CDI Scenarios

Topic: HIV Scenario: 65 year old hemophiliac presents with poor appetite, difficulty swallowing, and weight loss History and Physical: HPI: Recently moved to the US; reports poor appetite and sore throat over the last 3 months; reports being unable to get out of bed for a week; at patient’s last office visit, his lab work…

Topic: Multiple Significant Trauma Scenario: 65 year old male with a PMH of CAD, HTN, and Hyperlipidemia on Metoprolol and Lipitor who presented following a 10 foot fall onto the ground from a ladder while cleaning out the gutters. Per H&P pt. fell on his back striking his head with wife reporting to EMS he was…

Topic: Pancytopenia Scenario: A 51 year old female presents with nausea, vomiting, and weakness History & Physical: HPI: 51 year old female recently diagnosed with leukemia presents with nausea, vomiting, poor appetite, and weakness. Last chemotherapy treatment was one week prior to presentation. PMH: Osteoarthritis, diabetes mellitus type 2, HTN, obesity (BMI 35), no history…

Topic: Functional Quadriplegia Scenario: 72 year old male admitted from a skilled nursing facility with complaints of uncontrolled blood pressure by SNF staff. PMH of severe Alzheimer’s dementia, CAD, HTN, CKD3 with baseline creatinine of 1.5 Per H&P: SNF staff reported difficulty controlling blood pressure over the last 24 hours. BP at SNF reported to…

Topic:  GI bleeding Scenario:  80 y/o female presents with coffee ground hematemesis with a PMH of GERD, CAD, and Iron deficiency Anemia. She has home medications of Protonix PO daily, SlowFe PO daily, and ASA 81mg PO daily. H&P notes:  “acute upper GI bleed” with non-compliance with the Protonix and SlowFe because she says “they…

This training includes: Discussion of 2020 MS-DRG changes with CDI tip recommendations Discussion of 2020 IPPS changes with CDI tip recommendations Discussion of 2020 ICD-10-CM updates with CDI tip recommendations Why It’s Important: Coding is the basis of clinical documentation improvement Understanding coding fundamentals will assist in knowing what to look for in regards to…

Topic:  Fever of unknown origin Scenario:  65 year old male presented to the ED with a five-day history of increased congestion, cough, subjective fever, worsening lethargy, some confusion, weakness, and decreased oral intake. In the ED, the patient was febrile 102.0 F, heart rate 90, BP 112/71,  RR18,  SPO2 94% on room air. CT of…

Topic: Clinical Validation: Acute Post Operative Pulmonary Insufficiency/Acute Postoperative Respiratory Failure Scenario: H/P: 65 y/o male with past medical history of DMII, HLD, HTN, and obesity admitted with chest pain worse on exertion. Medications: Insulin, Metoprolol, Lisinopril, ASA, Crestor. BMI 34. Patient had a positive stress test. Cardiac cath shows severe three vessel disease and…

Topic:  Altered Mental Status, Dementia with Encephalopathy Scenario: 85 y/o female admitted with Sepsis secondary to UTI and altered mental status. History of dementia. Decreased responsiveness noted by patient’s sister who reports this is significantly different than her usual state. H/P: “Patient is disoriented, confused with decreased responsiveness, hard to arouse. The degree at onset…

Topic: Cardiac Arrest – the Underlying Condition Scenario: 19 y/o female brought to ED by ambulance accompanied by boyfriend The patient is found on presentation to the ED to be nonverbal, does not open eyes and has no motor responses Boyfriend reports to ED physician that patient ingested a large amount of heroin and was…

Topic: Complex Pneumonia Scenario: 82 yr. old female admitted from her skilled nursing facility with complaints of chest pain, SOB and cough with yellow mucus. Hx of COPD, on continuous O2 at 2L with recent hospital discharge for exacerbation, CVA with dysphagia. Assessment, patient noted with wheezing, rhonchi with mild dyspnea. VS: temp 99.2, HR…