2022 Congestive Heart Failure – Post Test

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Question 1 of 10

1. Question
1. A 71 year old with HFrEF (41%) presents with a 2 day history of weight gain, DOE, LE edema of +3, and a RA saturation of 92% (baseline is 95%). His labs are normal with K+ 4.2, Hgb 9.9, and a Cr of 1.4 (baseline 0.9). CXR shows increased lung markings and a slight effusion. His prior admission 2 months ago was 6 days and was complicated by acute kidney injury (Cr max was 2.8) after diuresis. This patient is best served by
- a. Inpatient admission due to the low hemoglobin, low oxygen saturation and HFrEF
- b. Inpatient admission due to the prior renal response and the assumption that a similar path will be taken given this presentation
- c. Outpatient observation because of the stable oxygenation on room air
- d. Outpatient observation because the Cr is only slightly elevated
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Question 2 of 10

2. Question
2. Hemodynamic instability (abnormal vital signs) on presentation to the ED in a heart failure patient is appropriate for inpatient admission.
- a. True
- b. False
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Question 3 of 10

3. Question
3. A 68 year old DM patient with ASCVD and HFrEF (40% EF), presents with Acute HF exacerbation. The patient, on day two has a Cr of 1.55, up from 1.06 (baseline 1.10). There are still crackles in the bases and +4 pre-tibial edema, but O₂ sats are better overall at 92% on 1 liter. You feel…
- a. Inpatient care is appropriate because of the O2 sat
- b. Observation is appropriate
- c. The patient can be discharged to home
- d. Inpatient care is appropriate because of the rising Cr and the continued need for more diuresis
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Question 4 of 10

4. Question
4. The Two Midnight Rule
- a. Requires all patients be in-house for two midnights before inpatient status is ordered
- b. Follows the Medical Inpatient Only listing which is updated each year
- c. States that documentation for inpatient far exceeds that for observation status
- d. States that active management of a clinical condition should be expected to transcend two midnights to be considered inpatient
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Question 5 of 10

5. Question
5. On day two of a hospital stay where the patient was admitted as inpatient, what would help secure this on day two?
- a. Occasional PACs on overnight monitor
- b. Noting an increased work of breathing on ambulation to the toilet (no accessory muscle use and RR 13) and RA saturation 96%
- c. Continued shortness of breath (sat 95% off supplemental O2) at rest. RR12.
- d. Shortness of breath on ambulation with O2 saturation 85% in a patient not on home O2
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Question 6 of 10

6. Question
6. A 82 year old with HFrEF (31%) presents with a 2 day history of weight gain, DOE, LE edema of +3, and a RA saturation of 92% (baseline is 95%). His labs are stable with K+ 4.2, Hgb 9.9 (baseline 10.1), and a Cr of 1.4 (baseline 0.9). CXR shows increased lung markings and a slight effusion. You order inpatient, but the Physician Advisor has requested a reconsideration for placement in Observation on day 2 after she reviewed the record. What are some clinical indicators on day TWO that would confirm a need for continued care beyond two midnights and merit an inpatient admission? Choose ALL that are correct:
- a. The saturation drops to 86% and the 2 liters of oxygen is titrated to 4 liters from 2 with a sat of 93% at rest
- b. The renal numbers increase on day two and you document a concern that further diuresis is needed and as such, the renal status may worsen. Rechecking of a basic metabolic panel is ordered
- c. When removing the oxygen (2 liters), the saturation drops to 85% on ambulation to the bathroom, requiring a re-institution of oxygen therapy to maintain baseline saturations
- d. The Hgb drops to 9.5. All other conditions are improving. Vitals are stable
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Question 7 of 10

7. Question
7. A 68 year old DM patient with ASCVD and HFrEF (40% EF), presents with Acute HF exacerbation. The patient, on day two has a Cr of 1.15, down from 1.16 (baseline 1.13). There are still crackles in the bases but weight is down 11 pounds and O₂ sats are better overall at 96% off of supplemental oxygen. On ambulation, sats remain > 95% on RA. He was admitted as observation by your colleague yesterday. He feels “great” and wishes to go home and agrees to close follow-up. You decide the patient is stable to go home and that ….
- a. Inpatient care is appropriate because of the O2 sat and crackles. You change to inpatient
- b. The patient can be discharged to home with the observation status as is. Had the patient been admitted inpatient given the clinical presentation it could not have been changed to observation because the admitting physician’s order trumps all others and cannot be changed
- c. Observation is appropriate, so the patient can be discharged to home
- d. Inpatient care is appropriate because of the Cr is still above baseline. Discharge is inappropriate
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Question 8 of 10

8. Question
8. Regarding HF diagnoses on hospitalized patients, which is/are true statements (select ALL that apply)?
- a. Noting a “previous echo two months ago w/ EF 23%” in the record will allow appropriate documentation of “Acute exacerbation of CHF, likely systolic”
- b. Acute HF means “new onset” and so any exacerbation of a known HF condition should be documented “acute on chronic”
- c. “Fluid overload” is a term that does not translate in the coding world, so it should not be used when noting heart failure exacerbation
- d. “History of” heart failure means that it was a condition in the past that no longer exists. So avoid use of “history of” if the patient is still being managed for that condition (with ACEI, diuretics, etc.)
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Question 9 of 10

9. Question
9. Hemodynamic instability (orthostatic VS, altered mentation) is found in a patient with heart failure on ED presentation. This patient is appropriate for inpatient admission IF the patient on day two continues to exhibit instability after treatment and appears to be in need of care that exceeds two midnights. That care must be noted in the progress notes to show “active management” to meet the medical necessity for the inpatient level of care.
- a. True
- b. False
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Question 10 of 10

10. Question
10. On day two of a hospital stay where the patient was admitted as inpatient, what would help secure this on day two?
- a. Occasional PACs on overnight monitor
- b. Noting an increased work of breathing on ambulation to the toilet (no accessory muscle use and RR 13) and RA saturation 96%
- c. Continued shortness of breath (sat 95% off supplemental O2) at rest. RR12.
- d. Shortness of breath on ambulation with O2 saturation 85% in a patient not on home O2
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2022 Congestive Heart Failure – Post Test

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