According to JNC 8 guidelines, hypertension is defined as a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher in the general population aged 60 years or younger. Sean’s specific blood pressure readings during this visit are not provided, but his history of hypertension and the fact that he was taken off medication warrant careful monitoring and reassessment to determine if he remains hypertensive.
In-office EKG Shows ST Depression:
Diagnoses with ICD-10 Codes:
- Unstable Angina (I20.0): The ST depression on the EKG is indicative of myocardial ischemia, which is consistent with unstable angina. This condition requires prompt attention to prevent progression to myocardial infarction.
- Hypertension, Unspecified (I10): Given Sean’s history of hypertension and the need for ongoing evaluation, it is important to document this diagnosis and ensure appropriate management.
- Hyperlipidemia, Unspecified (E78.5): Sean’s history of hyperlipidemia is a significant risk factor for coronary artery disease and contributes to his cardiovascular risk profile.
Rationale: Sean’s presentation, combined with his medical history, family history, and diagnostic findings (e.g., ST depression on EKG), supports the diagnoses of unstable angina, hypertension, and hyperlipidemia. These conditions must be managed promptly to reduce the risk of adverse cardiovascular events.
Plan for Each Primary Diagnosis:
Unstable Angina (I20.0):
- Further Diagnostic Work-up:
- Cardiac Enzymes: Serial troponins to rule out myocardial infarction.
- Coronary Angiography: To assess for coronary artery blockages.
- Medications:
- Aspirin 81 mg daily: To reduce the risk of thrombus formation.
- Nitroglycerin: Sublingual tablets as needed for chest pain.
- Beta-blocker (e.g., Metoprolol): To reduce myocardial oxygen demand.
- Statin (e.g., Atorvastatin): To manage hyperlipidemia and reduce cardiovascular risk.
- Referrals:
- Cardiology: For further evaluation and potential interventions, such as angioplasty or stent placement.
- Conservative Measures:
- Lifestyle Modifications: Encourage smoking cessation, weight management, and regular exercise as tolerated.
- Dietary Changes: Low-sodium, heart-healthy diet with reduced intake of saturated fats.
- Patient Education:
- Educate Sean on recognizing the signs of worsening angina or potential myocardial infarction, including when to seek emergency care.
- Discuss the importance of medication adherence and follow-up appointments.
- Follow-up Plan:
- In 1 Week: To reassess symptoms, review diagnostic results, and adjust the treatment plan as necessary.
Hypertension, Unspecified (I10):
- Further Diagnostic Work-up:
- Home Blood Pressure Monitoring: Encourage Sean to monitor his blood pressure at home and keep a log for review.
- Ambulatory Blood Pressure Monitoring (ABPM): If home monitoring indicates uncontrolled hypertension.
- Medications:
- Re-initiate Antihypertensive Therapy: Based on the latest readings, consider reintroducing Lisinopril or another suitable antihypertensive.
- Lifestyle Modifications:
- Continue to emphasize lifestyle changes, including a low-sodium diet, regular physical activity, and weight management.
- Follow-up Plan:
- In 1 Month: Reassess blood pressure control and make necessary adjustments to the treatment plan.
Hyperlipidemia, Unspecified (E78.5):
- Further Diagnostic Work-up:
- Lipid Panel: To assess current cholesterol levels and guide further management.
- Medications:
- Statin Therapy: Continue or initiate statin therapy to lower LDL cholesterol levels.
- Lifestyle Modifications:
- Reinforce dietary changes to reduce cholesterol levels, such as increasing fiber intake and reducing saturated fat consumption.
- Follow-up Plan:
- In 3 Months: Recheck lipid levels and adjust the statin dosage as needed.
This comprehensive response addresses Sean M.’s cardiovascular concerns, providing detailed questions, differential diagnoses, physical examinations, diagnostic testing, and a thorough management plan based on evidence-based guidelines. The inclusion of ICD-10 codes and references ensures accuracy and relevance in clinical practice.
