Topic: Altered Mental Status, Dementia with Encephalopathy
- 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 was severe. Pt. is bedbound 2/2 to her dementia and general debility. Chronic foley.”
- Treatment/evaluation: CT brain, IVF, change foley catheter, IV antibiotics, daily labs, neuro checks q 2h, turn schedule, psych consult.
- CT of brain shows diffuse microvascular chronic changes; no acute intracranial abnormalities.
- Progress note on hospital day three “Patient is back to baseline mental status.”
- Discharge summary on hospital day five notes, “Altered mental status secondary to UTI/Sepsis with underlying dementia. Patient is back to baseline.”
- Patient discharged to skilled nursing facility.
Question: Are there any query opportunities based on the scenario stated above?
Patient presents with indicators of acute encephalopathy based on the information provided.
- Acute Encephalopathy is characterized by alteration in brain function due to a systemic underlying cause usually resulting in altered mental status.
- Acute Encephalopathy is reversible and resolves when the underlying cause is corrected.
- Acute Encephalopathy does not involve structural brain changes on CT of brain.
- Acute Encephalopathy is noted as an acute or sub-acute mental status alteration associated with metabolic or toxic factors that improves or returns to baseline status when the causative factors are corrected.
- Improvement = probable encephalopathy No improvement = less likely encephalopathy
- Query for Encephalopathy: Specificity is important, unspecified encephalopathy is a CC whereas documentation of specificity (Metabolic) would add an MCC.
- Query for linkage between UTI and Chronic Foley.
Documentation without clarification:
Principal diagnosis: A419 Sepsis unspecified organism
Secondary diagnosis: F0390 Unspecified Dementia without behavioral disturbance
N39.0 Urinary Tract Infection
DRG 872 w/o MCC RW=1.0529, GMLOS= 3.7, SOI/ROM 2/2
Documentation with clarification:
Principal Diagnosis: T83.511A Infection and inflammatory reaction due to indwelling catheter
Secondary diagnosis: G93.41 Metabolic Encephalopathy
A41.9 Sepsis unspecified organism
F0390 Unspecified Dementia without behavioral disturbance
N39.0 Urinary Tract Infection
DRG 698 Other Kidney and Urinary Tract Diagnosis with MCC RW=1.6151, GMLOS=4.9, SOI/ROM 3/3
CDI Educational Tips:
- Altered Mental Status is considered a symptom and should be clarified.
- Clarify if there is a causal relationship between chronic indwelling Foley catheter and UTI.
- Encephalopathy can be either acute (functional) or chronic (structural).
- Baseline status is important for the clinical validation of several diagnoses, including encephalopathy.
- The underlying cause of dementia should be identified whenever possible.
- When a significant alteration of mental status has occurred and systemic toxic or metabolic factors are present, it is a rather simple matter to diagnose toxic or metabolic encephalopathy when mental status returns to baseline as these abnormalities are corrected.
- Encephalopathy greatly impacts severity of illness/risk of mortality.
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.