Medicare Case Description and Quiz

Learning Case: Introduction

This learning case is not graded and is meant as an educational exercise to increase your knowledge and understanding of some of the issues that patients and physicians encounter with Medicare.

Case Presentation

History of Present Illness:
71-year-old woman with sudden onset of pain in the upper arms and uncomfortable feeling in the chest. Feeling well until she developed bilateral arm pain, dizziness and mild nausea while carrying several cans of paint into the house a few hours ago. Drove herself to the Emergency Room.

Past Medical History:
Paroxysmal atrial fibrillation
Medications: Metoprolol. 50 mg bid, Coumadin as directed.
Allergies: None known

Social History:
Single, long-term boyfriend who can be a major stressor at times. Lives in rural Montana, works several part-time jobs to make ends meet. She is a U.S. citizen and had her employee Medicare taxes withheld for 13 years, although her last contribution was 10 years ago.

Family History:
No coronary artery disease, no diabetes, no cancers.

Hospital Course:
In the ED, she was evaluated and treated for Acute Coronary Syndrome. Initial troponin and EKG were normal but given concerning history, patient was admitted to the Intensive Care Unit for serial EKGs, troponins, telemetry, and ongoing medical management.

Over the next 18 hours, troponins rose into the abnormal range but all other symptoms resolved. Case was reviewed with the cardiology team at the nearest urban medical center with catheterization capabilities, approximately 125 miles away. The attending physician and cardiologist made the decision to transfer the patient by Advanced Cardiac Life Support (ACLS) ground ambulance for non-emergent catheterization. Both physicians felt this type of transfer was medically necessary and thus transfer options were not discussed with the patient.