Diagnosis: Cough, Fever, Chest Pain
Treatment: Inpatient Admission
The inpatient admission was medically necessary.

This patient presented with hypertensive emergency, fever, cough and chest pain. The patient subsequently developed atrial fibrillation with rapid ventricular rates, as well as pulmonary edema. Hypertensive emergency is defined as BP > (great than) 180/120 with target organ damage (Reference 1). In this patient, BNP (brain natriuretic peptide) was elevated consistent with left ventricular dysfunction and target organ damage. Given this patient's previous history of aortic dissection, admission to the hospital for aggressive blood pressure management was necessary. In fact, American Heart Association guidelines recommend admission to the ICU for management of hypertensive emergencies (Reference 1).

Additional reasons for hospital admission included treatment of rapidly conducted atrial fibrillation and influenza A infection. Patients presenting with atrial arrhythmia with rapid ventricular rates require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia.

An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen year period demonstrated an average length of stay of three days (Reference 2). This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital. The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted atrial fibrillation.

In conclusion, the inpatient admission was medically necessary.