Hospital Inpatient Case #1

Discharge Summary 

History and Physical Findings:

This 75-year-old female is a nursing home resident as a result of a cerebrovascular accident 2 years ago. She has had numerous hospital admissions for pneumonia and other infectious complications. On the day of admission, the patient was noted to be clammy, with tachypnea, had decreased level of responsiveness, and showed increased fever. She was seen in the ER, where evaluation revealed the presence of probable urinary tract infection (UTI) and sepsis.  

The patient was also found to have renal insufficiency with blood urea nitrogen (BUN) and creatinine elevated. Her white blood cell (WBC) count was 23,000 with decreased hemoglobin and hematocrit. He was admitted for treatment of E. coli sepsis.  

Physical examination revealed an elderly female who was aphasic and had left-sided hemiplegia (she is right-handed), both from a previous CVA. The heart had a regular rhythm. The lungs were clear. The abdomen was soft. Significant Lab, X-ray, and Consult Findings: Follow-up chemistry showed progressive decline in the BUN and creatinine to near normal levels. Initial WBC count was 23,700. Final blood count was 9,000. The urinalysis showed white cells too numerous to count. The urine culture had greater than 100,000 colonies of E. coli and Group B strep, which revealed the cause of the UTI. Repeated blood cultures grew E. coli with the same sensitivities as that of the urine. There were no acute abnormalities noted. EKG showed sinus tachycardia and low lead voltage, otherwise was normal and unchanged.

Hospital Course:

The patient was initially started empirically on Imipenem. She underwent fluid rehydration and her electrolytes were followed closely. Electrolytes improved through her hospital stay. She was continued on IV Primaxin until the date of discharge, when she was changed to Ciprofloxacin by tube. All of the bacteria grown in the urine and in the blood were sensitive to the Ciprofloxacin.  

The chest x-ray showed no change from previous admissions, and she was followed closely with additional oxygen as needed. The patient does have a history of chronic obstructive lung disease and has required intermittent oxygen therapy at the nursing home.  

At this time, the patient had reached maximal hospital benefit. She was switched to oral antibiotics. She was to continue on tube feedings, which she was tolerating quite well. The patient was discharged back to the nursing home on 5/4. 

Discharge Diagnoses:

1. E. coli sepsis

2. UTI, due to E. coli, and Group B strep

3. Renal insufficiency

4. Chronic obstructive lung disease

5. CVA with left hemiplegia

Assign the correct Principal Diagnosis.

Assign additional Diagnosis code(s).

History and Physical 

History of Present Illness

This 75-year-old female is a nursing home resident as a result of a cerebrovascular accident 2 years ago. She has had numerous hospital admissions for pneumonia and other infectious complications. The patient is noted to be clammy, with tachypnea and decreased level of responsiveness, and showed increased fever.  

She was seen in the ER, where evaluation revealed the presence of probable urinary tract infection (UTI) and sepsis. The patient was also found to have renal insufficiency with blood urea nitrogen (BUN) and creatinine elevated. Her white blood cell (WBC) count was 23,000 with decreased hemoglobin and hematocrit.  

Past Medical History

1.   Hypertension (on lisinopril)

2.   Chronic obstructive lung disease (dependent on oxygen)

 Physical examination revealed an elderly female who was aphasic and had left-sided hemiplegia (she is right-handed), both from a previous CVA. The heart had a regular rhythm. The lungs are clear. The abdomen was soft.

 Assessment and Plan

Patient is admitted for treatment of E. coli sepsis.

 Significant Lab, X-ray, and Consult Findings

 Follow-up chemistry showed progressive de-cline in the BUN and creatinine to near normal levels. Initial WBC count was 23,700. Final blood count was 9,000. The urinalysis showed white cells too numerous to count. The urine culture had greater than 100,000 colonies of E. coli and Group B strep, which revealed the cause of the UTI. Repeated blood cultures grew E. coli with the same sensitivities as that of the urine. There were no acute abnormalities noted. EKG showed sinus tachycardia and low lead voltage, otherwise was normal and unchanged.  

Discharge Summary

Course in Hospital:

The patient was initially started empirically on Imipenem. She underwent fluid rehydration and her electrolytes were followed closely. Electrolytes improved through her hospital stay. She was continued on IV Primaxin until the date of discharge, when she was changed to Ciprofloxacin. All of the bacteria grown in the urine and in the blood were sensitive to the Ciprofloxacin. The chest x-ray showed no change from previous admissions, and she was followed closely with additional oxygen as needed. The patient does have a history of chronic obstructive lung disease and has required oxygen therapy at the nursing home. At this time, the patient had reached maximal hospital benefit. She was switched to oral antibiotics. The patient was discharged back to the nursing home on 5/4.  

 Discharge Diagnoses:

1. E. coli severe sepsis

2. UTI, due to E. coli, and Group B strep

3. Acute renal failure due to sepsis, now resolved

4. Hypertension, stable, continue to lisinopril

5. Chronic obstructive lung disease, continue home oxygen at 2L

6. History of CVA with residual aphasia and left hemiplegia (patient is right-handed)

 Assign the correct diagnosis code(s).  

Code(s): _______________________________________________________________ 

1.   A41.51 Sepsis (generalized) (unspecified organism), Escherichia coli (E. coli).

2.   R65.20 Sepsis, Severe

3.   N39.0 Infection, infected, infective (opportunistic), urinary (tract)

4.   B95.1 Infection, infected, infective (opportunistic), bacterial NOS, as cause of disease classified elsewhere, streptococcus, group B

5.   N17.9 Failure, Renal, Acute

6.   J44.9 Disease, diseased, pulmonary, chronic obstructive

7.   I10      Hypertension, NOS

8.   I69.354 Accident, cerebrovascular, old, with sequelae – see Sequelae, infarction, cerebral. Sequelae (of), infarction, cerebral, hemiplegia.

9.   I69.320 Aphasia (amnestic) (global) (nominal) (semantic) (syntactic) following, cerebrovascular disease, cerebral infarction

10. Z99.81 Dependence on supplemental oxygen

 Rationale: Urine culture results were documented as group B streptococcus and E. coli. The EKG showed tachycardia, but unless the physician indicates this was a significant finding, the tachycardia would not be coded (also symptom of sepsis). During the course of the hospitalization, the patient underwent “fluid rehydration.” The coding professional may want to query the physician to determine if dehydration is an additional diagnosis and should be reported. The patient is on tube feedings. The coder should review the remainder of the health record to determine if the patient has a gastrostomy (Z93.1). B96.20 is not assigned for the E coli per AHA Coding Clinic® 1st Quarter 2018, page 16 because the A41.51 clearly identifies the cause of both the sepsis and UTI.