Reference no: EM133745881

1- You are abstracting a BKA case as your primary procedure. On postoperative day 3, while still inpatient, the nurse finds the patient to have altered mental status and facial droop. A Code Stroke is called, and a head CT is done. The impression from the CT notes no ischemia; however, a subdural hematoma is found. The patient continues to have facial droop and altered mental status for 30 hours. Would you assign Stroke/CVA to this case?

Postop Respiratory
2- You are reviewing a case of a 65-year-old male who underwent an emergent coronary artery bypass graft. On postoperative day 25, the patient is readmitted to your site with chest pain, shortness of breath, and dizziness. The emergency room physician documents "possible pulmonary embolism" and admits the patient to initiate workup. The patient expires on postoperative day 26. An autopsy later confirms that a patient had a pulmonary embolism. Would you assign a Pulmonary Embolism to this case?

3- The primary procedure was a left below-knee amputation. On POD 0, after leaving PACU, the patient had the following blood pressures not attributed to another known non-infectious etiology:
1123 82/50
1204 86/52
1230 88/54
0115 92/80
The hospitalist's documentation on the following day included:
peripheral vascular disease, PAD with critical limb ischemia
Group B streptococcus bacteremia
Patient on ceftriaxone and metronidazole
Vascular surgery following, status post BKA
Would you assign Postoperative Sepsis?

4- The patient received 2 units of fresh frozen plasma (FFP) preoperatively on the day of the primary procedure. What would you select for the preoperative risk factor RBC Transfusions?

5- You are abstracting a thoracotomy with wedge resection as a primary procedure. The patient has no history of C. diff Colitis and no documentation of C. diff/diarrhea preoperatively. On postoperative day 15, the patient has a telehealth visit and notes he has had loose stools for 3 days. The patient's primary care provider prescribes oral Flagyl with the indication of "diarrhea" and the patient is instructed to follow up with an in-person office visit. Would you assign C. diff Colitis to this case?
6- 63-year-old patient has a past medical history of COPD. Budesonide (Pulmicort) is listed on the patient's home medication list, however, the patient hasn't filled the prescription in months. Would you assign the preoperative risk factor History of Severe COPD?

7- You are abstracting a total hip arthroplasty as a primary procedure. Prior to the primary procedure, the patient had no history of requiring dialysis. The patient had preop labs drawn the morning of the surgery, and you note the patient's creatinine was 1.8mg/dL at that time. On postoperative day 1, the patient had a creatinine of 4.2mg/dL. On postoperative day 2, the patient required dialysis. What would you assign for this patient?

8- You are reviewing a cesarean section as a primary procedure in NSQIP. The patient was hypertensive upon admission and given a one-time dose of intravenous metoprolol. The patient had documentation of "mild gestational hypertension." There were no home medications for this patient. What would you select for the preoperative risk factor Hypertension Requiring Medication?

9- In the case you are abstracting, the patient has a creatinine value of 2.5mg/dL on preoperative day 5. On preoperative day 0, the patient's creatinine rose to 6.4mg/dL. Nephrology was consulted and documented "Patient requires dialysis, however, due to the urgent nature of procedure, will defer placement of temporary catheter until after the procedure when more stable." The patient was brought to the operating room for an emergent colectomy, which you abstract as your primary procedure. Which is the most appropriate option regarding the preoperative renal risk factors?
Preop Dialysis

10- The primary procedure is a partial thyroidectomy. On POD 2, the patient's chest x-ray impression reads: "patchy bibasilar opacification, possibly representing atelectasis. Mild pneumonia would be difficult to exclude."
POD 4 WBC 14.24 K/mm3
POD 5 Covid PCR test positive
Would you assign the postoperative occurrence Pneumonia to the case?

11- You are abstracting a laparoscopic hysterectomy, total bilateral salpingectomy as a primary procedure. The operative note states the following: "The patient entered the operating room and was placed supine on the operating table. Anesthesia was administered, and a time out was performed. The patient was prepped and draped in a sterile fashion. An abdominal incision was made at the umbilicus. Through this incision, a trocar was placed, and pneumoperitoneum was established. A camera was placed for visualization, and three additional trocar ports were inserted...At the completion of the procedure, an incision was created to remove the uterus. After removal of the uterus, the retractor was removed. Pneumoperitoneum was released, trocars removed, and skin was closed with 4-0 Monocryl and Dermabond. The patient was awakened and sent to the PACU in satisfactory condition. All sponge, needle, and instrument counts were correct post-procedure." What would you select for the Operative Approach variable?

12- You are abstracting an open reduction internal fixation (ORIF) of the right humerus. On POD 10, the patient went to urgent care and was diagnosed with cellulitis at the surgical site and prescribed Keflex. The patient sent pictures to the surgeon's office on POD 11. The surgeon replied to the patient: "The surgical site just looks like irritation to the skin and not an infection. Just to be safe, finish the antibiotic prescription." Would you assign Superficial Incisional SSI to this case?

13- The patient presents to the ED with abdominal pain. He is noted to be short of breath, diaphoretic, and febrile. He is placed on BIPAP while in the ER. The primary procedure is an appendectomy. Intraoperatively, the appendix is noted to be perforated with gross purulence. The patient is successfully extubated and taken to PACU. You determine that criteria are met to assign the occurrence of Sepsis to the case. Would you assign PATOS to the occurrence of Sepsis?
YES

14- On postoperative day 22 from the primary procedure, the patient had a cardiac arrest at home. When first responders arrived, the patient was noted to be pulseless, and CPR was initiated. Shortly after, the patient was pronounced deceased. Would you capture Cardiac Arrest Requiring CPR in this scenario?

