Diagnosis: Chest pain
Treatment: Inpatient stay

Summary:
The patient is a female. She presented with chest pain and dyspnea. She had multiple other symptoms, including diaphoresis, palpitations, fatigue, weakness and slurred speech. She received heparin, IVF, ASA (aspirin) and NTG (nitroglycerin).

The patient presented with atypical symptoms and no direct evidence of ischemic heart disease. The EKG (electrocardiogram) was benign. Enzymes were negative. There was no WMA (wall motion abnormality). CT scan showed Calcium score of zero. The "stenosis" described with negative calcium is not considered diagnostic, nor did the treating physicians act on it.

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care. In this case, the patient's symptoms were atypical and unlikely to be representative of acute coronary syndrome (ACS). Her exam and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia. CXR (chest x-ray) was normal. Echocardiogram showed no wall motion abnormality. Physicians' treatment did not reflect any serious concern about patient's cardiac condition. Orders did not include medical therapy for ACS such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or IV NTG.

There was no acute intervention, nor was one indicated. The patient did not have evidence of unstable angina. CT angiography does not require inpatient level of care. While risk factors present are significant, the patient did not have actual clinical CAD that required intervention. Discharge diagnosis does not include ACS. All of the testing and therapy that were provided would have been appropriate, safe and guidelines consistent in lower level of care. Thus, inpatient level of care was not medically necessary.