Question

DISCHARGE DX CODES FOR:

1. COMPLICATED UTI D/T MSSA

2. SEPSIS D/T MSSA ERUTPING FOR TURP AND STENT PLACEMENT PRIOR TO THIS ADMISSION

3. BACTEREMIA

4. PROSTATE CANCER METASTATIC TO BONE

5. MITRAL VALVE REGURGITATION

Answer 1

1)COMPLICATED UTI D/T MSSA

Complicated UTI is an infection associated with a condition, such as structural or functional abnormalities of the genitourinary tract or the presence of an underlying disease, which increases the risks of acquiring an infection or of failing therapy. Two criteria are mandatory to define a complicated UTI: a positive urine culture and one or more of the factors listed in Table: Factors That Suggest a Potential Complicated UTI. Complicated UTI can arise in a heterogeneous group of patients. But neither patient age nor gender per se are part of the definition of a complicated UTI. With regard to prognosis and clinical studies, it is advisable to stratify complicated UTIs due to urological disorders into at least two groups:

1. Patients in whom the complicating factors could be eliminated by therapy, e.g. stone extraction, removal of an indwelling catheter.

2. Patients in whom the complicating factor could not be or is not removed satisfactorily during therapy, e.g. permanent indwelling catheter, stone residuals after treatment or neurogenic bladder.

Clinical Presentation

A complicated UTI may or may not be associated with clinical symptoms (e.g. dysuria, urgency, frequency, flank pain, costovertebral angle tenderness, suprapubic pain and fever). Clinical presentation may vary from severe obstructive acute pyelonephritis with imminent urosepsis to a catheter-associated post-operative UTI, which might disappear spontaneously as soon as the catheter is removed. It also has to be recognized that symptoms, especially lower urinary tract sympoms (LUTS), are not only caused by UTIs but also by other urological disorders, such as benign prostatic hyperplasia (BPH), TURP, etc.

Apart from urological abnormalities, concomitant medical conditions, such as diabetes mellitus (10%) and renal failure, which can be related to urological abnormalities, are often present in a complicated UTI.

Urine Cultures

Significant bacteriuria in a complicated UTI is defined by counts of ≥ 105 cfu/mL and ≥ 104 cfu/mL, in the mid-stream sample of urine of women and men, respectively. If a straight catheter urine sample is taken, ≥ 104 cfu/mL can be considered relevant. For an asymptomatic patient, two consecutive urine cultures (at least 24 hours apart) yielding ≥ 105 cfu/mL of the same micro-organism are required. The requirement for pyuria is ≥ 10 WBC per high-power field (x 400) in the resuspended sediment of a centrifuged aliquot of urine or per mm3 in unspun urine. A dipstick method can also be used for routine assessment, including a leucocyte esterase test, haemoglobin and probably a nitrite reaction. Sterile pyuria is commonplace in patients with indwelling bladder catheters.

2. SEPSIS D/T MSSA ERUTPING FOR TURP AND STENT PLACEMENT PRIOR TO THIS ADMISSION

Transurethral resection of the prostate (TURP) is a common operation (150, 000 per year in US) and is associated with a significant infective morbidity. Reported rates of bacteraemia following TURP without antimicrobial prophylaxis vary widely (0–31%), but decrease to 1% with antimicrobial prophylaxis[1,2]. Anecdotes of severe sepsis following TURP are common[3] and we have recently shown an association between urological procedures and an increased risk of enterococcal endocarditis[4]. A better understanding these infective complications is necessary to design effective prevention and treatment strategies.

Few studies have been specifically designed to assess the frequency and implications of bacteraemia related to TURP; most studies report bacteriuria, urinary tract infections (UTIs) and fever. Only if patients were clinically suspected to have a bacteraemia (e.g. fever or rigors), were blood cultures then taken to determine the presence of bacteraemia. The rate of asymptomatic bacteraemia in TURP patients is not known; only a few old studies, with design limitations, have addressed the issue [5–8].

All major urology guidelines recommend the use of antimicrobial prophylaxis during a TURP[9–11]. However, antimicrobial prophylaxis is used to decrease the incidence of post-operative bacteriuria, rather than other significant infective parameters such as bacteraemia, bloodstream infection or severe sepsis[12–14]. Urological instrumentation is associated with enterococcal endocarditis, (~1 in 4200 procedures), [4] however, it is still not known why some patients develop such severe infective episodes whilst others have an uneventful procedure. It is not known if prostate pathology affects the risk of serious infective complications.

