H&P: Patient presented with shortness of breath and palpitations noted to be in atrial fibrillation and with AKI. Patient with baseline creatinine of 1.1, noted as 1.5 on admission. Give IVF for AKI and monitor labs. Platelets 64, consult Hematology for ITP treatment recommendations
PMH: Idiopathic thrombocytopenia purpura (ITP) treated in past with IVIG with last known platelet level 150, COPD, paroxysmal atrial fibrillation.
Home Medications: Prednisone 10 mg po daily, Eliquis 5mg po bid, Symbicort 160 mcg inhalation aerosol 2 puffs bid, Combivent Respimat 20 mcg one puff qid
Physical Exam: VS:110/60, 114, 27, 100.9F, BMI 38.2 and patient complaining of feeling light headed with palpitations.
Labs: On admission: Platelets 64×10 (9)/L, creatinine 1.5, Day 2 platelets 105×10 (9)/L, creatinine 3.39. Day 3 platelets 110 (9)/L, creatinine 3.23, Day 4 platelets 115, creatinine 2.02, Day 5 platelets 123, creatinine 1.79
U/S Kidneys: Bilateral kidneys unremarkable, no hydronephrosis.
Hematology/Oncology Consult: Day of admission: Patient with a history of persistent atrial fibrillation and ITP with a decrease in platelets lower than baseline of 150. Give IV immune globulin (IVIG).
Treatment: Diltiazem 25mg IV x2, Plavix 75mg po daily, Metoprolol 12.5mg po bid, IVIG 400mg/kg daily-discontinued on day 2, IVF NS 100ml/hour, monitor creatinine levels daily
Discharge Summary: Patient admitted with persistent atrial fibrillation, ITP, and AKI. Patient to f/u with cardiology for atrial fibrillation. AKI which is resolving with creatinine down to 1.79. Plan monitor creatinine outpatient.
Discharge Medication: Prednisone 10 mg po daily, Eliquis 5mg po bid, Symbicort 160 mcg inhalation aerosol 2 puffs bid Combivent Respimat 20 mcg one puff qid
Question: Are there query opportunities based on the scenario stated above?
Discussion: The patient presented with shortness of breath and palpitations. Patient with persistent atrial fibrillation, AKI, and worsening platelet count. After the administration of IVIG the patient had worsening creatinine levels. The creatinine level remained elevated with a near return to baseline by the 5th day. AKI that lasts for greater than 72 hours should be evaluated for the additional diagnosis of Acute Kidney Injury (AKI) with Acute Tubular Necrosis (ATN). Acute Tubular Necrosis is the cause of AKI in approximately 30% of hospitalized patients. However, it is a diagnosis that is frequently overlooked resulting in the need to query for clarification.
UASI Recommends:
Query for Acute Kidney Injury with Acute Tubular Necrosis
Documentation without Clarification:
Principal Diagnosis: I48.19 Other persistent atrial fibrillation
Secondary Diagnosis: J44.9 COPD, D69.2 Immune thrombocytopenic purpura (ITP), N179 Acute Kidney Injury (AKI)
Working DRG: 309
RW: 0.7494 GLMOS: 2.4 SOI/ROM: 2/2
Documentation with Clarification:
Principal Diagnosis: I48.19 Other persistent atrial fibrillation
Secondary Diagnosis: J44.9 COPD, D69.2 Immune thrombocytopenic purpura (ITP), N17.0 Acute Kidney Injury (AKI) with Acute Tubular Necrosis
Working DRG 308
RW: 1.1993 GLMOS: 3.5 SOI/ROM: 3/3
CDI Educational Tips:
- Monitor for AKI that is not resolved in 72 hours or less for the diagnosis of ATN.
- Acute Tubular Necrosis (ATN) is defined as AKI due to an ischemic injury or a toxic injury which leads to dysfunction of the renal tubules.
- ATN must meet criteria for AKI with a cause for ATN such as IV contrast, toxins, or medications.
- Elevation of urine sodium concentration and fractional excretion of sodium are optional lab tests but can be found to be normal. Therefore, normal levels do not exclude the diagnosis of ATN.
- ATN can lead to electrolyte imbalances, monitor for imbalance especially hyperkalemia and hyponatremia. Query as needed.
- ATN is a more specific and accurate diagnosis that provides an MCC which further represents the severity of illness of the patient.
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.