and felt
she was safe for discharge home with home ___. The daughters
were concerned whether she would be able manage alone (she has
refused home care in the past). Ultimately, after much
discussion, the decision was not to go for SNF, but instead
retry home with services. She was continued on Donepezil,
Sertraline and B12.
# Hypertension:
BP currently well-controlled. HCTZ was discontinued given
hypokalemia. She was continued on metoprolol.
# Hyperlipidemia: statin was stopped given transaminitis and
unclear benefit
# Gout: continued home allopurinol
TRANSITIONS OF CARE
-------------------
# Follow-up: She will follow up with her PCP and ___, both
appointments to be scheduled. ___ and VIP levels will need
to be followed up, as will liver biopsy result. Patient will
follow up further with PCP if rash does not resolve with control
of pruritus and less scratching of lesion.
# Contacts/HCP/Surrogate and Communication: Dr. ___
___ (___)
# Code Status/ACP: Per patient, FC for now. Daughter will
discuss
___ further with patient
***. | 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.
***
This patient is a ___ year old male with history of chronic
ulcerative colitis who is status post dilatation of ileoanal
anastomosis under anesthesia and closure of ileostomy. Pt
received colectomy with ileoanal pouch in ___.
Patient tolerated the procedure well and was brought to the PACU
for a short recovery before being brought to the floor. His
hospital course was remarkable for fevers on POD1 for which he
received blood and urine culture which at time of discharge
revealed no growth to date. Also patient's stool output through
colostomy remained high throughout hospital stay for which pt
was started on Loperamide which was titrated up.
Neuro: Post operatively patient had PCA in place. Once patient
was tolerating oral intake the PCA was subsequently discontinued
and he was transitioned to oral pain medication
(Tylenol/Toradol).
Cardiovascular:Patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Electrolytes
were normal except for phosphorus and was repleted.
Pulmonary: Patient remained stable from a pulmonary standpoint;
vital signs were routinely monitored. Good pulmonary toilet,
early ambulation and incentive spirometry were encouraged
throughout hospitalization.
GI/GU/FEN: Post-operatively, patient was made NPO with
intravenous fluids. POD 1, the diet was advanced to clear sips
until return of bowel function. on POD3 the patient was able to
tolerate clears and his diet was advanced to regular which he
tolerated well. Pt's colostomy output remained high and
therefore pt's Reglan was stopped and pt was started on
Loperamide which was titrated accordingly. The patient did
develop nausea and vomiting; clinical exam and xray suggested
ileus. An NG-tube was placed and the stomach was decompressed
of air and fluid. The NG-tube was removed the next day and the
patient had no further issues with nausea or vomiting. He did
have an issue with high stool output and his bowel medications
were titrated appropriately. He also was started on Ativan for
stomach cramps, which worked well.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. The incision remained
clean, dry, and intact throughout this admission. Patient spike
a fever to 102.1F on POD1 for which blood and urine cultures
were drawn. At time of discharge there was no growth to date on
these cultures. Also patient received a CXR which revealed no
intrapulmonary process. The patient had no further issues.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible and he ambulated well on
the ward.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding well, and pain was well-controlled.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
***. | MINOR 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.
***
___ year old female with history depression and prior suicide
attempt presenting with severe hyponatremia, cholestatic liver
injury, acute kidney injury and encephalopathy found to have E.
coli UTI treated with cipro. Hospital course c/b C. diff
(treated w 14 day course vancomycin) and large melenotic stool
x2 for which she had EGD and capsule endoscopy without
intervention.
# Acute liver injury, cholestatic hepatitis: Pt presented with
a primarily cholestatic pattern of liver injury with mildly
elevated transaminases. However, she had evidenced of impaired
liver synthetic function with encephalopathy, asterexis,
hypoalbuminemia, and elevated INR, high MCV and
thrombocytopenia. Tox panel negative for tylenol x2. Hep viral
panel negative. RUQUS with patent duct, coarsened echotexture,
and patent vasculature. hepatic biopsy ___ revealed fatty
liver and toxic-metabolic injury, without fibrosis. Cholestatis
pattern and impaired liver function thought to be due to post
sepsis cholestasis and liver injury. Briefly got NAC. Liver
function ___ recovered.
# Acute kidney injury: Muddy brown casts seen on urine sediment,
likely ATN. Feeling is that she got extremely hypovolemic from
diarrhea and GNR sepsis at home, and sustained ATN. Did not
require dialysis. Renal ultrasound with patent urinary drainage
system. Patients renal function trended back to baseline. Cr on
discharge 1.3.
#GNR sepsis: Likely urosepsis with E. Coli growing in both urine
and blood. Put on Zosyn and narrowed to Cipro once sensitivities
returned. Was never hemodynamically unstable, though was
tachycardic, which persisted after several liters of fluid.
#C. Diff: Patient presented with loose foul smelling stools and
elevated WBC. C. Diff Positive. Started on PO vancomycin
(___). Her leukocytosis peaked at 30K and downtrended and was
stable at 19K on discharge. she should continue to have her
white count monitored for resolution after discharge.
# Severe hyponatremia: Pt presented to OSH with Na 116 that
improved to Na 120 at ___. Urine lytes, hypochloremia, and
tachycardia all consistent with dehydration with poor solute
intake, hypovolemic hyponatremia. Her sodium continued to
improve with NS resuscitation. (NOTE GOT VASOPRESSIN ON ___
Sodium trended up and Na on discharge stable at 133.
# Encephalopathy: Pt presents with encephalopathy in the
setting ___ and renal failure. Initially concerned for
alcohol withdrawal, but never scored on CIWA. Mental status
cleared as infection was treated.
#Edema - patient developed significant lower extremity edema
after fluid resussitation for sepsis. Likely complicated by
impaired synthetic liver function causing hypoalbuminemia and
deconditioning causing patient to be stationary. Patient was
treated with diuretics and discharged on spironolactone which
should be discontinued as an outpatient once edema has improved.
#Melena- Patient had episode of larg melena overnight on ___.
EGD ___ did not reveal source of bleeding. Follow up capsule
endoscopy on ___ showed some black material from afferent Roux
limb, but no active bleeding. She had no further melena.
Patient was started on pantoprazole 40mg daily which should be
continued for at least 3 months.
#Anemia- Patient was found to have severe anemia thought to be
due to inadequate production after episode of large melena (see
above). She is a Jehovas witness and refused all blood products
so she was treated with 3 days of procrit and 3 months of iron.
She was asymptomatic. She should have her blood counts continued
to be monitored as an outpatient.
Transitional Issue:
- Please check BNP at PCP ___ to trend creatinine (1.6 on
discharge) and potassium levels.
- Please check CBC at PCP ___ to trend H/H (was 6.9/21.7
on discharge). She received Procrit x2 while hospitalized and
was started on ferrous sulfate. She should continue on ferrous
sulfate for at least 3 months.
- Please check LFTs at PCP ___ to trend AST, ALT, and
Bilirubin. These were 92, 82, and 11.0 on discharge,
respectively.
- ___ she was clinically well on discharge, her WBC was 19
and she was still having frequent stool (although formed). She
has ID ___ and if there is a concern for non-resolving C.
Diff or recurrent infection, would need futher treatment.
- Patient was counseled on abstinence from alcohol in the
setting of alcoholic liver disease. Please continue to counsel
her.
- Patient was seen by physical therapy prior to discharge and
provided with a script for outpatient ___.
- Given melena and possible bleeding from Roux limb (which
stopped while hospitalized), she was started on a daily PPI. She
should continue this for at least 3 months.
- She was started on spironolactone 50mg daily to help with
lower extremity edema (along with her hypokalemia). When edema
resolves, please stop spironolactone. She does not need this
long-term.
- When hyponatremia resolves, restart citalopram for depression,
but monitor sodium levels.
***. | SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is a ___ male with seronegative arthritis
(possible ankylosing spondylitis) who is bedbound and on chronic
prednisone, DVT/PE (previously on enoxaparin), h/o MDR UTIs, and
nephrolithiasis, who was most recently admitted (___) for
Klebsiella and Proteus UTI for which he was treated with
etrapenem for 14 days, who was brought to the ED by his rehab
for dysuria after refusing PO antibiotics, found to have C.
difficile colitis.
ACUTE/ACTIVE PROBLEMS:
======================
# Urinary tract infection:
Of note, recent admission for Klebsiella UTI in ___ for
which he completed a ___ ertapenem course who was transferred
from nursing home to the ___ ED on ___ with 1 month history
of dysuria with no systemic evidence infection otherwise. ID
consulted & guiding therapy. Of note, they questioned these
"recurrent" UTIs/positive urine cultures as being possibly
driven by an infected renal staghorn calculus. This was
discussed with his urologist, Dr. ___ concern was
that there is no definite proof that the left sided renal stones
are infected, since there are only 2 different positive urine
cultures in the last few months, with 2 different organisms
(Proteus & Klebsiella). PICC line placed (with ___, and
anesthesia using MAC, not GA).