The primary aim of the study was to investigate the incidence, timing, duration and identity of bacteraemia or bloodstream infection occurring during TURP. A secondary aim was to investigate the patient (e.g. underlying prostatic disease) and procedure-related risk factors associated with the development of peri-operative bacteraemia during TURP.

Materials and Methods

Ethics

Ethics approval was obtained from the Leeds West research ethics committee (REC number: 10/H1307/5) and institutional approval was also obtained(R&D number: UR09/9173). All patient gave written consent to participate in the study.

Study design, inclusion and exclusion criteria

For the primary aim, a prospective, cohort study design was undertaken on patients having TURP at our institution. For the secondary aim, a case control design was used where ‘cases’ were those patients who had evidence of bacteraemia and the controls were patients who did not develop bacteraemia. The study included both catheterised patients undergoing TURP for acute urinary retention and non-catheterised patients undergoing TURP for lower urinary tract symptoms (LUTS). Patients with both benign prostatic hyperplasia and known prostatic adenocarcinoma of the prostate were included in the study.

3. BACTEREMIA

Introduction

Bacteremia, in the strictest sense, refers to viable bacteria in the blood. Asymptomatic bacteremia can occur in normal daily activities such as conducting oral hygiene and after minor medical procedures. In a healthy person, these clinically benign infections are transient and cause no further sequelae. However, when immune response mechanisms fail or become overwhelmed, bacteremia becomes a bloodstream infection that can evolve into many clinical spectrums and is differentiated as septicemia. Untreated and clinically significant bacteremia progresses to systemic inflammatory response syndrome (SIRS), sepsis, septic shock, and multiple organ dysfunction syndrome (MODS).

Etiology

Determining the primary source of infection is critical in the management of a patient with bacteremia, as well as in the identification of the affected patient population. Common sources in hospitalized patients include the respiratory tract and indwelling catheters, specifically central venous catheters. Untreated urinary tract infections most commonly cause community-acquired bacteremia. Soft tissue and intraabdominal infections are not as common and are more prevalent in the post-operative surgical setting. Escherichia coli is the most common cause of gram-negative associated bacteremia, while Staphylococcus aureus is the most common gram-positive organism.

Epidemiology

Geographic region, patient population, drug resistance, and infection prevention practices at each institution drive the causative organisms of bloodstream infections. Taking into account that older patients with multiple comorbidities are more likely to reside in community centers and be hospitalized, it is no surprise that they are at an increased risk of developing bacteremia. Traditionally gram-negative bacilli were the driving force for most hospital-acquired bloodstream infections in the United States and are still the most common organism associated with community-acquired bacteremia. However, with the onset of an aging population and device-related procedures, gram-positive aerobes have seen an increase in prevalence over the last two decades.

Pathophysiology

All bacterial infections are dependent on the host immune system, which is affected by their genetic signature, as well as congenital and acquired deficiencies. Cellular innate and adaptive immune responses are responsible for initial microbe clearance, while the liver and spleen filter active bacteria in the circulating blood. In its most basic form, bacteria will begin to colonize at its primary source of location. At this point, the bacteria may become transient and clinically insignificant or can escape the host immune response and increase in number and become a local infection that can eventually migrate to other parts of the body. If the bacteria are viable and enter the circulating bloodstream, the infection still may spontaneously clear or progress to septicemia. The first barrier to bacterial invasion is the skin and mucosal surfaces. Conditions that interfere with these natural defense barriers commonly include medical procedures that pass through the skin and anatomical lumina. Additionally, events can precipitate defense breakdown via trauma, burns, ulcers, and the natural elements of aging.[6]

History and Physical

The classical presentation in a bacteremic patient is the presence of a fever. Chills and/or rigors do not need to present; however, the presence of such signs should clue the provider that a febrile patient is now bacteremic. The development of septicemia leading to sepsis and septic shock will commonly cause hypotension, altered mental status, and decreased urine output due to hypovolemia from leaking capillaries. As the infection disseminates, other organs can become affected, causing acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI).

