Diagnosis: Diabetes type II, status post mechanical fall
Treatment: Inpatient admission
The inpatient admission as not medically necessary.

The patient is a female with past medical history of schizophrenia and type II DM (diabetes mellitus). She was seen at the emergency room, after a trip and fall with laceration to the forehead. She denied headache, abdominal pain, neck pain, back pain, numbness, weakness, and vision changes.

The patient's vitals were as follows: BP (blood pressure) 104/71; P (pulse) 95; RR (respiration rate) 16; Temp 36.6C; SpO2 (pulse oximetry) 95% on room air. On physical examination, there was a 1.0 cm subcutaneous linear shaped, injury to the right forehead. No neurology exam, motor strength was 5/5, sensation intact, cranial nerves intact; normal gait. She was awake, alert and oriented times three. She had mild tenderness in the right knee.

The patient's laboratory studies revealed the following: urinalysis was unremarkable; hemoglobin was 12.2, hematocrit 36.3, platelet 206, WBC (white blood count) 8.7, potassium 3.7, sodium 143, and creatinine 0.7. CT of the cervical spine and head demonstrated no evidence of acute pathology. Chest x-ray showed no evidence of acute cardiopulmonary disease. EKG (electrocardiogram) showed normal sinus rhythm (NSR) at 70 bpm. Right knee x-ray revealed mildly comminuted vertically oriented fracture of the mid to lateral patella with minimal displacement; moderate suprapatellar effusion. Impression included unspecified fall, and vertical patellar fracture.

Medical records noted that the patient lives alone, with no home care; She has had two falls in a week and ambulates with unsteady gait in the emergency room. It was noted that patient has poor insight, poor historian and unable to care for herself, will require admission for placement. Management included placement in knee immobilizer, Weight bearing as tolerated, RLE (right lower extremity) elevation; it was recommended that she follow with outpatient orthopedics. While on admission, she was seen by physical therapy.

On the day of discharge, the patient was medically stable for discharge home. It was noted that she will receive home care.

The patient was admitted to the hospital following a fall, and was diagnosed with patellar fracture, and mild laceration of the forehead. Recommended treatment was conservative as well as outpatient follow-up by orthopedic specialty. She was hemodynamically stable when she presented to the emergency department. There was no evidence of altered mental status, confusion, respiratory compromise, significant persistent life-threatening arrhythmias, or sepsis. There were no serious neurologic abnormalities like brain infection, cerebral bleeding/ischemia, increased intracranial pressure or spinal cord injury. CAT scan of the brain did not show any acute bleed or hemorrhage.

In view of the foregoing, the inpatient admission was not medically necessary, because the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.