This is a patient with a history of sickle cell disease, avascular necrosis of the right hip, chronically anticoagulated with Lovenox secondary to pulmonary emboli, history of transient ischemic attack (TIA), and prior episode of acute chest crisis. She presented to the emergency department with a one-week history of upper respiratory symptoms, with nasal congestion cough and fatigue. The patient started to have back and leg pain 3 days prior to presentation, unrelieved with home dosing of Dilaudid. She was evaluated in the emergency department and was given 2 milligrams (mg) of intravenous (IV) Dilaudid as well as 4 mg of intramuscular (IM) Dilaudid, without relief, so she was admitted to the hospital.
The cardiovascular exam was unremarkable except for mild tachycardia. The patient had mild swelling of the right hand, with no erythema or warmth, and mild swelling of both feet. The patient had a right port, which looked clean dry and intact. She was started on her home regiment of Dilaudid, and was given additional IV Dilaudid as well. IV fluids were started and the patient was encouraged to have increased oral hydration. Lovenox was continued at therapeutic doses. The patient did not have hypoxemia or pleuritic chest pain, therefore, no further imaging was performed. In regards to the sickle cell disease exacerbation, the admitting physician documents no red flags, the patient appeared comfortable during the exam, had only a mild elevation of the reticulocyte count, and the hemoglobin was at baseline.
On the following day, the pain specialist was consulted, to evaluate the patient. They went over her regimen of pain medications and discussed options. The health plan's determination is upheld. The patient does not satisfy inpatient criteria for admission. There is no evidence of severe adverse reaction to treatment, there is no severe underlying condition, that is exacerbated such as chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF). The patient has underlying sickle cell disease, that does not appear to be severely exacerbated, as evidenced by a stable hemoglobin and only slightly elevated reticulocyte count. Her symptoms are very subjective. There is no evidence of chest syndrome, there is no evidence of end-organ damage in this situation. There is no evidence of an infectious process, with normal white blood cell count, normal temperatures, no hemodynamic instability. The patient does not have severe electrolyte derangements, injuries, poisoning. Care could have been provided at a lower level than inpatient.