Diagnosis: Pain (sickle cell disease)
Treatment: Inpatient admission
The proposed treatment of inpatient admission is not deemed medically necessary.
This female patient, with a history of sickle cell disease and recurrent pulmonary embolism, presented to the ER for further evaluation/management of chest, back, hip and leg pain. Intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. Examination was non-focal with no significant abnormalities noted including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen. Laboratory and ECG testing was also within normal limits with exception of mild chronic anemia. The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where she received supportive care with IV fluids and prn analgesics. She responded well to the prescribed therapies and was subsequently discharged in stable condition. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting the patient's safety or outcome. For these reasons, the proposed treatment of inpatient admission is not deemed medically necessary.