-- Treated with meropenem, d1 = ___ , with transition to
ertapenem on discharge per ID, plan for 14 days (final day =
___.
-- Per Dr. ___, would like to see another sample
or 2 positive for the same pathogen with similar susceptibility
patterns to support diagnosis of infected stone; if this is
demonstrated, then the plan may be going forward is to place a
nephrostomy on the L side, and monitor urine culture from within
the kidney. If the same pathogen grows, he may need surgical
intervention, though acknowledging that it would be a
complicated procedure, with the need for multidisciplinary
surgical intervention.
-- NOTE INSTRUCTIONS BELOW FROM ___ INFECTIOUS DISEASES
REGARDING URINE CULTURES GOING FORWARD
# Recurrent C. difficile colitis:
He was started on metronidazole in the ED which he has been
refusing because he says it never works for him. Started on PO
vancomycin. Treated with vancomycin 125 mg PO QID, while on
antibiotics for UTI (until ___, and with taper after, as
below:
- 125 mg twice daily for 7 days, followed by
- 125 mg once daily for 7 days, followed by
- 125 mg every other day for 7 days, followed by
- 125 mg every 3 days for 7 to 14 days
CHRONIC/STABLE PROBLEMS:
========================
# History of DVT/PE
Home enoxaparin ordered, however patient reports this was
stopped by his PCP ___. Discussed role of prophylactic
enoxaparin during hospitalization, citing risk for recurrent
DVT. Patient understands this and declines DVT prophylaxis. Used
mechanical DVT prophylaxis.
# Seronegative arthritis
# Chronic pain
Continued home gabapentin, hydromorphone, methadone, prednisone
20 mg daily. Continued home TMP-SMX for PJP prophylaxis.
# Major depressive disorder
# Generalized anxiety
# Bipolar disorder
Continued home quetiapine and home clonazepam
====================
TRANSITIONAL ISSUES
====================
-- IV ertapenem, final day = ___
-- PO vancomycin, 125 mg QID until ___, then begin taper as
below:
- 125 mg twice daily for 7 days, followed by
- 125 mg once daily for 7 days, followed by
- 125 mg every other day for 7 days, followed by
- 125 mg every 3 days for 7 to 14 days
====================
TIME ATTESTATION
====================
45 minutes spent on care coordination & discharge planning.
=============================== ============================
INSTRUCTIONS FOR CARE AT ___ RE: GETTING URINE CULTURE
=============================== ============================
Instructions for the rehab/SNF/NH in regards to getting urine cx
from here onwards:
- try to avoid oral abx treatment unless clinically felt to be a
UTI including looking for fevers and/or leukocytosis as dysuria
may not be a symptom necessarily of a UTI alone - however
clinical review by an MD ___ ultimately decide if treatment
needed or not
- if c/f UTI, then please obtain a urine sample at the best of
your ability with a STRAIGHT CATHETERIZATION to obtain a good
urine sample as per Dr. ___ - if the same
pathogen of klebsiella or proteus grows again then will need to
notify Dr. ___ office about this
- PICC line with abx is not needed for dysuria alone
***. | MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mrs. ___ was an ___ year-old woman with atrial fibrillation
on warfarin, history of cystic carcinoma, and basal cell
carcinoma who presented with anemia, fatigue, and guaiac
postive stool concerning for GI bleed.
.
# Anemia - Mrs. ___ was found to have a hematocrit of 25%
on presentation in the setting of aspirin, Plavix and warfarin
use with a guaiac positive stool. This presentation was
suggestive of a gastrointestinal bleed. Her low iron, high TIBC
and low-normal ferritin were diagnostic of iron deficiency
anemia. She received 2 units of packed red blood cells with an
appropriate rise in her hematocrit. An her hematocrit remained
stable throughout her hospitalization. Mrs. ___ had
difficulty completing the bowel preparation with golytely and
required an extended bowel preparation consisting of a clear
liquid diet and magnesium sulfate for two days. An EGD performed
revealed numerous healing erosions in the esophagus and stomach,
but no lesion that could easily explain her acute drop in
hematocrit. The colonoscope was unable to be advanced beyond the
rectum and no lesions were identified within the rectum on
colonoscopy. A CT (virtual) colonoscopy was performed and
revealed no concerning mass. She was advised to continue taking
pantoprazole twice daily and to maintain close follow up with
her PCP and the ___ clinic as needed.
.
# Atrial fibrillation - She was appropriately rate controlled in
the 70-80s with her home dose of metoprolol 50mg BID ___
daily). Her warfarin had been held in the setting of a suspected
GI bleed with anemia and guaiac positive stool. She became
tachycardic with atrial fibrillation with rapid ventricular
response on two occasions during her admission; these episodes
always involving a missed metoprolol dose because the patient
was away receiving a procedure or imaging. She received
intravenous metoprolol and diltaizem to quickly achieve rate
control during the two episodes tachycardia and resumed
appropriate control with her home dose of metoprolol. She was
discharged on her home dose of metorolol. Her INR uptrended from
1.5 on admission to 2.1 on the day of discharge despite holding
her warfarin while in house. On discharge she was advised to
take one 2mg dose of warfarin two days after discharge and again
four days after discharge and present to her PCP's office six
day after discharge to check her INR and adjust her warfarin
dose.
# Hypertension - She was continued on her home dose of
metoprolol 50 mg BID throughout her hospitalization and on
discharge
# CAD: - She was continued on her home dose of metoprolol,
Plavix, Aspirin
# Depression - She was continued on her home dose of sertraline
***. | G.I. HEMORRHAGE WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with history of diabetes mellitus, ___ ___ ablation ___,
NICM (last EF ___, ___ ICD, CRT-D, SVT ablation ___,
reportedly non-adherent with therapy, alcohol abuse presents
with
worsening of SOB, ___ edema to ___, transferred for concern for
cardiogenic shock
#CORONARIES: normal in ___
#PUMP: Severe systolic dysfunction (EF ___
#RHYTHM: V-paced
============================
ACUTE ISSUES
============================
#Acute on chronic systolic HF
#Cardiogenic shock - resolved
Mr. ___ presented with exertional shortness of breath in the
setting of not being able to obtain his medications during a
move from ___ back to ___. He was seen initially admitted
to ___ and diuresed. However, he
subsequently became hypotensive during his admission. RHC was
performed with elevated PCWP to 21 and CI of 1.2. TTE was also
performed that was significant for EF ___, severe global
hypokinesis, Severe MR, Severe TR, and biatrial enlargement.
Patient was started on dobutamine 2.5 mg and dopamine 2.5 mg and
transferred to ___ CCU for further management. After transfer,
he was subsequently weaned from dopamine. He was initiated on
Lasix boluses before being started on Lasix gtt and diuresed
well. With diuresis, he was able to be weaned off of pressors
and his dyspnea improved. He was able to be transferred to the
regular nursing floor and was restarted on his home afterload
reduction (hydralazine and isosorbide dinitrate) and beta
blockage (carvedilol). He was also started on spironolactone
while in the hospital. The patient continued to improve, and was
able to be discharged home with follow-up with both cardiology
and heart failure.
#Hyperbilirubinemia
At admission, the patient was noted to have a hyperbilirubinemia
to 2.3. Fractionation revealed a conjugated hyperbilirubinemia.
The patient also had mild tenderness to palpation in the RUQ,
which improved during his hospitalization. His
hyperbilirubinemia appeared to be elevated since ___ based
on review of OSH records. The patient also had a prior US in
___ showing hepatic steatosis and abnormal gallbladder. We
felt the likely etiology of his hyperbilirubinemia was mixed
congestive hepatopathy and steatosis.
#Microcytic anemia - The patient has a stable anemia with Hgb
10.6 in ___. Transferrin sat 7.7% with borderline low
ferritin 49, consistent with iron deficiency. The patient was
given IV ferric gluconate for repletion without significant
improvement in his Hgb.
___ on CKD
At admission the patient's Cr was measured as 2.27, elevated
from 1.97 on ___, felt to be likely cardiorenal. Improving
with diuresis as anticipated.
#History of ETOH use - last drink 3 months ago
#History of homelessness and difficulty getting meds - SW c/s
====================
TRANSITIONAL ISSUES:
====================
[] Advanced HF follow up - scheduled for ___ at ___, but
please make sure patient goes to this follow-up
[] Cardiology follow up
[] PCP follow up
[] Chem-10, CBC, and LFTs in 1 week
[] Continue to work up iron deficiency anemia as an outpatient
if not already done
NEW medications: None
CHANGED medications:
- Carvedilol 3.125 twice a day (decreased dose from 6.25mg)
- Isosorbide Dinitrate 20mg three times a day (increased
frequency from BID and dose from 10)
- Spironolactone 12.5 mg daily (decreased frequency from BID)
- Hydralazine 10mg three times daily (increased frequency from
BID)
STOPPED medications:
- Metolazone - restart after your doctor tells you to
___ weight: 57.5kg, 126.76 lb
Discharge Cr: 1.7
Discharge Hgb: 9.4
#CODE: Full
#CONTACT/HCP: Mother ___ ___
***. | 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.
***
Mr. ___ is a ___ gentleman with history of hypertension,
hyperlipidemia, HFpEF, restless leg syndrome, opioid use with
opiate agreement, presenting with restless leg symptoms.
