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Wyckoff Heights Medical Center Case Summary

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After review of the clinical information provided by Wyckoff Heights Medical Center, the Medical Director has denied your admission to Wyckoff Heights Medical Center. It was determined that the clinical information did not justify an inpatient stay. Acute inpatient hospitalization was not medically necessary. The admitting diagnosis was chest pain, shortness of breath, decompensated congestive heart failure. You have a past medical history of hypertension, pacemaker, defibrillator, chronic systolic congestive heart failure, diabetes mellitus and atrial fibrillation. You advised that you were prescribed Xarelto, ejection in the dosage a fraction less than 20 percent. You are a 60 year old male who presented to the emergency room with the …show more content…
You stated that you could only walk a few steps. Vital signs: blood pressure: 141/76, Pulse: 82, Respiratory rate: 20, Temperature: 97.9 Fahrenheit, oxygen saturation: 100 percent. Electrocardiogram (recording of your heart activity or sinus rhythm) and chest x-ray showed right basilar infiltrate with small pleural effusion. Your physical exam showed; chest pain, orthopnea and edema of lower extremities. Lungs showed crepitation and rales: Troponin was 0.030. You were treated with fluid restriction; Lasix intravenous two times a day, oxygen per nasal cannula, continued home medications and admitted to telemetry. The other medication orders were for Toprol XL daily, Valsartan daily and to continue Xarelto. Based on the Interqual guideline criteria for heart failure, the clinical guidelines were not met because there was no documented hepatomegaly, jugular venous distention or weight gain greater than or equal to three (3) pounds over two (2) days prior to admission. A review of your records showed that you could have been placed in observation under monitoring, had an evaluation, been tested and treated symptomatically while awaiting test results. Consultation with other healthcare professionals could also have been done in

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