Diagnosis: Headache
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
Following this patient's ED evaluation, she was clinically stable. It was suspected that her symptoms were due to a TIA. Despite this, she had a normal neurologic exam. No treatment had been given for the patient's elevated blood pressure. She was awake and alert, with normal mental status. A CT scan had ruled out a cerebral bleed. Blood work was normal. The admission note for this patient indicates that her plan of care would include a neurology consultation. An ultrasound of the carotid arteries was ordered. No treatment for hypertension was planned except giving the patient her home medications. At the time this patient was kept in the hospital, it would have been reasonable to believe that this limited plan of care could be accomplished for a stable patient with a very short stay in the hospital. For this reason, an inpatient admission was not medically necessary.

The patient had no severity of illness to justify an inpatient admission. She had no neurologic deficit on exam. She had no lab abnormality. Her blood pressure, while elevated, was being treated with oral medication. There was no intensity of services required for the patient to justify an inpatient admission. The patient would be seen by a neurologist. She would have a carotid ultrasound performed.

In conclusion, the patient was clinically stable following her ED evaluation. A limited plan of care was anticipated for. An inpatient admission was not medically necessary for this patient.