ACUTE/ACTIVE ISSUES:
====================
#Cellulitis:
Patient presented with right lower extremity redness and pain.
Exam consistent with cellulitis. Initially on ceftriaxone.
Switched to Keflex at discharge.
#Acute encephalopathy:
Patient had reported confusion at admission and was unsure why
he came to the hospital or how he had gotten there. However, by
the time of presentation, he was fully oriented without any
issues with mental status. CT head was obtained and was only
remarkable for global involution and chronic microangiopathic
changes. By the morning after presentation, the patient was
alert and oriented x3 with intact attention as assessed by
days-of-the-week-backwards, was able to follow two step
commands, and had normal remote recall. Overall etiology was
felt to be potentially related to multiple narcotic medications,
although it was unclear at time of discharge.
#Restless leg syndrome:
Patient has poorly controlled symptoms of restless leg. Per OMR,
plan was to transition to methadone from oxycodone for symptom
control given burden of frequent dosing, but per med refill
history the patient filled a month's supply of methadone
initially in ___ but has not filled it since then. We
recommend further follow-up as an outpatient for adjustment of
pain regimen.
#Urinay retention:
Patient reported urinary frequency during his hospitalization.
Bladder scans were performed and post-void residuals were not
large enough to require straight catheterization. He was
continued on his home Tamsulosin. We recommend further work-up
as an outpatient for lower urinary tract symptoms.
#Normocytic anemia:
Patient's hemoglobin was noted to be 11.5 from 13.8 several
weeks ago, although recheck had corrected to 12.4. We recommend
recheck of Hgb as an outpatient and age-appropriate cancer
screening.
CHRONIC/STABLE ISSUES:
======================
#HTN:
Continued home lisinopril, amlodipine, carvedilol.
#GERD:
Continued home omeprazole.
#HFpEF:
Continued home furosemide.
TRANSITIONAL ISSUES:
====================
[] TSH and B12 were pending at discharge. Please follow-up and
address as necessary.
[] Patient was diagnosed with cellulitis for which he was
discharged with a seven day course of cephalexin (total 10 days
of therapy). Please follow-up on the patient's lower extremity
pain and redness and make sure he completes his antibiotic
regimen.
[] Please follow-up the patient's lower urinary tract symptoms
as an outpatient
[] We recommend further follow-up and potential work-up for
anemia as an outpatient, including age-appropriate cancer
screening.
# CODE: Full presumed
# CONTACT: ___, daughter, ___
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
***. | CELLULITIS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
ASSESSMENT AND PLAN: Mr ___ is a ___ M with a h/o CAD s/p
multiple interventions and systolic HF with EF 30% transferred
from ___ with burning epigastric chest pain likely
related to gastritis.
.
ACTIVE ISSUES
=============
# CORONARIES: PMH significant for multiple PCIs followed by CABG
in ___, he had a cardiac catheteriztion at ___ in ___
which showed no intervenable lesions and stress MIBI ___ at
___ a fixed perfusion defect in the inferior wall. According
to the myocardial perfusion scan report obtained from ___
___, an inferior wall lesion is seen which does not likely
represent an area of new ishcemia. He was ruled out with two
sets of enzymes at ___ (records obtained and entered
in chart). EKG is consistent with old inferior wall infarct
without evidence of new ischemia. His chest pain is unlikely to
be related to myocardial ischemia. Continued beta blocker,
statin, aspirin, plavix, imdur without dose changes. He has not
seen his primary cardiologist in ___ years due to geographic
limitations, encouraged patient to seek cardiologist who is
closer to him by asking his PCP for ___ referral.
.
# Abdominal Pain and burning chest pain: Related to
gastroesophageal reflux disease, patient reported symptoms of
burning chest pain were improved by food, made worse by taking
his medications on an empty stomach. H. pylori serologies were
sent and wer epending at the time of discharge. We started
Sucralfate, provided him with a handout on GERD and encouraged
him to take his medications with a small amount of food.
.
INACTIVE ISSUES
=============
# PUMP: Last TTE showed EF 30% with global hypokinesis related
wit ischemic cardiomyopathy with chronic congestive heart
failure with systolic dysfunction. Currently patient appeared
euvolemic. Continued home regimen of ACE, Aldosterone
antagonist, beta blocker, and aspirin.
.
# RHYTHM: Has history of NSVT and depressed ejection fraction
and has a ___ ICD. Continued home mexilitine,
sotalol.
.
# Psychologic Issues: Continue home regimen including home pain
meds
.
# HTN: continue home meds.
.
# Pain medication seeking: patient requested prescription for
percocet for abdominal pain, discussed that this would be doing
more harm than good and did not give him new Rx.
.
TRANSLATION OF CARE:
====================
- Issues needing followup: pending h. pylori serologies
- Social: patient reported low socio economic class and poor
access to food and money. Will benefit from social work in the
future.
CODE: Presumed full
EMERGENCY CONTACT: Sister ___ ___
***. | 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.
***
Mr. ___ presented to ___ holding at ___ on ___ for
a laparoscopic right colectomy. He 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.
On POD1 the patient's pain was well-controlled and he had no
nausea or vomiting. He was advanced to a clear liquid diet. He
tolerated this diet well and was subsequently transferred to PO
pain medications and his fluids were discontinued. On POD2 the
patient was advanced to a regular diet. He tolerated this diet
well and his pain was controlled on PO pain medications. He was
discharged home on POD2 with follow-up in the clinic with Dr.
___.
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 rehabilitation 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
discharge.
[x] No social factors contributing in delay of discharge.
***. | MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year old man with known non-displaced hip fracture who
presented this time with a fall after stepping on ice cube.
Films in the ER did show same acute/subacute non-displaced hip
fracture (Left inferior pubic body and superior pubic rami
acute/sub-acute fractures, more clearly seen compared with
radiograph from ___
)without new findings except for mild asymmetrical cortical
thickening of the proximal and mid left femur seen only on the
oblique views. This may represent area of prior subacute
fracture. A follow up testing may be indicated in out patient if
he continues to have anterior thigh pain. He denied any symptoms
except for anterior thigh pain. He had no syncope. His physical
exam was unremarkable. He was able to ambulate with minimal pain
in the thigh. He does have maximal home services and he uses a
wheel chair occasionally. He has chronic asymptomatic
hyponatremia on Lasix and oral fluid restriction. He agreed to
discharge to home after receiving a meal in the hospital as
there is no need for further diagnostic tests at this moment. He
can ambulate. He can arrange for ___ with his PCP with close
follow up for his chronic asymptomatic hyponatremia. He can also
follow up with orthopaedic surgery for the non displaced
fracture. All of the above was communicated with him.
***. | FRACTURES OF HIP AND PELVIS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
This is a ___ year old single, domiciled, employed man with past
medical history of hyperlipidemia, Type II DM, Hypertension,
intellectual disability with history of depression, anxiety, no
prior psychiatric hospitalizations or suicide attempts, who
presents to ___ complaining of worsening anxiety and abdominal
discomfort with frequent ED presentations in the setting of his
brother leaving the ___ area.
Interview with Mr. ___ was limited, given that he is a
relatively poor historian, likely secondary to his intellectual
disability, but concerning for worsening of baseline anxiety in
the setting of recent decrease in his clonazepam and loneliness,
anxiety that his brother was no longer in town. Mental status
examination notable for anxious appearing man who is cooperative
and pleasant with interviewers, good hygiene and grooming,
denial of suicidal ideation or homicidal ideation, with thought
process that is somewhat disorganized and tangential (likely due
more to significant anxiety in the setting of intellectual
disability).
.
Diagnostically, etiology of presentation is consistent with
worsening generalized anxiety disorder with limited coping
skills and reported panic attacks. Of note, although patient
complained of depression at times, he was mostly euthymic on
examination once his anxiety improved with limited
neurovegetative symptoms during this admission.
#. Legal/Safety: Patient was admitted on a ___ upon
admission he signed a CV, which was accepted. He maintained his
safety throughout his hospitalization on 15 minute checks and
did not require physical or chemical restraints.
#. Generalized anxiety disorder: with features of depression as
noted in HPI.
- Patient was compliant in attending groups and maintained
excellent behavioral control throughout his admission. He
participated appropriately in the milieu and was noted to be
bright with peers and staff.
- Given reports of depression, anxiety and difficulty sleeping,
we discussed the risks and benefits of Remeron, which was
started at 7.5 mg po qhs and titrated up to 15 mg po qhs.
