Sepsis vs
I have patient with a history of hyperekplexia who was treated as outpt for uti with Bactrim. He came in because he had been vomiting, not eating, fever 102, occasional chills and syncopal episode and was dx with uti, dehydration and syncope.
H/P says acute renal injury, hyperekplexia with severe muscle cramps.
First progress note says uti, sepsis consider contamination from port, aki. UTI, aki and sepsis have been documented on subsequent notes.
VS are normal (no tachypnea or tachycardia, BP wnl), had the reported temp of 102 at home but temp has been normal his whole stay. WBC 11.9, 91 neuts, 10.5 absolute neuts, Lactic acid and procalcitonin normal. Bld cult showed alpha strep (no sensitivities done).
i asked the doctor if he thought the renal failure was due to sepsis or dehydration or other and he said and documented that the renal failure was due to dehydration.
He barely qualifies for sepsis being treated with Rocephin. He was fluid resuscitated for the renal failure and his creatinine improved from 1.81 to .82. He had neither ID or renal consult.
In this case, do you think Acute Renal Failure could be sequenced as PDx over sepsis?
Comments
Look forward to other comments, Always more than one way to approach these complex cases.
Beth Wolf, MD
If after querying, the attending physician affirms that a patient has a particular condition in spite of certain clinical parameters not being met, the facility should request the physician document the clinical rationale and be prepared to defend the condition if challenged in an audit. The facility should assign the appropriate code(s) for the conditions documented.