Question

REASON FOR ADMISSION Acute on chronic hypoxemic respiratory failure, status post tracheostomy tube, and ventilatory dependence. HISTORY OF PRESENT ILLNESS Ms.________ is a 59-year-old Caucasian female with a history of advanced chronic obstructive pulmonary disease on 4 L of oxygen at home, atrial fibrillation, bilateral pulmonary emboli status post IVC filter years ago, type 2 diabetes, and diastolic heart failure, who was admitted to Acute Care Hospital on July 30, 2016, with 3 days of watery diarrhea. Upon admission to Acute Care Hospital, the patient was found to have fever and leukocytosis. A C diff culture was sent, which was subsequently negative. She was admitted for evaluation and quickly developed rapid atrial fibrillation and hypoxemic respiratory failure. She was treated with IV diuretics and IV steroids. She progressed with acute hypoxemia. The chest x-ray showed whiteout of the left lung secondary to mucous plugging. Pulmonary toileting was initiated. She continued to require high O2 needs. She was placed on a Cardizem drip for her rapid atrial fibrillation. Her respiratory status has been tenuous. She has been intubated and extubated 4 different times. The patient underwent a tracheostomy tube placement initially on August 29 with malposition post placement, required reintubation on September 7th. The patient was extubated on September 8th status post tracheostomy tube replacement. Again, the patient's tracheostomy tube became dislodged, requiring endotracheal reintubation on September 13. The patient was seen by ENT, and an extra-long UniPerc tracheostomy tube was placed on September 15. The patient has been on ventilatory support nocturnally. She becomes hypoxic and dyspneic with exertion. The patient was treated for atelectasis secondary to mucous plugging as well as 2 bouts of HCAP with IV antibiotics. In addition to her hypoxemic respiratory failure, the patient also has atrial fibrillation with rapid ventricular response, requiring beta blockade and Cardizem drip. She is now on Lovenox b.i.d. for both atrial fibrillation and a history of bilateral pulmonary emboli, status post IVC filter in the past. She did have bouts of acute delirium, was on Seroquel but, unfortunately, had thrombocytopenia related to the Seroquel with a PF4 antibody negative to rule out heparin-induced thrombocytopenia. The patient was transitioned over to Zyprexa. She also has significant anxiety as well as dysphagia with acid reflux and needed a gastrostomy and jejunostomy placement, which occurred on September 12th. At this point in time, the patient has been stable at Acute Care Hospital, tolerating trach mask while awake and nocturnal ventilatory support. She is being admitted to LTCH for potential liberation from mechanical ventilatory support. She is alert, although anxious, upon presentation with stable vital signs. PHYSICAL EXAMINATION Vital Signs: Temperature of 98.4, heart rate of 77, blood pressure of 105/67, respiratory rate of 22, O2 saturation of 90% on 40% FiO2. General: This is older than stated age female in no apparent distress, although anxious. On trach mask currently at the time of admission. HEENT: Head is atraumatic, normocephalic. Pupils are round and reactive to light, approximately 3 mm, and brisk. Sclerae non-icteric. Mucous membranes are pink and moist. Dentition is poor. Tongue is midline.    Neck: Supple. No JVD, no thyromegaly. She has a #8 Portex extra-long tracheostomy tube present without erythema or drainage. Chest: Symmetrical. Cardiovascular:  Irregularly irregular. S1, S2. No murmurs, rubs, or gallops. Lungs: Scattered rhonchi throughout. Diminished at the bases. Abdomen: Positive bowel sounds. Nontender, nondistended. Well-healed abdominal incision scar. She has a gastrostomy tube in her left upper quadrant with the bumper freely moveable and no erythema or drainage. Genitourinary: Genitalia: Normal external female genitalia with indwelling Foley catheter draining concentrated yellow urine. Extremities: Have no edema, clubbing, or cyanosis. She does have chronic steroid-induced skin fragility. She has a stage II on her coccyx and right gluteal fold. ASSESSMENT AND PLAN 1. Acute on chronic hypercapnic hypoxemic respiratory failure, status post tracheostomy tube and maintained on nocturnal ventilatory support. We will continue with trach mask trial. The patient does have a #8 extra-long Portex tracheostomy tube that was placed in the operating room secondary to multiple tracheostomy tube changes and malpositioned, questionable of a false lumen. We will hold on a tracheostomy tube change currently. We will continue with trach mask while awake with the nocturnal ventilatory support with AC/VC mode of ventilation at night. The patient was maintained on BiPAP via her tracheostomy tube nocturnally. This will be discontinued at LTCH, and she will be placed on mechanical ventilatory support for safety. We will obtain a chest x-ray, arterial blood gas, as well as determining if the patient is a weanable candidate. Given the size of her tracheostomy tube, she will not tolerate Passy-Muir valve at the present time. We will also send off a sputum for culture and sensitivity, as the patient does have a history of HCAP. 2. Atrial fibrillation with rapid ventricular rate. She is currently in an AFib rhythm. She is rate controlled. She is on Cardizem as well as Lopressor. We will continue with this medication regimen, continue with cardiac monitoring and intervene as appropriate. The patient should be maintained on long-term anticoagulation secondary to both her AFib history and bilateral pulmonary emboli. She is currently on Lovenox 80 mg b.i.d. 5. Chronic diastolic congestive heart failure. The patient appears euvolemic at the time of examination. We will continue to monitor and spot-dose Lasix as appropriate.     7. Severe debility. She will be seen by physical therapy and occupational therapy services with the goal to return her to her baseline functional status. 8. Prophylaxis. Again, the patient is maintained on a PPI for PUD prophylaxis and continues on Lovenox 80 mg b.i.d., which will cover the VTE prophylaxis, as the patient does have a history of bilateral pulmonary embolism as well as DVT and atrial fibrillation. She should be transitioned over to Eliquis pending her acute illness stability. DISPOSITION The patient is a full code, being admitted to the LTCH under the vent weaning program. All polypharmacy has been reviewed. Plan discussed with Dr.