- To target significant anxiety, we discussed the risks and
benefits of converting Clonazepam to Valium, given Valium's
quicker onset of action. Valium was started and titrated to 5 mg
po bid, which Mr. ___ tolerated well with no episodes of
confusion and without excessive sedation.
- Despite the above medications, patient continued to experience
significant anxiety and after discussion of the risks and
benefits, we initiated Gabapentin 100 mg po tid with the
recommendation to cross titrate Gabapentin up and Valium down as
tolerated to avoid tolerance and to avoid polypharmacy.
- Of note, Mr. ___ consistently denied suicidal ideation or
thoughts of self harm throughout his psychiatric hospitalization
with no unsafe behaviors. In the setting of the above medication
changes and the stabilizing environment of the milieu, Mr.
___ anxiety improved significantly and he was amenable to
discharge with referral to ___ to help with his medication.
- The treatment team worked closely with Mr. ___ PCP and
outpatient psychiatrist who agreed to the above assessment and
plan.
#. Abdominal pain: ___ complained of abdominal pain
associated with his anxiety. He was evaluated in the ED which
was negative for acute ischemia. He also had a CT abd/pelvis
performed which was significant for bladder distention without
hydronephrosis. ___ denied any difficulty urinating. This
distention was thought to be possibly secondary to BPH. His PCP
is aware of this finding and will continue to follow this.
#. HLD: stable
- Patient was continued on atorvastatin 80mg QHS
#. HTN: stable
- Patient was continued on Coreg 25mg BID, Lisinopril 40mg
daily, and Chlorthalidone 25mg Daily. BPs were well controlled
throughout admission.
#. Type II DM, non-insulin dependent.
- Initially his oral hypoglycemic were held in the setting of
metabolic acidosis. He was covered with an insulin sliding
scale during that time. He was re-started on metformin 1000mg
BID and Glipizide 5mg (previous dose 10mg daily). Again, his
PCP was notified of this and will continue to follow his blood
sugars and recommend further changes in management.
***. | ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Following an uncomplicated surgery, the patient was admitted to
the ORL service.
Diet was advanced and hope medications were started. Initially,
blood pressure was elevated but was then controlled with home
medications. Drain output from a single JP drain was
appropriate. The drain was removed when standard criteria were
met.
Heme: prophylatic heparin was used during the hospitalization.
ID: Ancef was used for coverage during hospitalization.
GI: Diet was advanced as tolerated
Wound: no evidence of wound complications
CV: the patient was initially hypertensive post-op but pressures
normalized with home medications.
At the time of discharge, vitals were stable and the team and
staff agreed on discharge.
***. | LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURE WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ yo F with history of dementia (TBI vs LBD vs pseudodementia)
and hypotension who p/w with near syncope and second episode of
UTI in the setting of confusion.
# AMS - Acute on chronic confusion in the setting of ? UTI and
decreased PO. She was oriented only to self. Patient was
delirious following ___ admission for pyelonephritis and
never returned to baseline. During this admission she had no
obvious inciting medications or infectious sources other than
possible UTI. She was initially treated for UTI as below, but
given culture later returned negative was unlikely to have had a
true infection. Her altered mental status may have been
secondary to her progressing dementia with fluctuating levels of
confusion.
# ? UTI - Patient was previously treated for pyelonephritis in
___. Urine culture from ___ grew enterococcus and was
started 7 day course of macrobid on ___. On admission, patient
had T 101.6 F without CVA tenderness, but denied dysuria or
hematuria. U/A (x2) during current admission was unremarkable in
the setting of 1 day on macrobid. She was treated with IV
CTX/vanc based on prior culture data and was discharged on a 3
day total course of ciprofloxacin for uncomplicated UTI. Urine
culture later returned post discharge with no growth, and
patient and family were instructed to discontinue antibiotics.
Fever was thought to possibly be secondary to autonomic
dysfunction in the setting of ___ body dementia.
# Near syncope - Likely d/t hypovolemia in the setting of
decreased PO. She has a history of orthostatic hypotension with
recent presentation to ED on ___ for dizziness that responded
to IVF. Her orthostatic hypotension was thought to possibly be
due to autonomic dysfunction in the setting of ___
body dementia.
# Dementia - Followed by Dr. ___ neurology for ___
dementia vs TBI vs psuedodementia. Improved with donepezil.
Transitional Issues
==========================
- discharged on PO cipro to complete 3 day antibiotic course.
Urine culture returned negative on day after discharge and
patient and family instructed to discontinue antibiotics
# CODE STATUS: Full Code per husband, will verify with daughter
# CONTACT: ___, daughter: ___ (cell)
___ (home)
***. | KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Mr. ___ is an ___ man with recently diagnosed ___
with metastatic pancreatic cancer with known mets to bone who
was transferred for abdominal pain, nausea, vomiting, decreased
PO intake. EGD/EUS demonstrated 5cm oozing mass at fundus of the
stomach and malignant duodenal stricture s/p stenting. Biopsies
of gastric, duodenal and pancreatic mass all showed
adenocarcinoma, poorly differentiated. Per evaluation during
admission, patient's functional status is too low for
chemotherapy and radiation is unlikely to provide benefits to
outweight risks of toxicity. At discharge, Patient was able to
tolerate minimal amounts of food, but functional status is still
quite limited. Plan for follow up with GI oncology once
functional status improves.
#Gastric outlet obstruction
#Gastric Mass
#GI Bleed: Per patient report, EGD at OSH was notable for "large
mass in the stomach". Patient required transfusion of multiple
units of PRBCs prior to transfer to ___. EGD at ___
demonstrated 2.5x3.5cm mass in the head of the pancreas along
with 5cm oozing mass in the fundus of the stomach consistent
with inflammatory polyp v. metastatic deposit. EGD at ___
demonstrated malignant duodenal stricture, s/p successful
placement of duodenal stent. Biopsies of gastric, duodenal and
pancreatic mass all showed adenocarcinoma, poorly
differentiated. Patient was started on a low residue diet, which
he tolerated although he still had poor appetite. He was
continued on pantoprazole and zofran. We will continue to try to
increase p.o. intake prior to consideration of chemotherapy as
an outpatient.
#Metastatic pancreatic cancer: Metastatic pancreatic
adenocarcinoma to liver and bone in ___, now with biopsies
of gastric, duodenal and pancreatic mass during this admission
consistent with adenocarcinoma, poorly differentiated. Patient
was seen by radiation oncology who felt that palliative
radiation would not benefit patient and would likely have
significant toxicity. Chemotherapy deferred given poor
functional status, but will consider single-agent gemcitabine as
an outpatient if nutritional status improves. Nausea controlled
with Zofran.
#Bilateral DVTs: Patient with asymmetric calf swelling noted on
___. LENIs demonstrated bilateral DVTs. Patient denied dyspnea
and had no tachycardia or hemoptysis to raise concern for PE. He
was initially started on heparin at decreased rate given recent
GI bleed. His hemoglobin remained stable, so he was transitioned
to lovenox. Patient had difficulty learning to use lovenox shots
given eyesight and coordination. Was provided with option to
start rivaroxaban instead, despite knowledge that it may be
inferior for treating malignancy associated DVT and he preferred
to switch. He was provided with a prescription for rivaroxaban
15mg twice daily for the next 3 weeks followed by 20mg daily.
#Upper extremity erythema: Patient had area of erythema on left
upper extremity where he previously had an IV. Likely
infiltrated IV. Ultrasound negative for DVT and no evidence of
superficial thrombophlebitis. He will continue to monitor
post-discharge.
# Concern for raynauds: Patient with pale digits overnight
during admission. Labs to assess for scleroderma, ___ negative,
anti-centromere negative, scleroderma antibody neg. RNA
POLYMERASE III AB still pending, but raynauds is unlikely given
other labs are negative.
#Glaucoma
#Corneal opacification and band keratopathy: Hx of left open
globe injury He was continued on:
erythromycin ointment TID to the left eye. dorzolamide/timolol
2% 1 drop R eye BID timolol 0.5% L eye BID brimonide tartrate 1%
R eye BID lubricant eye drop BID
# HLD
Continued on atorvastatin 10mg daily
# Allergic rhinitis
Continued on fluticasone 2 spray nasal daily
# IPF: Patient with reported history of IPF and uses BIPAP.
Continued home bipap at night
# GERD
He was placed on pantoprazole IV as above, which will be
transitioned back to PO after d/c.
# HTN
Olmesartan was held. Can consider restarting after discharge if
develops hypertension.
Transitional Issues
===================
[] Follow up appointment with GI Oncology scheduled for ___
with Dr. ___ consideration of treatment with gemcitabine
pending improved functional status.
[] Consider initiating cycle of gemcitabine pending in
improvement in functional status.