15- You are reviewing a case of a 67-year-old female status post right hemicolectomy. During your review, you find a preoperative report of a computed tomography (CT) scan taken two weeks before the primary procedure during the patient's visit to the surgeon of record's office. The CT report notes "ascites not evident at this time." In the operative note from the primary procedure, the surgeon documented "the fascial incision was extended and abdomen explored with significant ascites suctioned from the abdomen." Would you assign the preoperative risk factor Ascites to this case?

16- You are reviewing a case with an operative date of January 20, 2024. In the preoperative history and physical, the surgeon notes the patient is a current vape smoker. There is no indication in the patient's chart that the patient has ever used tobacco cigarettes. Would you assign Current Smoker to this case?

17- The primary procedure you are abstracting is a liver resection. The patient has a preoperative diagnosis of metastatic melanoma. The patient was found to have a liver lesion. The biopsy revealed a metastasis from melanoma. Would you assign the preoperative risk factor Disseminated Cancer?

20- You are reviewing a case of a hepatectomy performed on a 58-year-old male due to liver cirrhosis. The surgery start time was 1100 on 3/1/2024. The patient entered the post-anesthesia care unit (PACU) at 1800 on 3/1/24 and was found to have a hemoglobin of 7.5 g/dL. The patient received 300 mL of autologous blood while in the PACU and another 500 mL upon their transfer to the SICU at 2230 on 3/1/24. On postoperative day 4, the patient again required a transfusion of 500 mL of packed red blood cells. You assigned the postoperative occurrence Blood Transfusion to this case. What would you enter for the number of Blood Units Transfused?
2 Units

21- You are abstracting the case of 61-year-old male who received a total knee replacement. Prior to the primary procedure, the patient completed a preoperative fall risk assessment. As part of this assessment, the patient stated that he did not require assistance or supervision for daily tasks, mobility, transfers, or ambulation. What would you select for Functional Health Status?

22- While following up with a patient via phone call, the patient stated they went to urgent care on POD 28 and were diagnosed and tested positive for COVID-19. Criteria were not met to assign the preoperative risk factor COVID-19 Diagnosis. What would you select for the postoperative variable New Postop COVID-19 Diagnosis?

23- The patient for the case you are abstracting has a diagnosis of sleep apnea. He utilizes a CPAP machine at home without supplemental oxygen and uses it every night. The preoperative nurse documents that the patient used his CPAP machine last night. Would the preoperative risk factor Oxygen Support be assigned to this case?

24- An 87-year-old female with a history of chronic urinary tract infections had a hip fracture repair at your facility, which you are abstracting as a primary procedure. Preoperatively, on the day of the primary procedure, the patient had a symptomatic UTI and was treated with antibiotics. The patient's symptoms resolved on postoperative day 4 with completion of antibiotics. The patient presented to the emergency department on postoperative day 25 with altered mental status and fever of 38.2 C. A urine culture obtained that day revealed:
100,000 CFU/mL klebsiella oxytoca
60,000 CFU/mL escherichia coli
Would you assign the occurrence Urinary Tract Infection to this case?

25- The primary procedure was a targeted hip fracture repair following a fall. ICD-10 code S72.142A was assigned to the case. The primary procedure was performed during the first medical visit following the injury. The patient had a small scrape on her arm in addition to the hip fracture. Would the scrape count as an additional injury, and therefore the case would be excluded? Or would this case be included in your sample?
Inclusion
26- You are abstracting a breast lumpectomy as your primary procedure. The primary procedure occurred on January 1, 2024. While reviewing the patient's preoperative medication list, you note the patient was on the following medication:
1. Enbrel 50mg weekly for Rheumatoid Arthritis
Date last taken: December 18, 2023
27- After extensive chart review, you note that the patient has no other medications or diagnoses listed in the preoperative timeframe. Would you assign Immunosuppressive Therapy to this case?

28- On postoperative day 14, the patient presents to the ED with complaints of severe tingling in their right hand. The nurse notes decreased pulses, and an ultrasound is ordered. The ultrasound was concerning for near complete occlusion of the right subclavian artery extending into the proximal brachial artery. Vascular was consulted, and the patient was started on a heparin drip. Would you assign Venous Thrombosis Requiring Therapy?

29- A patient had a colectomy as the primary procedure. All levels were closed after this procedure. The patient was emergently brought back to the OR for anastomotic leak on POD 2. During this second operation, the anastomosis was resected, and the patient was left in discontinuity. Plans were documented to reoperate the next day. Would both returns to the OR be assigned 30-Day Unplanned Return to OR, or just the initial emergency return to OR?

30- You are abstracting a mastectomy as your primary procedure. You note the patient's creatinine values are as follows: preoperative (drawn the morning of the primary procedure): Cr 1.0mg/dL; POD 1: Cr. 2.4mg/dL; POD 2: Cr 2.4mg/dL; POD 3: Cr 2.5mg/dL. Postop Renal Insufficiency was assigned to this case. What would be assigned for Most Severe Creatinine Increase?