Patient: 68 yr. old male admitted from home through the ED with complaints of SOB and lower extremity swelling. Pt with bilateral lower extremity 2+ edema, expiratory wheezing, dyspnea at rest, use of accessory muscles.
PMH: CHF, HTN, COPD on continuous home 02 at 2L, BMI 44.5
Vitals: HR 98, RR 26, temp 98.2, BP 130/72, 02 Sat 84% on 02 at 2L, improved to 95% on 5 liters of O2.
Labs: ABG’s: pH 7.29, PO2 48, PCO2 60, Echocardiogram: EF 35%, with systolic dysfunction
Chest x-ray: – bilateral pleural effusion and pulmonary edema consistent with CHF.
PE: Rhonchi and rales bilaterally, cough, + sputum, +2 edema bilaterally lower extremities
Treatment: O2 to keep Sa02 above 90%, Dietary Consult for BMI > 40, 1800 calorie Cardiac diet, Cardiology Consult, Bariatric hospital bed, Physical therapy evaluation for decreased exercise tolerance
Meds Ordered: Lasix 40 mg IVP BID changed to Lasix 20mg po bid on day 3, Lisinopril 10 mg PO daily, Solumedrol 60 mg IV q 6 hours, Albuterol aerosol q 6 hours
Cardiology Consult: Patient continues to be short of breath, Diagnosis: Acute Exacerbation of Systolic CHF
Discharge Summary: Patient admitted due to shortness of breath and lower extremity swelling. Given IV Lasix, found to be in exacerbation of CHF. Final diagnosis: Acute exacerbation of systolic CHF, COPD, hypoxia
Question: Are there query opportunities based on the scenario stated above?
Discussion: Patient presents with indicators of acute on chronic hypercapnic respiratory failure, COPD exacerbation, and BMI elevated indicative of morbid obesity. Patient’s risk factors/clinical indicators:
- Acute on chronic systolic CHF
- BMI 44.5
- COPD on home O2 at 2L w expiratory wheezing, dyspnea at rest, cough, sputum, accessory muscle use
- VS of elevated RR 26, O2 Sat of 84% on o2 2L N/C which improved to 95% on 5L of O2
- ABGs with pH 7.29, PO2 48, PCO2 60
- CXR positive for bilateral pleural effusion and pulmonary edema
- Treatment included oxygen therapy, ABGs, IV diuretics, IV Solumedrol, Albuterol neb.
UASI Recommends:
- Query for acute on chronic hypercapnic respiratory failure
- Query for morbid obesity
- Query for COPD Exacerbation
Documentation without Clarification:
- Principal Diagnosis: Hypertensive heart disease with heart failure (I11.0)
- Secondary Diagnosis: Acute on chronic systolic CHF (I50.23), COPD unspecified (J44.9), dependence on oxygen (Z99.81), hypoxia (R09.02)
- Working DRG: 291 Heart Failure & Shock w MCC
- RW: 1.2683 GLMOS: 4.9 SOI/ROM: 1/1
Documentation with Clarification:
- Principal Diagnosis: Hypertensive heart disease with heart failure (I11.0)
- Secondary Diagnosis: Acute on chronic systolic CHF (I50.23), morbid obesity (E66.01), BMI 44.5 (Z68.41), COPD exacerbation (J44.1), acute on chronic hypercapnic respiratory failure (J96.22), dependence on 02 (Z99.81),
- Working DRG: 291 Heart Failure & Shock w MCC
- RW: 1.2683 GLMOS: 4.9 SOI/ROM: 3/3
CDI Educational Tips:
- Clinical Indicators for COPD Exacerbation:
- Medical problems such as CHF can prompt an exacerbation of COPD
- Increased cough with sputum production
- Treatment to look for to support a diagnosis of acute exacerbation of COPD
- Initiation of IV meds. – i.e. corticosteroids, increase/initiation bronchodilators, increase/initiation 02
- Clinical Indicators for Acute Respiratory Failure:
- Labs – ABGs pH < 7.35, PO2 < 55, PCO2 > 50 (please note a patient with COPD / chronic lung disease may have an abnormal ABG level that could be considered at baseline for that patient)
- P/F Ratio (on oxygen) < 300: Calculation of P/F Ratio – p02 divided by FI02 = P/F Ratio,
- please note cannot be used in a setting of chronic hypoxemic respiratory failure
- O2 Sat < 91% on room air and/or < 95% on oxygen, Tachypnea/RR > 20; or decreased RR < 10
- Shortness of breath/dyspnea, Cyanosis, Pursed lip breathing, use of accessory muscles, Difficulty/inability to speak
- Additional s/sx’s that might be seen are anxiety/restlessness, tachycardia, and profuse sweating, confusion/lethargy
- Common causes/treatment to support a diagnosis of Respiratory Failure:
- Common causes:
- Pneumonia, Heart Failure Exacerbation, COPD Exacerbation
- Additional causes (not all inclusive): PE, asthma exacerbation, cardiac arrest, chest trauma, pulmonary fibrosis, obesity hypoventilation syndrome
- Treatment:
- Oxygen therapy: look for increase in amount of oxygen; i.e. Increased to high flow, bipap, mechanical ventilation, prolonged mechanical vent after surgery; documentation of continuous home O2 for an indication of chronic respiratory failure
- Pulmonology consult
- Breathing Treatments
- Labs, and Radiology – ABGs, serial CXR’s, CT Chest
- Common causes:
This is a short synopsis of a possible patient record and is not intended to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.