[] Patient started on rivaroxaban for treatment of DVT. Please
check CBC at follow on ___ to ensure stability of CBC.
[] Continue low residue diet to reduce risk of stent blockage
[] Patient not scheduled with follow up with advanced endoscopy.
Consider referral to advanced endoscopy if symptoms persist or
has recurrence of nausea/vomiting.
[] Patient well controlled inpatient on glargine. He will
continue on 12u detemir nightly. Will not be taking reiniated on
glipezide.
[] RNA polymerase pending to complete workup for scleroderma
given possible Raynaud's with history of IPF.
[] Biopsies of gastric, duodenal and pancreatic mass during this
admission consistent with adenocarcinoma, poorly differentiated.
[] Olmesartan was held given normotension. Can consider
restarting after discharge if hypertensive.
[] Consider referral to ___ for diabetes management if
continues with difficult to control blood glucose.
# HCP/Contact:
Name of health care proxy: ___
Relationship: daughter
# Code: Full Code (confirmed)
***. | COMPLICATED PEPTIC ULCER WITH CC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
*** year old female well known to cardiac surgery services. She
is s/p cardiac surgery with ___ on ___. She presents
to the ED today complaining of shortness of breath and rapid
heart rate, on Keflex for sternal wound. CXR shows
pulmonary edema. She was admitted to ___ for further work up.
She was initially placed on Cefazolin for her sternal wound.
Blood CXs and labs drawn,ECG and diuresis with IV Lasix was
initiated. Her sternal wound had been debrided the day prior on
___ 6 by ___. The wound is C/D with the inferior pole open
and packed with a wet to dry dressing in place. Continue
anticoagulation for AFib with Coumadin. TTE done which revealed:
The aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. The mitral
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. Moderate to severe [3+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. She continued to
diurese and was rate controlled on Amio, and increased Diltiazem
and Lopressor. HD#4 she was ready for rehab when hematuria was
noted. ___ wanted to keep her for further observation. Her
UA/CX was negative and her urine cleared throughout the
morning.Physical Therapy was consulted for evaluation of
strength and mobility. By HD#5 she was cleared for discharge to
___. Blood Cxs at discharge were No Growth
to Date. All follow up appointments were advised.
***. | HEART FAILURE AND SHOCK 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.
***
___ is a ___ woman with a history of
fibromyalgia, migraines, GERD, IBS, depression and narrow angle
glaucoma who was admitted after visual disturbances and
confusion and was found to have a right parietal tumor s/p
___ transferred to the OMED service for HD MTX.
1. Right Parietal Tumor/PCNSL: s/p resection on ___,
pathology confirmed Diffuse Large B cell lymphoma. Patient
tolerated methotrexate without adverse reaction and cleared
well. She was continued on dexamethasone 4mg q8h while on the
OMED service, to be downtritated to 4mg BID on discharge.
Patient also continued on keppra 500mg BID for seizure
prophylaxis. Next scheduled admission will be ___.
Transitional Issues
===================
- next admission scheduled for ___
- will need port placed at next chemo admission in 2 weeks
- discharged with 24 hour urine collection kit
- will continue with dexamethasone 4mg BID until next admission
with plan to taper and defer prophylaxis at this time.
- f/u TTE read
- will need removal of surgical sutures
***. | LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER 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.
***
Mr ___ is a ___ old man with a past medical history of
non-Hodgkins lymphoma status post allo SCT in ___, recent
history of MRSA and Pseudomonas sinusitis as well as Pseudomonas
pneumonia who was admitted from clinic on ___ to ICU for
shortness of breath, hypoxia, pulmonary infiltrates occuring in
the setting of magnesium infusion.
.
#. Acute cardiopulmonary episode - On initial presentation, pt
with acute SOB, crackles, rigors, hypertension, and tachycardia.
Differential included PE, MI, anaphylactic reaction, line
infection, or pulmonary flash. In the ICU, he was found to have
multilobar consolidations (and absent PE) on CXR and CT, and
empiric treamtent for pneumonia was begun with vancomycin and
meropenem. He had a recurrent episode of tachycardia,
hypertension, and chills/rigors after the ___ was used on
___ overnight. With this evidence and blood cultures positive
for Klebsiella, his right subclavian Hickman was removed on
___. Discharged on Ciprofloxacin.
.
#. Non-Hodgkin's lymphoma. CT scan on ___ continued to
show response to his transplant. There is a long-term plan to
repeat CT scans of the torso and sinus CT on ___ after he
completes his antibiotics for his pneumonia. Continued
post-transplant prophylaxis.
.
#. GVHD, chronic extensive. (As per ___ clinic note). Mr. ___
has had a persistent
rash, thought at first to be related to a drug rash, but now
biopsy-proven GVHD. His PUVA therapy remains on hold. His liver
enzymes are markedly improved.He will decrease his prednisone to
15 mg and continues on started Entocort. He remains on a low
dose of Neoral. His skin is darker in tone but with some lighter
areas and his rash overall is improved. He has hypopigmented
areas. He will continue to use Clobetasol ointment on his hands
every other night with gloves.
.
#. Hypertension. Continued outpatient regimen
.
#. Steroid induced diabetes. Stable on the Glipizide. While his
prednisone is tapered we will need to keep a closer eye on his
blood sugars.
***. | OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ with hx of COPD, Alzhemer dementia, atrial fib not on
coumadin, recent recent M2 stroke (___), severe AS presented to
___ from SNF for unwitnessed fall and traumatic SAH.
Neurosurgery recommended holding aspirin for 7 days. Patient was
admitted in setting of altered mental status. She was started on
standing 7PM olanzapine to normalize sleep-wake schedule and
prevent delirium.
#Toxic-Metabolic Encephalopathy
#Alzheimer's Dementia
#Recent CVA
#Concussion
#___
Patient with multiple causes for altered mental status. Her CT
scan and exam are reassuring that this was not a new CVA. I
suspect the combination of recent stroke in setting of
___'s dementia had already set her mental status back. Now
with addition of head trauma and SAH, she became more
confused/lethargic. She became more alert throughout her
hospital course although was oriented only to self and had poor
safety awareness. Her aspirin should be restarted ___. Her
donepezil was held to avoid any anticholinergic side effects.
Atorvastatin was continued. Olanzapine 2.5mg was started q7PM,
but should be attempted to be weaned off as mental status
improves. On day of discharge, pt had no complaints.
# Fall, ?syncope
Patient with unwitnessed fall(s) at rehab. She denied LOC and
any alarm symptoms, including no chest pain, palpitations, or
shortness of breath. Fall is likely due to recovery from stroke
and poor self/safety awareness. Troponin negative. CXR without
infection. Recent TTE with AS. Consider further cardiology
follow up, if intervention would be within patient and family
goals. Patient is asymptomatic.
# UTI: She was treated with ceftriaxone 1g q24h x5 days
#COPD: continued home inhalers, used formulary substitute for
symbicort
#HTN: Held lisinopril in setting of normotension
#CODE: DNR/DNI per her granddaughter (HCP); ___ discussed over
phone and confirmed DNR/DNI by ___, witnessed by Drs.
___.
#COMMUNICATION: granddaughter ___ ___
TRANSITIONAL ISSUES
===================
- Consider stopping olanzapine q7PM as mental status improves
- Restart aspirin ___
- Donepezil held I/s/o delirium; consider restarting if
improving
- Restart Lisinopril 10mg if she becomes persistently
hypertensive
- Encourage normal sleep/wake cycle
- Delirium precautions
- Continue physical therapy, occupational therapy for fall
safety
- Consider repeat TTE vs cardiology follow for recent
___ TTE with aortic stenosis
***. | TRAUMATIC STUPOR AND COMA COMA <1 HOUR 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 right-handed man with past medical history
significant for hyperlipidemia, coronary artery disease,
multiple orthopedic injuries and a history of intermittent neuro
deficits with multiple negative work-ups who presented for
evaluation of acute bilateral leg weakness.
#Functional Neurologic Disorder
Patient has had multiple extensive work-ups since ___ for
various neurological complaints by different providers which has
all been unremarkable (has seen epilepsy, movement, autonomic
and cardiology specialists). He has carried a diagnosis of
function neurologic disorder in the past. He presented this
admission with acute onset bilateral leg weakness and sensory
loss. MRI total spine revealed worsening degenerative disease in
the cervical and lumbar spine without any acute pathology. These
findings are out of proportion to his complaints/examination. On
confrontational testing has at least 4+/5 strength in his lower
extremities, a positive Hoover sign, and sensory loss in a
non-dermatomal distribution consistent with functional disorder.
Given his history of vascular risk factors, spinal AVM is on the
differential but is unlikely. CT abdomen shows severe
atherosclerotic disease.
#CAD
Continue ASA 81mg daily. Start statin per below
#Atherosclerosis
LDL is 190. Patient has been on atorvastatin in the past.
