This is a patient who presented with vomiting and diarrhea, who had 12-14 episodes of emesis as well as 1 episode of diarrhea. The patient also had decreased oral intake. Patient's mother was also ill with vomiting. On the day prior to presentation the patient was seen by her primary doctor and was given Pedialyte and Zofran.
On presentation to the emergency department patient was described as appearing pale and weak, with poor skin turgor and capillary refill greater than 3 seconds. Patient was given 2 boluses of normal saline and was started on intravenous fluids. Patient was found to have a blood glucose of 55 and was also given a bolus of dextrose. Patient's bicarbonate was low at 12 millimoles per liter (mmol/L), and sodium was 133 mmol/L. The patient required 2 subsequent boluses of dextrose. The patient continued to have difficulty tolerating oral fluids and was admitted to the hospital on for moderate dehydration with hyponatremia and persistent hypoglycemia, for continued intravenous rehydration and monitoring of electrolytes and blood glucose.
On the hospital floor the patient required another bolus of dextrose for a blood glucose of 50. Subsequently, the vomiting and diarrhea resolved, and the patient was encouraged to take fluids. The endocrinology team was consulted and felt that the patient likely had ketotic hypoglycemia due to dehydration and gastroenteritis, and they didn't feel additional workup was needed at that time. The intravenous fluids were able to be discontinued, the laboratory values had normalized, and the patient was felt to be stable to discharge to home with follow-up with primary doctor in 2-3 days. The health plan's determination is overturned.

This is a very young patient who presented with significant vomiting and diarrhea as well as inadequate oral intake and decreased urine output. The patient continued to have these symptoms despite appropriate treatment as an outpatient. In the emergency department the patient was found to have poor skin turgor and capillary refill greater than 3 seconds, representing dehydration. The patient was also found to have a significantly low bicarbonate level as well as hypoglycemia and required multiple dextrose boluses as well as boluses of intravenous fluids. Despite this, the patient continued to have inadequate oral intake and required hospital admission for ongoing administration of fluids and glucose as needed, and for close monitoring in an inpatient setting.
The decision making at the time of admission for this patient with consistent with the patient's young age, the presence of dehydration with abnormal laboratory values and an inability to orally rehydrate, and the need for ongoing intravenous fluids with dextrose as needed along with close monitoring for potential deterioration of clinical status.