Title: Final Case Study Project
Course: HIM 3620 - TAACCCT Grant > Section: Module 14 - Final Project Case Studies

Rather than a final exam, you will be completing a final project.

You are applying for a CDI position at a hospital in your area. Please answer the following questions for EACH the following 2 cases.

1. Identify the reason after study as to why the patient required inpatient treatment (principal diagnosis)
2. Identify any comorbid conditions that were evaluated or treated (secondary diagnosis)
3. Identify any potential query opportunities:

- Diagnoses that could potentially require clarification or lack specificity
- Treatment, monitoring, or evaluation of a condition without a diagnosis; identification of abnormal lab values or medications

Case Study 1

- A 65-year-old female arrives with shortness of breath (SOB), chest discomfort, and is experiencing respiratory distress after collapsing at home. The physician diagnoses the patient with syncope and possible pneumonia. She is transferred to a medical floor with diagnoses of #1 SOB (respiratory distress), #2 syncope, and #3 pneumonia.

  - Four hours later the patient’s breathing is worsening. Blood gases are drawn, and the decision is made to transfer her to the ICU for respiratory support. Progress notes list severe respiratory distress, pneumonia, and syncope. That afternoon in the ICU, the patient worsens, and documentation of possible aspiration pneumonia occurring during syncope is noted in the critical care note.
  - The patient improves and two days later is on a medical floor. A swallow evaluation is done and the patient is placed on thickened liquids. Antibiotics continue for pneumonia and the patient’s respiratory distress is resolved.
  - On hospital day 4 the patient is transferred to medical rehab. Discharge diagnoses are #1 pneumonia and #2 syncope

Case Study 2

- An 79-year-old female is admitted through the emergency room from a nursing home with confusion, fever, and cough. Admission diagnoses are listed as #1 fever and #2 pulmonary infiltrates with a history of congestive heart failure (CHF), dementia, and decubitus ulcers.
  - The admission assessment by nursing notes a Stage IV decubitus ulcer with consult to the wound nurse.
  - That afternoon cardiology is consulted due to increased BNP and acute CHF is documented and treated with IV Lasix.
  - On hospital day 2 the attending documents diastolic CHF improved with possible discharge the next day.
  - On hospital day 3 the patient is transferred back to the nursing home. Discharge diagnoses are acute diastolic CHF, dementia, and fever resolved.

Each Case study query will be between 1-2 pages.  Using the skills learned and resources found online with your text, create a query for each case.