4. PROSTATE CANCER METASTATIC TO BONE

Bone metastasis and prostate cancer

About 80 percent of the time prostate cancer cells metastasize, or spread, they will spread to bones, such as the hip, spine, and pelvis bones. It can be by direct invasion or by traveling through your blood or lymphatic system. Metastatic prostate cancer is considered advanced prostate cancer.

Once relocated, the cells begin to grow and form new tumors. This new growth is still classified as prostate cancer because the cancer first developed in the prostate. You may notice new or different symptoms once you have bone metastases.

Having bone metastases will change your treatment options, prognosis, and outlook. As you begin to consider your next steps, it’s important to know that you have many options.

What are the symptoms?

Symptoms of advanced prostate cancer include:

difficulty urinating

bloody urine or semen

erectile dysfunction

painful ejaculation

swelling in pelvic area or legs

fatigue

unexplained weight loss

Understanding advanced prostate cancer

Bone metastasis

After the cancer cells spread to the bones, you may experience:

bone pain

weak bones, increasing your risk for fractures

spinal cord compression and related weakness or numbness

high blood calcium levels

stiffness or pain in the hip, thighs, or back

These symptoms can cause severe discomfort and disability. Spinal cord compression can result in nerve damage, which can lead to muscle weakness or paralysis, numbness in the legs or arms, or loss of control of bladder and bowel functions.

Higher levels of calcium in the blood can occur as cancer replaces normal bone. This can trigger:

vomiting

dehydration

confusion

abdominal discomfort

Talk to your doctor if you have any of the above symptoms. Early treatment can help slow the cancer’s progression in your bones and improve your life expectancy.

5. MITRAL VALVE REGURGITATION

Mitral valve regurgitation — also called mitral regurgitation, mitral insufficiency or mitral incompetence — is a condition in which your heart's mitral valve doesn't close tightly, allowing blood to flow backward in your heart. If the mitral valve regurgitation is significant, blood can't move through your heart or to the rest of your body as efficiently, making you feel tired or out of breath.

Treatment of mitral valve regurgitation depends on how severe your condition is, whether it's getting worse and whether you have symptoms. For mild leakage, treatment is usually not necessary.

You may need heart surgery to repair or replace the valve for severe leakage or regurgitation. Left untreated, severe mitral valve regurgitation can cause heart failure or heart rhythm problems (arrhythmias). Even people without symptoms may need to be evaluated by a cardiologist and surgeon trained in mitral valve disease to determine whether early intervention may be beneficial.

Symptoms

Some people with mitral valve disease might not experience symptoms for many years. Signs and symptoms of mitral valve regurgitation, which depend on its severity and how quickly the condition develops, can include:

Abnormal heart sound (heart murmur) heard through a stethoscope

Shortness of breath (dyspnea), especially when you have been very active or when you lie down

Fatigue

Heart palpitations — sensations of a rapid, fluttering heartbeat

Swollen feet or ankles

Mitral valve regurgitation is often mild and progresses slowly. You may have no symptoms for many years and be unaware that you have this condition, and it might not progress.

Your doctor might first suspect you have mitral valve regurgitation upon detecting a heart murmur. Sometimes, however, the problem develops quickly, and you may experience a sudden onset of severe signs and symptoms.

When to see a doctor

If your doctor hears a heart murmur when listening to your heart with a stethoscope, he or she may recommend that you visit a cardiologist and get an echocardiogram. If you develop symptoms that suggest mitral valve regurgitation or another problem with your heart, see your doctor right away. Sometimes the first indications are actually those of mitral valve regurgitation's complications, including heart failure, a condition in which your heart can't pump enough blood to meet your body's needs.Causes

Chambers and valves of the heart

Chambers and valves of the heart Open pop-up dialog box

Your heart has four valves that keep blood flowing in the correct direction. These valves include the mitral valve, tricuspid valve, pulmonary valve and aortic valve. Each valve has flaps (leaflets or cusps) that open and close once during each heartbeat. Sometimes, the valves don't open or close properly, disrupting the blood flow through your heart to your body.

Heart showing mitral valve prolapse and regurgitation

Mitral valve prolapse and regurgitation Open pop-up dialog box

In mitral valve regurgitation, the valve between the upper left heart chamber (left atrium) and the lower left heart chamber (left ventricle) doesn't close tightly, causing blood to leak backward into the left atrium (regurgitation).