ATTENDING PHYSICIAN DISCHARGE DIAGNOSES 1. Acute on chronic hypoxemic hypercapnic respiratory failure status post tracheostomy tube placed on September 9, with decannulation on November 7. 2. Advanced chronic obstructive pulmonary disease, long term oxygen therapy dependent on 4 L of O2 around the clock premorbidly. 3. Bilateral pulmonary embolism, status post inferior vena cava filter. 4. Chronic diastolic congestive heart failure. 5. Atrial fibrillation with rapid ventricular rate. 6. Acute thrombocytopenia with PF4 negative antigen. 7. Acute dysphagia, status post gastrojejunostomy tube placement. 8. Right cephalic deep vein thrombosis. 9. Obstructive sleep apnea. 10. Anxiety. 11. Diabetes, type 2. 12. Diverticulosis. 13. Ventral hernia. 14. Positive tobacco history. 15. Positive ethyl alcohol. 16. Coronary artery disease. 17. Hyperlipidemia. HOSPITAL COURSE Ms. ________ is a 59-year-old female with a history of advanced chronic obstructive pulmonary disease on 4 L of oxygen around the clock, atrial fibrillation, bilateral pulmonary emboli status post IVC filter, maintained on chronic anticoagulation, type 2 diabetes and diastolic heart failure and current smoker, who was admitted to Acute Care Hospital on July 30th with complaints of 3 days of watery diarrhea. She was admitted for rapid atrial fibrillation and hypoxemic respiratory failure. The patient underwent a tracheostomy tube and ventilatory dependence at Acute Care Hospital and was transitioned over to LTCH for potential liberation from mechanical ventilatory support. The patient did weaning trials while at LTCH, was successfully off trach mask around the clock, tolerated trach plug around the clock, did not quality for any noninvasive support secondary to acceptable blood gases. She was successfully decannulated on November 7, 2016, without issue. She continues on 6 L of oxygen via Oxymizer secondary to her underlying pulmonary emboli and hypoxia. From a debility perspective, should continue with PT and OT services. She will require extension rehab services to return her to her baseline functional status. We did offer smoking cessation to Ms. ______ which she denied. We titrated her nicotine patch. Again we did reinforce the need for smoking cessation given her extensive advanced chronic obstructive pulmonary disease and O2 dependence. From a cardiac perspective, she continued in atrial fibrillation. She did have episodes of bradycardia. Her medications were titrated. Her Cardizem was decreased from 90 mg q.6 hours to 60 mg q.6 hours and her digoxin level was checked which was within therapeutic range. From a dysphagia perspective, the patient was taken off of her tube feeds. She does have a GJ-tube for p.r.n. support. She continues on a p.o. regular diet. She is inhibited by dentition although able to tolerate a regular diet at this point in time. DISCHARGE RECOMMENDATIONS 1. Advanced chronic obstructive pulmonary disease, O2 dependent. Continue with O2 titration. She is currently on 6 L of Oxymizer down-titrate 4 L when the patient tolerates. She also had a history of obstructive sleep apnea but has had acceptable arterial blood gases while at LTCH and does not qualify for any noninvasive support. Her most recent ABG was 7.41, pCO2 of 46, pO2 of 86 and bicarb of 29.2. 2. Diabetes, types 2. Continue with fingerstick a.c. and h.s., Lispro sliding scale coverage and Lantus that has been titrated up secondary to nonadherence with diet restriction. She continues on an ADA diet, also does have food delivered from home causing spurts of hyperglycemia. 3. Anxiety. She continues on Klonopin b.i.d. as well as p.r.n. for breakthrough anxiety. 4. Depression. She continues on an SSRI, has had no suicidal ideations or unsafe behavior. 5. Debility. She will be seen by PT and OT services with the goal to return her to her baseline functional status. 6. Atrial fibrillation. She is now rate controlled on digoxin 125 mcg daily and Cardizem 60 mg q.6 hours. She has been discontinued from cardiac monitor and has been stable since that point in time. Continue with Eliquis 5 mg b.i.d. 7. Smoking cessation. Again smoking cessation has been a strong point in her plan at LTCH. The patient declined any smoking cessation counseling and did transition off of her nicotine transdermal patch per her request. Plan discussed with Dr.

