Diagnosis: Pneumonia
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient is a young male child with medical history significant for late preterm birth at 36 weeks' gestation and small for gestational age with birth weight of three pounds. He presented to the ED with several days of fever to 104, cough, and decreased intake. The family had recently returned from a trip to Bangladesh, and the child began to feel feverish on the plane home. He was seen in a clinic for fever and cough, with recommendations to continue Tylenol and Motrin. He had some post-tussive emesis as well as a couple episodes of diarrhea.

The patient's vital signs in the ED included temperature 98.0, heart rate 129, respiratory rate 28, and 99% saturation in room air. Examination was significant for no distress, well-hydrated appearance, moist oral mucosa, coarse breath sounds bilaterally with fair air entry, no retractions, good perfusion, and non-vocal neurologic exam. Laboratory evaluation revealed WBC (white blood cell) count 28.5K with 76.5% neutrophils, mild hyponatremia with sodium 134, elevated CRP (C-reactive protein) 25.05, and negative influenza/RSV (respiratory syncytial virus). Chest x-ray revealed right upper lobe infiltrate with small right pleural effusion. Blood cultures were obtained that were ultimately negative. There was concern for Salmonella enteritis because of the recent travel and occasional diarrhea.

The patient was given a dose of ceftriaxone as well as IV fluids and admitted for management of pneumonia. Admission orders included thoracic ultrasound for pleural effusion, treatment with ampicillin, stool cultures, and regular diet. He was afebrile overnight, with some improvement in cough but still poor appetite. He had no respiratory distress or oxygen requirement. Ultrasound failed to show evidence of pleural effusion.

Two days after presentation, the patient's appetite was much improved, he remained afebrile and stable in room air, and was deemed appropriate for discharge home.

This patient presented to the ED with fevers, cough, and poor appetite. He had not been treated in the outpatient setting except with antipyretics. Chest x-ray revealed an upper lobe pneumonia with suspected effusion, and laboratory evaluation revealed elevated inflammatory markers and WBC count. While it was not unreasonable to monitor him for adequate oral intake, he was overall hemodynamically stable with no oxygen requirement, no respiratory distress, and no signs or symptoms of sepsis. He did not require acute inpatient admission, and he could have been safely managed at a lower level of care.