Mitral valve regurgitation causes

Mitral valve regurgitation can be caused by problems with the mitral valve, also called primary mitral valve regurgitation. Diseases of the left ventricle can lead to secondary or functional mitral valve regurgitation.

Possible causes of mitral valve regurgitation include:

Mitral valve prolapse. In this condition, the mitral valve's leaflets bulge back into the left atrium during the heart's contraction. This common heart defect can prevent the mitral valve from closing tightly and lead to regurgitation.

Damaged tissue cords. Over time, the tissue cords that anchor the flaps of the mitral valve to the heart wall may stretch or tear, especially in people with mitral valve prolapse. A tear can cause leakage through the mitral valve suddenly and may require repair by heart surgery. Trauma to the chest also can rupture the cords.

Rheumatic fever. Rheumatic fever — a complication of untreated strep throat — can damage the mitral valve, leading to mitral valve regurgitation early or later in life. Rheumatic fever is now rare in the United States, but it's still common in developing countries.

Endocarditis. The mitral valve may be damaged by an infection of the lining of the heart (endocarditis) that can involve heart valves.

Heart attack. A heart attack can damage the area of the heart muscle that supports the mitral valve, affecting the function of the valve. If the damage is extensive enough, a heart attack can cause sudden and severe mitral valve regurgitation.

Abnormality of the heart muscle (cardiomyopathy). Over time, certain conditions, such as high blood pressure, can cause your heart to work harder, gradually enlarging your heart's left ventricle. This can stretch the tissue around your mitral valve, which can lead to leakage.

Trauma. Experiencing trauma, such as in a car accident, can lead to mitral valve regurgitation.

Congenital heart defects. Some babies are born with defects in their hearts, including damaged heart valves.

Certain drugs. Prolonged use of certain medications can cause mitral valve regurgitation, such as those containing ergotamine (Cafergot, Migergot) that are used to treat migraines and other conditions.

Radiation therapy. In rare cases, radiation therapy for cancer that is focused on the chest area can lead to mitral valve regurgitation.

Atrial fibrillation. Atrial fibrillation is a common heart rhythm problem that can be a potential cause of mitral valve regurgitation.

Risk factors

Several factors can increase your risk of mitral valve regurgitation, including:

A history of mitral valve prolapse or mitral valve stenosis. However, having either condition doesn't necessarily mean you'll develop mitral valve regurgitation. A family history of valve disease also can increase risk.

A heart attack. A heart attack can damage your heart, affecting the function of the mitral valve.

Heart disease. Certain forms of heart disease, such as coronary artery disease, can lead to mitral valve regurgitation.

Use of certain medications. People who take drugs containing ergotamine (Cafergot, Migergot) and similar medicines for migraines or who take cabergoline have an increased risk of mitral regurgitation. Similar problems were noted with the appetite suppressants fenfluramine and dexfenfluramine, which are no longer sold.

Infections such as endocarditis or rheumatic fever. Infections or the inflammation they cause can damage the mitral valve.

Congenital heart disease. Some people are born with an abnormal mitral valve prone to regurgitation.

Age. By middle age, many people have some mitral valve regurgitation caused by natural deterioration of the valve.

Complications

When it's mild, mitral valve regurgitation usually does not cause any problems. However, severe mitral valve regurgitation can lead to complications, including:

Heart failure. Heart failure results when your heart can't pump enough blood to meet your body's needs. Severe mitral valve regurgitation places an extra strain on the heart because, with blood pumping backward, there is less blood going forward with each beat. The left ventricle gets bigger and, if untreated, weakens. This can cause heart failure.

Also, pressure builds in your lungs, leading to fluid accumulation, which strains the right side of the heart.

Atrial fibrillation. The stretching and enlargement of your heart's left atrium may lead to this heart rhythm irregularity in which the upper chambers of your heart beat chaotically and rapidly. Atrial fibrillation can cause blood clots, which can break loose from your heart and travel to other parts of your body, causing serious problems, such as a stroke if a clot blocks a blood vessel in your brain.

Pulmonary hypertension. If you have long-term untreated or improperly treated mitral regurgitation, you can develop a type of high blood pressure that affects the vessels in the lungs (pulmonary hypertension). A leaky mitral valve can increase pressure in the left atrium, which can eventually cause pulmonary hypertension. This can lead to heart failure on the right side of the heart.

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