After reading the medical record, answer the following questions:

1. Based on the information discussed in the text book and your review of the medical record, do you believe that the principal diagnosis should have been coded to acute and chronic respiratory failure with hypoxia or do you think the principal diagnosis should be vent weaning? Explain why you picked one over the other.

2. Based on the knowledge you obtained from reading the text book, why is the principal diagnosis difficult to determine in the LTCH setting?

3. Finally, review the patient's diagnoses, then explain why patient's in the LTHC setting tend to have so many secondary diagnoses?  

Your initial post must be 2-3 paragraphs (5-7 sentences each) in length

Answer 1

1. The principal diagnosis is the chief diagnosis that the patient admitted to the hospital. Coding guidelines define the principal diagnosis is coded based on the circumstances of the patient clinical dependability. In the respiratory failure condition, If the patient has hypoxia, hypercapnia, and supported with ventilation and require continuous weaning, then the vent weaning could be the principal diagnosis. Then the acute or chronic respiratory failure diagnosis is followed by the vent weaning.

2. The principal diagnosis is difficult to determine in long term care because the patient is associated with many acute and long -term condition and also need of rehabilitative and skilled services. The reimbursement is based on the average length of stay and reason for long term care. According to the coding guidelines, the principal diagnosis must be accurate and applicable to the long term care hospitals. The principal diagnosis should be specific to the long term care hospitals. Inaccurate coding will also affect the MS-DRG system.

3. Long term care patient has so many conditions and also tend to develop an associated condition during the stay of the hospital. They have a wide range of associated medical conditions that could be grouped into the diagnostic category. The disease condition must be associated with multiple organ disorder and rehabilitative services are needed. The patient is focused on specialty care. These are all to be included in the diagnosis. So the long term care patient has many secondary diagnosis.