Restart statin
#DJD
Restart amitriptyline and escitalopram (last filled in ___
Transitional Issues:
Follow-up with PCP regarding lipid management
***. | OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms ___ is a ___ female with ESRD secondary to
congenitally undeveloped kidneys and with deafness (Alports
disease) s/p renal transplant in ___ and then again in ___
complicated by advanced chronic allograft dysfunction, recently
initiated on HD, CMP 40%, DM2, HTN, presenting from HD with new
afib.
ACTIVE ISSUES
=============
# Decompensated Systolic Heart Failure (EF: 40-45%): BNP 47000,
significantly elevated. Evidence of hypervolemia on exam, with
accumulation in the lungs primarily. Recently underdialyzed (has
been doing half sessions), likely resulting in accumulation of
fluid. TTE in ED showed small pericardial effusion, with no
evidence of tamponade. Dry weight from last d/c 50kg, 52kg on
admission. In the ICU, the patient underwent HD for fluid
removal, with removal of 3.5L fluid on ___. Home diuretic
regimen restarted on ___. Patient subsequently remained
euvolemic, and was discharged on her home diuretic regimen.
# Hypotension: Patient hypertensive on admission, possibly in
the setting of 3.5L fluid removal with dialysis the day prior vs
medication effect from rate control meds, given she was bolused
with IV metoprolol due to afib w/RVR. Bolused with 1L IVF. Did
not require pressors, but remained normotensive with only
b-blockade. Hypotension resolved prior to discharge from the
ICU.
# CONS Bacteremia: 1 bottle grew CONS; started on vanco/cefepime
(day ___ prior to speciation in setting of hypotension with
dialysis. Vanco/cefepime stopped ___ once speciated as CONS,
presumed contaminant. Patient became febrile to 100.9 on ___ X
1 with no further fevers or presumed infectious etiolgy.
# Afib w/RVR: CHADS2 3. New-onset, likely triggered by volume
overload in setting of HFrEF with underlying enlarged LA without
evidence of ischemia, thyroid disease, or concern for VTE. Given
high risk of CVA, started on coumadin and maximized oral beta
blockade with NSR x 24 hours. Should continue to optimize volume
status and enteral rate control as an outpatient. Coumadin
started as an inpatient, but was initially supratherapeutic so
held for several days. INR and coumadin dosing and will be
managed by the ___ clinic moving forward.
# Troponinemia: Trop peaked to 0.20 on admission, CK-MB
otherwise flat. Likely in setting of Afib w/RVR. Patient
otherwise without chest pain or EKG findings suggestive of
ischemia.
# ESRD: Secondary to ___'s s/p transplant x2 now on HD. The
patient was continued on HD. Her home Tacrolimus and Predisone
were continued.
# ___ pain: sigificant pain: Has been limiting dialysis sessions.
The patient was continued on her home Gabapentin,
Amitryptiline, and Oxycodone.
CHRONIC
=======
# Hypertension: continued home Carvedilol. Held home lisinopril.
# Hyperlipidemia: Home aspirin and atorvastatin continued.
# Diabetes: last HgbA1c 9% on this admission. Continued home
70/30 and ISS.
# GERD: Continued home omperazole
# Anemia: Continued home darbapoetin
TRANSITIONAL ISSUES
===================
- Please ensure close follow up with INR monitoring and coumadin
dosing, as patient has not yet been stabilized on a set home
dose
- Patient has been having pain during dialysis, and should be
treated with her home pain medication regimen
- Patient will receive home ___ on discharge
#CODE: Full (confirmed)
#EMERGENCY CONTACT HCP: ___
Relationship: Sister
Phone number: ___
Cell phone: ___
***. | CARDIAC ARRHYTHMIA AND CONDUCTION 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.
***
#1. Abdominal/ chest pain exacerbation: Etiology of chronic
abdominal pain has been particularly difficult to elucidate
given the patient's vague description of pain and multiple
possible causes including chronic pancreatitis, mesenteric
ischemia and GERD. A coronary etiology was unlikely given the
patient's unchanged EKG, normal cardiac enzymes and lack of
relief with nitroglycerin. During this hospitalization it
seemed unlikely that an acute process was occurring given the
patient's normal CT scan, laboratory results and lactate.
Surgery was once again consulted and recommended no intervention
in management of mesenteric ischemia as patient was able to
tolerate intake without much change in her pain. Pain
management was the priority during this hospitalization rather
than definitive treatment which can be addressed in the
outpatient setting. Future venues that could be pursued include
placing a stent in the celiac trunk, repeating MRCP to assess
for ongoing pancreatitis or repeating an EGD to reassess
severity of gastritis.
Initially pain was controlled using IV dilaudid and then
transitioned to extended release oxycontin with percocet as
needed for breakthrough pain. This regimen balanced pain with
functional status, allowing the patient to remain alert but
relatively symptom free. Patient was discharged with a 2 week
prescription for oxycontin 10 mg BID and percocet 5 mg BID as
needed for breakthrough pain. The patient signed a narcotic
agreement adhering to the goals and terms of her treatment
regimen.
#2. Urinary Tract Infection: Upon presentation, patient
complained of dysuria and was found to have acute cystitis.
This infection might have precipitated acute pain episode that
brought patient to the emergency department. Treatment was
initiated with ciprofloxacin but changed to linezolid once
culture results showed >100,000 colonies of VRE. Patient was
discharged with instructions t complete a 5 day course of
linezolid.
#3. Coronary Artery Disease: As stated above, it was felt to
be very unlikely that pain was secondary to an acute cardiac
etiology. However, given the patient's multiple risk factors
for myocardia ischemia (PVD, known CAD, Diabetes, HTN) the
patient was ruled out with normal EKG and baseline cardiac
enzymes. She was continued on her home aspirin, plavix, statin,
beta blocker, Ace-inhibitor and isosorbide.
# 4. End stage renal disease (on hemodialysis)- The patient
went for dialysis on ___ and ___. Blood pressure
targets were systolics in the 130s given concern for
hypoperfusion exacerbating her chronic ischemia. She was
continued on clacitriol, calcium acetate.
# 5. Hypertension: Systolic blood pressure in the emergency
department was 200 in the context of having vomited or missed
her morning meds and significant pain. This came down to the
150s with pain control.
Systolics were running high in the 190s on the morning following
admission again in the context of having refused her morning
antihypertensives and pain and again resolved to the 130s-140s
with IV pain control. She was otherwise continued on her home
amlodipine, lisinopril, furosemide, metoprolol and hydralazine.
#h/o Peripheral vascular disease-- Patient was continued on her
home aspirin 81mg, and plavix
# asthma- She was continued on her home fluticasone/salmeterol,
albuterol, and ipratropium.
# Schizoaffective d/o- She was continued on her home abilify and
citalopram
# anemia- She was continued on her home iron
***. | OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient is an ___ y.o. M with h/o CVA, prostate cancer h/o
hematuria, CVA in ___ on aggrenox, prostate cancer s/p XRT,
assistant ___ to wife who presents s/p unwitnessed
fall/syncopal episode.
He had no clear cause for his syncopal episode. His orthostatics
were normal, he had an EKG which was unchanged from prior with
two negative sets of cardiac enzymes. He had no evidence of
arrhythmias on telemetry. He was noted to have tachypnea, and a
D-dimer was checked, which was elevated, and he had a CT of his
chest which did not show a pulmonary embolus.
His head and neck CT were negative as well.
For his hypoxia and tachypnea, an echo was performed which
showed evidence of diastolic dysfunction, for which he was
diuresed with furosemide. He was started on a standing dose,
with oral potassium supplements. Physical therapy cleared the
patient for going home.
Patient was felt to be depressed during his hospital stay,
likely situational secondary to increased stressors related to
his wife's illness. His thyroid function was normal.
He had one episode of a fever to 102, with a negative evaluation
for the source of the fever, including a urinalysis and culture,
blood cultures, and chest x-ray. It was felt to be secondary to
a viral infection.
***. | HEART FAILURE AND SHOCK WITHOUT CC/MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
The patient was admitted to the hospital with right upper
quadrant pain. She underwent an ultrasound which showed
cholecystitis. Upon admission, she was made NPO, given
intravenous fluids and started on ciprofloxacin and flagyl. She
had a white blood cell count of 18 upon admission. She was
taken to the operating room on HD # 1 where she underwent a
cholecystectomy. The operative course was notable for a very
large gallbladder that tracked down into the right lower
quadrant which was inflammed and adherent to the abdominal
wall. Because of the adhesions, it was difficult to distinguish
between surrounding tissues and inflamed peritoneum. The
gallbladder was difficult to decompress and for this reason, the
patient underwent an open cholecystecomy. At the close of the
procedure, ___ drain was placed in the gallbladder fossa.
