AKI with ATN CDI Scenario – July 2021

Medical Coding

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…

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Atrial Fibrillation Outpatient CDI Scenario – April 2021

UASI Solutions

Topic: Outpatient CDI: Atrial Fibrillation Office Visit 2/15/2021: 78-year-old gentleman, lives with wife. Recently hospitalized from 1-2-2021 to 1-7-2021 for Acute MI and Atrial fib with RVR. No voiced complaints. No complaints of heart racing, chest pain. Able to walk around house, up and down flight of steps without stopping.  Seen last week by Ostomy Nurse…

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Pancreatitis CDI Scenario – March 2021

UASI Solutions

Topic:  Pancreatitis H&P: 68-year-old male presents with a history of a sudden onset of acute upper central abdominal pain radiating to his back. The pain began two days prior with intermittent vomiting, without relief of his pain PMH: Appendectomy, Tonsillectomy, Hypertension, Pre-diabetic Pertinent Family History: Cholelithiasis and cholecystectomy in multiple family members Pertinent Social History:…

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Monthly CDI Scenario Discussion – February 2021

UASI Solutions

Topic: Outpatient CDI: Diabetes with Chronic Complication Office Visit 6/8/2020: 87-year old Caucasian female who lives with her son being evaluated today for diabetes. Her son reports elevated blood sugars in the past 4 weeks. Starting from yesterday the readings are 272, 172, 202, 242, and 198. These are on a daily basis in the morning….

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Monthly CDI Scenario Discussion – December 2020

UASI Solutions

Topic: Cerebral Palsy Scenario: 12-year-old male presents with fever, loud breathing and cough PMH: Premature birth at 28 weeks gestation weighed 680g due to PRM; NICU for 4 mouths; on mechanical vent 7 days then on/off NCPAP then Vapotherm for respiratory distress. Received Surfactant, steroids, vaccines and antibiotics at appropriate times.  NICU diagnoses included: Grade II…

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Monthly CDI Scenario Discussion – October 2020

UASI Solutions

Topic:  Diabetes Scenario: 68 yr. F presents with nausea/vomiting and upper abdominal pain for 7 days with PMH of Diabetes H&P: Pt. arrived to ED with complaints of nausea and vomiting with upper abdominal pain for 7 days. ABD CT negative for any acute pathology. PHM of type 2 diabetes, neuropathy, hypothyroidism, and SBO.  She…

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Monthly CDI Scenario Discussion – August 2020

UASI Solutions

Topic: Poisoning/Overdose Scenario: 65 yr. old female with Metastatic Bone Cancer on oral Dilaudid with Chronic Back Pain due to the cancer H&P: Pt arrived to the ER due to diminished responsiveness per family and found to have hypersomnolence.  CT of head ordered and negative for stroke, labs reveal nothing significant. Per review of prior…

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Monthly CDI Scenario Discussion – June 2020

UASI Solutions

Topic: Deep Tissue Injury and Pressure Ulcers Scenario: 88-year-old female patient with wound to buttock H&P: HPI: 88-year-old female brought in from nursing home facility with concern of an open wound to left buttock. Patient has contractures due to previous CVA with left-sided hemiparesis. Patient is limited in mobility due to obesity. PMH: CVA left-sided…

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Monthly CDI Scenario Discussion – April 2020

UASI Solutions

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…

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