H & P: 68 y/o female presents with epigastric and upper right quadrant pain radiating to right shoulder. She also reports nausea and vomiting over the past 24 hours.
PMH: HTN, DM2, CKD 3, recent intentional weight loss of 10 pounds and anemia.
Vital Signs: 100.6 F, HR 88, RR 24, SpO2 98%, BP 154/84, BMI 43.4
Physical Exam: patient appears in distress with right sided guarding. Appears slightly jaundiced.
Labs: WBC: 12.0; hyperbilirubinemia, total bilirubin 2.0 (0.3-1.0), Amylase 1400 (60-180); Lipase 300 (1-160), HBG 10.9
CT Scan: cholelithiasis with cholecystitis, pancreatic inflammation
Treatment: Keep NPO; NS at 100ml/hr; Zosyn 4g IV every 8hrs; ERCP; Toradol IV for pain
Progress Notes: patient hydrated overnight with pain control; several episodes of vomiting. Zofran administered for nausea. Morning labs indicate an increase in Amylase and Lipase along with hyperbilirubinemia, HBG 11.2. Patient taken for ERCP with biliary “sludge” was extracted. Patient remained hospitalized and was kept NPO for four days. Pain and jaundice resolved.
Discharge Summary: Cholelithiasis with cholecystitis with obstruction (K80.41). Patient discharged home in stable condition. Outpatient surgical consult placed for cholecystectomy. Take Levaquin 500mg PO for seven days and Ibuprofen for pain. Resume normal medications for HTN and DM2.
Question: Are there query opportunities based on the scenario stated above?
Discussion: The patient was noted to have the following:
- Pancreatic inflammation
- Jaundice
- Elevated amylase, lipase and bilirubin
- ERCP with removal of bile duct ‘sludge’
- Admitting diagnosis of cholelithiasis with cholecystitis with obstruction
- BMI 43.4
- PMH of CKD stage 3 with history of anemia
UASI Recommends:
- Query for Gallstone Pancreatitis
- Query for Morbid Obesity
- Query for Anemia in CKD
Documentation without Clarification:
- Principal Diagnosis: K80.41 Calculus of bile duct with cholecystitis, unspecified, with obstruction
- Secondary Diagnosis: I129 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, E1122 Type 2 diabetes mellitus with diabetic chronic kidney disease, N1830 Chronic kidney disease, stage 3 unspecified, R17 unspecified jaundice, and D649 Anemia, unspecified
- Procedure: BF141ZZ Fluoroscopy of Gallbladder, Bile Ducts and Pancreatic Ducts using Low Osmolar Contrast; 0FC98ZZ Extirpation of Matter from Common Bile Duct, Via Natural or Artificial Opening Endoscopic
- Working DRG: 445 Disorders of the biliary tract w CC
- RW: 0.8166 GLMOS: 2.2 SOI/ROM: 2/2
Documentation with Clarification:
- Principal Diagnosis: K80.41 Calculus of bile duct with cholecystitis, unspecified, with obstruction
- Secondary Diagnosis: K85.10 Biliary acute pancreatitis without necrosis or infection, E6601 Morbid (severe obesity due to excess calories, Z6841 Body mass index 40.0-44.9, I129 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, E1122 Type 2 diabetes mellitus with diabetic chronic kidney disease, N1830 Chronic kidney disease, stage 3 unspecified, R17 unspecified jaundice, and D631 anemia in chronic kidney disease (manifestation)
- Procedure: BF141ZZ Fluoroscopy of Gallbladder, Bile Ducts and Pancreatic Ducts using Low Osmolar Contrast; 0FC98ZZ Extirpation of Matter from Common Bile Duct, Via Natural or Artificial Opening Endoscopic
- Working DRG: 444 Disorders of the biliary tract w MCC
- RW: 1.6716 GLMOS: 5.7 SOI/ROM: 3/2
CDI Educational Tips: Gallstone Pancreatitis is an inflammation or irritation of the pancreas that is caused by a gallstone stuck while passing out of the bile duct. Gallstones cause about 40% of cases of acute pancreatitis. The precise mechanism of gallstone pancreatitis is unknown but likely involves increased pressure in the pancreatic duct caused by obstruction at the ampulla secondary to a stone or edema caused by the passage of a stone.
Clinical Indicators for Gallstone Pancreatitis:
- Pain in the right upper quadrant
- Nausea and vomiting
- Increased amylase and lipase
- ALT, AST, alkaline phosphatase and bilirubin can be elevated as well
- CT scan can indicate irritation of the pancreas
Treatment Includes:
- IV Fluids
- Nothing to eat or drink
- Pain Medications
When reviewing patients with Gallstone Pancreatitis, look for evidence of the following and query as clinically supported:
- SIRS/Sepsis and any associated organ failure
- Recognize an additional query may be need to clarify POA if unclear
- Pancreatic necrosis
- Infected necrosis
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.