The patient was extubated after the procedure and monitored in
the recovery room. The patient's antibiotics were discontinued
on POD #1. At this time, she developed a fever and blood
cultures were sent. The results of the bile culture showed
sparse haemophilus species, and no antibiotic coverage was
indicated. She was also noted at this time to have mild
erythema around the umbilicus and on the staple. The area was
assessed daily and no further evidence of extension of erythema
was noted. Because bowel function was slow to return, the
patient underwent an x-ray of the abdomen which showed a
non-obstructive gas pattern. Her bowel function did gradually
return and the patient was introduced to sips and transitioned
to a regular diet. Her vital signs remained stable and she was
afebrile. The drain in the gallbladder fossa was removed on POD
#5. She was evaluated by physical therapy and recommendations
made for discharge home with ___ services. The patient was
discharged home on POD #5 in stable condition. Her white blood
cell count had normalized. Appointments for follow-up were made
with the acute care service.
***. | CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE 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.
***
Mr. ___ is a ___ gentleman with history of severe
nonischemic cardiomyopathy with LVEF as low as 10% in ___, up
to 30%-35% after successful DCCV of his atrial fibrillation, now
with recurrent atrial fibrillation and EF of 10% who presented
for tailored therapy. ___ placed on admission and admitted to
CCU for medication adjustment. ___ removed on ___ and
transferred to floor where he was started on Entresto. He did
very well and his renal function improved. CPET showed poor
functional status and poor prognosis but otherwise he is feeling
well. Close follow up scheduled.
#) ACUTE DECOMPENSATED SYSTOLIC HEART FAILURE: LVEF 10% ___
class III
Patient with known non ischemic cardiomyopathy. Hospitalized
twice in the past several months for CHF exacerbations and was
found to be back in a-fib with his EF decreased to ___ again
on his TEE. He was unable to be cardioverted due to ___
thrombus. ___ placed on admission and admitted to CCU for
medication adjustment. ___ removed on ___ and transferred to
floor where he was started on Entresto. He did very well and his
renal function improved. Repeat TEE continued to show ___
thrombus and he was unable to be cardioverted. CPET showed poor
functional status and poor prognosis. Patient discharged on the
following medications for heart failure: aspirin 81 daily, bumex
1mg daily, digoxin 0.0625 daily, Entresto 97-103 Q12H,
pravastatin 20 daily, metoprolol XL 50 daily, isosorbide 60 Q8H,
hydralazine 100 Q8H.
#) ATRIAL FIBRILLATION
He was previously loaded with Digoxin, then started on 0.0625 mg
daily. Plan was for ___ with cardioversion during previous
admission, but ___ showed persistent thrombus, so cardioversion
was not performed. He was discharged on digoxin 0.0625,
metoprolol XL 50mg daily, amiodarone 200mg daily and apixaban.
#Thrombocytopenia: Patient with negative bone marrow biopsy for
cause of thrombocytopenia. Suspected to be drug related. He was
switched from torsemide to bumex.
#functional iron deficiency: Patient received IV iron x7 days
and was transitioned to oral iron.
#GOUT: Patient discharged on allopurinol and colchicine for gout
flair while in the hospital. Colchicine should be discontinued
after acute symptoms resolve. Celecoxib was discontinued on
discharge secondary to cardiac disease
___: Secondary to cardiorenal. Cr down to 1.4 on discharge from
high of 1.7.
CHRONIC STABLE ISSUES:
============================
DMII
- Patient discharged on home glipizide, please continue to
monitor blood sugars and HgbA1c. Patient to continue home
glargine 10u qPM.
HTN: Hydralazine 100mg q8h, isosorbide dinitrate 60mg q8h,
Entresto, metoprolol XL 50
HLD: Continued Pravastatin
Hypothyroidism: increased synthroid to ___. Continue to
follow as an outpatient
TRANSITIONAL ISSUES:
====================
- Patient should be scheduled for a right heart catheterization
in 1 month for follow up numbers.
- Patient takes celecoxib for gout flares prescribed by
rheumatologist, this medication was discontinued on discharge
secondary to cardiac disease.
- Consider outpatient CT chest for transplant workup when
stable.
- Patient discharged on allopurinol and colchicine for gout
flair while in the hospital. Colchicine should be discontinued
after acute symptoms resolve.
- Patient discharged on the following medications for heart
failure: aspirin 81 daily, bumex 1mg daily, digoxin 0.0625
daily, Entresto 97-103 Q12H, pravastatin 20 daily, metoprolol XL
50 daily, isosorbide 60 Q8H, hydralazine 100 Q8H. Please
continue to monitor BP, HR and volume status. On discharge he
was Euvolemic, BP range 93-114 / 50-70, HR range ___ in
a-fib.
- Patient discharged on digoxin 0.0625 daily, amiodarone 200
daily and apixaban 5mg BID for a-fib. Considered cardioversion
but TEE on ___ showed left atrial appendage thrombus so no
cardioversion attempted.
- Patient with cardiorenal ___ during admission, Cr down to 1.4
on discharge, please continue to monitor and repeat Cr and
electrolytes at next follow up appointment.
- Patient discharged on home glipizide, please continue to
monitor blood sugars and HgbA1c.
# DISCHARGE WEIGHT: 66.5 kg
# CODE: Full code
# EMERGENCY CONTACT: ___ ___
***. | HEART FAILURE AND SHOCK WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
___ year old woman with history of HTN, Raynaud's, and scoliosis
s/p multiple surgeries, initially admitted for elective spinal
fusion of T11-S1 with L3 osteotomy, admitted to the MICU with
hypotension, found to have a PE, complicated by right heart
strain and flash pulmonary edema; now improved.
#Spinal fusion of T11-S1 with L3 osteotomy: Patient admitted
for spinal fusion with osteotomy for symptomatic scoliosis with
sicatica. Following surgery, patient's leg pain improved.
Surgical site remained C/D/I and patient without evidence of
hematoma. Neurologic exam remained intact throughout admission.
The patient was evaluated by physical therapy, and was able to
walk the hallway with a brace in place prior to discharge. She
must wear the brace when getting out of bed. The patient was
maintained on oxycontin, oxycodone, gabapentin, and
cyclobenzaprine for pain control. She will follow up with Dr.
___ as previously arranged on discharge.
#Pulmonary embolism - Patient with large pulmonary embolism,
provoked by spinal surgery. At onset, pulmonary embolism caused
hypotension with right heart strain as seen on EKG and ECHO.
The patient was started on coumadin and a heparin drip to bridge
(day 1 ___. She was continued on the heparin drip until
therapeutic on coumadin for 24 hours. The patient should
maintain INR between ___ at all times. As she recently had
spinal surgery, INR not to exceed 3.0. If patient becomes
subtherapeutic in the future, must be bridged with heparin, per
spine surgeon. Lovenox contraindicated in this patient given
history of spinal surgery. The patient should undergo
transthoracic echo in 6 weeks to follow up cardiac function with
resolution of pulmonary embolism. Please check INR on ___ and
adjust coumadin dosing as needed.
#Flash pulmonary edema/acute right heart failure - Due to large
volume of fluids and blood administered for hypotension in the
setting of massive PE. LVEF 55% on most recent TTE, however now
with right heart strain. The patient was diuresed with IV lasix
following episode of flash pulmonary edema, and volume status
improved. Patient continues to have lower extremity edema and
JVD to 1 cm below jaw, requiring further diuresis on discharge.
The patient was discharged on lasix 20 mg PO daily. She should
continue on this medication until she becomes euvolemic.
Baseline weight 140lbs. Weight at discharge was 164.6lbs. She
should undergo an electrolyte check on ___ for stability
following diuresis. At that point, a decision can be made about
whether it is necessary to continue oral lasix. Patient was not
on any diuretic therapy prior to the current admission.
.
___ - During admission, creatinine peaked at 2.7 in the setting
of right heart failure. ___ prerenal due to poor forward flow
based on urine lytes. Likely also a componenet of ATN given
episodes of hypotension. Creatinine returned to baseline with
diuresis from lasix, and possibly post-ATN autodiuresis.
.
#Hyponatremia - Sodium decreased from 135 to 126 in the setting
of volume overload, consistent with hypervolemic hyponatremia.
Resolved with diuresis.
.
#HTN - Home antihypertensives held in the setting of hypotension
from PE. Following stabilization in the MICU, the patient was
started on lasix. ___ was resumed at discharge.
.
# Gout - Chronic. The patient was continued on allopurinol.
.
# Code: Full (confirmed with patient)
=========================================
TRANSITIONAL ISSUES:
# Patient to continue lasix until euvolemic. Dry weight 140
lbs.
# Patient should undergo INR and electrolyte monitoring every
other day starting ___ while on coumadin and lasix. Goal
INR ___.
# Patient to follow up with PCP and ___ on discharge
from rehab.
# Multiple blood cultures pending at discharge
***. | 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.
***: EKG - v-paced at rate ~70bpm. No change from prior.
___ CXR: No acute Cardio-pulmonary process
___ TTE:
The left atrium is elongated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular ejection fraction is normal (LVEF 60%). However, the
apex appears hypokinetic. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse.
