Diagnosis: Abdominal pain
Treatment: Inpatient admission

The acute inpatient stay for the management of this patient was not appropriate and medically necessary for the management of this patient's condition.

The patient is a female with h/o (history of) cholecystectomy for gall stones 10 years ago. She was seen by her surgeon in his office for upper abdominal pain with radiation to the back associated with nausea and vomiting. She had no fever or chills. She had similar episodes of abdominal pain off and on in the recent past when she was visiting Jamaica. She underwent US (ultrasound) of the abdomen in his office, and it revealed dilated common bile duct measuring approximately 2cm in size and possible sludge/stones in the common bile duct. She was sent to ED, where she was evaluated.

In the ED, the patient was hemodynamically stable and afebrile. Her labs revealed normal CBC (complete blood count) with normal Hb/HCT (hemoglobin/hematocrit) and WBC (white blood count). The Chem panel revealed normal lytes, BUN/Cr (blood urea nitrogen/creatinine), and normal liver function tests. The ultrasound of the abdomen done in the ED revealed dilated common bile duct measuring 1.1cm in size.

The patient was evaluated by GI (gastroenterology) and General Surgery. The GI recommended ERCP (endoscopic retrograde cholangiopancreatography) for the management of the common bile duct stones. She underwent ERCP and Common bile duct measured approximately 1.2cm in size and it revealed multiple stones. The biliary sphincterotomy was performed, and copious amount of stones and sludge were removed with balloon extraction. Biliary stent was placed after the duct was cleared of stones.

The patient tolerated the procedure well. She was started on clear liquid diet and sent to the medical floor. The plan was to repeat the ERCP in six to eight weeks for biliary stent removal. The next day, she was discharged home and with outpatient follow-up with GI.

The patient had a history of cholecystectomy for gall stones about 10 years back and presented to the her Surgeon's office with upper abdominal pain nausea and vomiting (biliary colic). She was found to have choledocholithiasis on the ultrasound of the abdomen. She was sent to the hospital for further management of choledocholithiasis. She was evaluated by GI and underwent ERCP, sphincterotomy, stone extraction and biliary stent placement for the management of choledocholithiasis. She did well after the procedure and observed overnight and discharged home the next day. Given this clinical scenario and clinical course, the patient could have been safely managed under lower level of care. Acute level inpatient admission was not medically necessary.