What is the correct status-Inpatient or Observation?

69-year-old female with history of Systolic CHF [EF 25%], COPD and Moderate Mitral Regurgitation presents to the ER with complaint of shortness of breath, cough and leg swelling for a week. She was unable to lie flat, had activity intolerance, and she reports that she ran out of medications recently. She was recommended ICD but refused in the past. Oxygen saturation was 89% on RA. Blood sugar was elevated at 300. BP was also slightly elevated at 170/110mm Hg.

Patient has commercial insurance.

Day 1 of admission: She was diagnosed with Acute on Chronic systolic CHF, was given one dose of IV Lasix 40mg in ER. Cardiology saw and recommended Bumex iv 1mg BID. Weight 195lbs.

Day 2: IV Bumex 1mg BID continued. HBA1C 9.9.

Day 3: Diuresis continued.

Day 4: ECHO was done which showed EF 30%. Bumex changed to Bumex 1mg IV daily.

Day 5: Received IV Bumex AM dose. Patient discharged home after lunch. Desat study showed that she did not require oxygen. Pre discharge weight was 185lbs. Cardiology added Aldactone, Entresto, and Coreg.

Questions:

  1. Is this case appropriate for Inpatient or Observation? Answer: Observation

2. What other information will help in better evaluation of the status? Answer: Whether patient had hypotension, electrolyte issues, worsening kidney function, Significant physical complaints like Dyspnea on minimal exertion, Morbid obesity with edema extending up into the dependent areas like sacrum, abdominal fullness beyond obs time frame etc.

3. Would you do Peer to Peer review if the inpatient status is denied? Answer: It depends on presence of above findings mentioned in Question 2.

Note: This is a hypothetical case but helpful to discuss this type of a case as it is very common in our practice.

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