Diagnosis: Decreased Oral Intake
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The determination is upheld.

The patient is a female who was brought to the emergency department in the afternoon with fussiness and decreased oral intake since awakening at 8:00 in the morning on the day of admission. The patient did not have a fever and she was not vomiting. The patient's vital signs were normal. The emergency department (ED) physician's physical exam documented moist mucus membranes, a normal appearing, non-toxic patient, with clear lungs, no respiratory distress, a soft abdomen and capillary refill was less than two seconds. The impression was 24 hours of decreased feeding and increased fussiness. The patient is well appearing with a benign physical exam. The patient is hemodynamically and clinically stable. The patient had normal labs upon review. The patient was given a normal saline bolus. In the ED, the patient had one large loose stool and was sucking normally on a pacifier, but not taking through mouth (per orem), by mouth, or oral nutrition (po), so the patient was admitted for more intravenous (IV) fluids. Her admission history and physical (H&P) was essentially the same as in the emergency department, but soon after arrival, she started taking po. She was kept overnight and discharged the next day.

The patient is a well appearing, female with less than 24 hours of a reduced oral intake. The vital signs were normal and there were no objective physical or laboratory signs of dehydration. The patient did not have a fever and the laboratory workup was unconcerning for the possibility of serious bacterial infection. The patient was not clinically dehydrated. The patient was mildly "dry" and that concern was managed by giving IV fluid boluses in the emergency department. The patient was sucking well on a pacifier all along, but did not want to suck on a bottle. Outpatient management typically involves small, frequent oral fluid administration via a syringe if the patient is not vigorously taking the bottle before considering hospitalization for "refusal to take po".

This would also be considered before the possibility of becoming dehydrated even though the patient is not currently dehydrated and did not have any electrolyte abnormalities. The patient's fluid maintenance requirements are approximately 26 milliliters (ml) per hour with 30ml being equal to one ounce. This is a relatively small amount of fluid and equals one tablespoon of liquid every half hour that would be necessary to give by syringe or bottle to maintain adequate hydration. There is no evidence this would not be provided at home. The patient started having a po intake not long after admission.