Physiologic mitral regurgitation is seen (within normal limits).
The estimated pulmonary artery systolic pressure is normal.
There is an anterior space which most likely represents a fat
pad.
IMPRESSION: apical hypokinesis
Compared with the report of the prior study (images unavailable
for review) of ___ the apex now appears hypokinetic.
STRESS MIBI:
INTERPRETATION: This ___ year old man with a history of
hypertension
and A-V pacemaker ___ was referred to the lab for evaluation of
chest
pain and shortness of breath. The patient exercised for 10
minutes of a
modified ___ protocol and stopped for fatigue. The estimated
peak MET
capacity was 8.2 which represents a good physical working
capacity for
his age. No arm, neck, back or chest discomfort was reported by
the
patient throughout the study. He did note shortness of breath
which was
appropriate for the task. The ST segments are uninterpretable
for
ischemia in the setting of A-V pacing. Several isolated apbs and
vpbs
were noted in recovery. Appropriate increase in systolic BP with
a
blunted HR response on beta blocker therapy.
IMPRESSION: No anginal type symptoms or interpretable ST
segments.
No perfusion deficits on nuclear imaging.
HOSPITAL COURSE:
# CAD: Nl ETT in ___. CP similar to usual angina. Acute MI
was ruled out with serial ekgs and cardiac enzymes. No events
occured on telemetry. He was started on an aspirin and continued
on his ___ and beta blocker. LDL cholesterol was checked and
was 121. Because he had no evidence of CAD he was not started on
a statin. After his TTE showed new apical HK he was sent for a
stress test to r/o flow-limiting coronary disease. This showed
excellent exercise capacity for age with no perfusion deficits
on the nuclear imaging. He remained chest pain free while
hospitalized. He was continued on beta blocker, ___.
# Pump: Nl EF in ___. With possible pulmonary edema in ED with
rales and HTN although CXRs negative. Could be from med/diet
non-compliance although patient denied, tachy-arrythmias leading
to cardiomyopathy, or atrial-tachycardias leading to poor
diastolic filling and pulmonary edema. TTE showed new HK of apex
with normal systolic function and lvh consistent with perhaps
diastolic dysfunction. He underwent stress testing as above. He
was continued on ace, beta blocker, and started on ___. LDL was
121 and has no evidence of CAD so did not start statin.
# Rhythm: Previous h/p high-degree AV block now s/p ppm. The EP
service interrogated his ppm to ensure no episodes ventricular
tachycardia and to see if patient had atrial tachycardia that
could have led to poor diastolic filling and poor forward flow
and thus pulmonary edema. They found complete heart block with
pacer dependent rhythm.
# Asthma: patient has recent PFTs that show FEV1/FVC ratio of
94% of predicted with mild obstructive pulmonary disease. He
reports recent increase in symptoms associated with a cold.
Currently not wheezing. Continued home regimen of albuterol and
flovent.
# BPH: initially held tamsulosin for now given patient
complaining of ___ at home and may be ortho-static
hypotension although not orthostatic currently. Since continued
to be stable restarted this medication.
***. | HYPERTENSION 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.
***
Upon arrival to the ED, he was febrile to 102.7, BP 133/102, HR
112, RR 16, Sat 98% on room air. He was given approximately 1500
cc of normal saline, 1000 mg acetaminophen x2, cefepime ___ mg
IV, and vancomycin 1000 mg IV.
1. Neutropenic fever: Patient with known idiopathic
agranulocytosis and was admitted with with fever and ANC of 168.
He complained of upper respiratory symptoms and had cervical
lymphadenopathy. Blood cultures, U/A, and urine cultures and
abdominal CT had no evidence of infection. He was continued on
cefepime until his total granulocyte count was >500. He did not
require broader coverage as he only had one further fever to
101.3 on the second day of admission. He was also given
meperedine prn for rigors and placed on neutropenic precautions.
He was seen by the hematology team who started him on neupogen
480mcg/day and his ANC went from 40 to 80 to 140 to 170 to 1050.
He should continue on neupogen three times a week (___)
until his heme follow up appointment with Dr. ___ on ___.
2. Agranulocytosis: Despite extensive heme workup on the
previous admission and as an outpatient the cause of his
agranulocytosis remains idiopathic. Hematology was consulted and
looked at his blood smear. Of note, he did not have any
granulocyte precursor cells or granulocytes. They asked for a
rheumatology consult and rheum asked us to add on c3, c4,
ds-DNA, and IGD. He will get rheum and heme outpatient follow
up. He may need a lymph node biopsy as an outpatient when he
recovers.
3. Cervical LAD: LN biopsy may be helpful in the future after
patient is no longer febrile or neutropenic.
4. Anemia: stable, no signs of bleeding. Likely ___ chronic dz.
5. Sciatica: During the end of the admission, pt was stretching
in his room and developed a flare of his known sciatica. His
symptoms were the exact same as he has with prior episodes of
sciatica. He was discharged on a small supply of Percocet to use
as needed for this.
Full code
***. | MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION 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.
***
___ yo F with history of HTN, cholelithiasis s/p cholecystectomy,
obesity s/p gastric bypass, who presents with fatigue and
jaundice diagnosed with alcoholic cirrhosis.
.
1. Alcoholic Cirrhosis: The patient presented with AST>ALT and
tbili 9.0. Based on history, serologies, and liver biopsy, the
diagnosis of alcoholic cirrhosis was made. The patient had only
trace ascites, no encephalopathy, and no other chronic stigmata
of liver disease. The patient had negative hepatitis serologies,
negative smooth muscle, negative AMA, negative iron stain, and
negative ceruloplasmin. The patient did have a positive ___ with
high titer, but liver biopsy did not show evidence of autoimmune
hepatitis. The patient was started on prednisone 40mg for acute
alcoholic hepatitis. The patient will continue the prednisone
for 30 days with a two week taper after that. The patient was
educated about the necessity of abstaining from alcohol,
maintaining her nutrition, and taking her medications as
prescribed. The patient was set up with follow up in the liver
clinic.
.
2. Anemia: The patient's Hct ranged from ___ on this
admission. She had no evidence of occult bleeding. Iron studies
were performed that were most consistent with anemia of chronic
inflammation. Her reticulocyte index was slightly low for her
level of anemia. Hemolysis labs were positive, but Coombs was
negative. Hematology was consulted who believed that the patient
had bone marrow suppression from alcohol abuse in the setting of
baseline microcytic anemia. An EPO level was sent that returned
normal. The patient was transfused one unit of blood during her
stay and responded appropriately to the transfusion. Her Hct on
discharge was 31, however, her baseline is closer to ___.
3. Positive ___: The patient had a positive ___ with 1:640 titer
during workup for autoimmune hepatitis. Rheumatology was
consulted. Other serologies were sent including dsDNA,
centromere, that returned negative. CK and muscle enzymes were
negative as well. The patient also endorsed weight loss (see
below). Rheumatology only recommended followup in clinic and no
further acute management.
4. Unsteady gait: Patient with proximal muscle weakness of both
upper and lower extremity on admission, with gait that reflects
this weakness. Patient also with slight sensory loss in
stocking/glove pattern, likely from alcohol v nutritional
deficiency given gastric bypass. CK normal. B12, folate normal.
Patient worked with Physical Therapy, who agreed with home
discharge.
.
5. Weight loss: Pt notes unintentional 50 pound weight loss over
a few months. The most likely diagnosis is poor nutritional
intake. CT neck/chest did not show Pancoast or SVC syndrome. TSH
c/w hypothyroidism, though in setting of acute illness, so
levothyroxine not started. The patient also had elevated ACE
level and ground glass opacities on chest CT, concerning for
sarcoid. The patient will f/u with rheumatology and her PCP.
.
6. HTN: Discharged on home metoprolol.
.
7. GERD: Continued home omeprazole
TRANSITIONAL ISSUES:
- F/U appointments
- The patient is working with social work about getting Mass
Health
- Ensure steroid taper after 30 days
***. | CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC |
What is the most likely Medicare Severity Diagnosis Related Group (MS-DRG) based on the following discharge summary of a hospitalization? Provide the complete text description of the DRG code without including the numerical code.
***
Ms. ___ was readmitted with rapid atrial fibrillation and
subsequently found to have MSSA bacteremia. She was placed on
antibiotics per the infectious disease service. Her atrial
fibrillation was treated with Amiodarone and Lopressor. These
medications improved her rate but she remained in Atrial
fibrillation. She was also started on Coumadin. During the
course of this hospitalization she had an echo to assess for
endocarditis and chest CT to assess for other infective sources.
By hospital day 9 she was ready for discharge to home with
visiting nurses. SHe is to be followed closely by infectious
disease department, ___ Home therapy will administer her
antibiotics. She is to follow up with Dr. ___ in 3 weeks
***. | OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC |
Subsets and Splits