Differential Diagnoses
The most probable differential diagnoses for this visit are hypertension, subendocardial ischemia, and ischemic stroke.
Primary Diagnosis
Myocardial infarction of unspecified site, ICD-10-CM Diagnosis Code I21.3 (ICD-10-CM Codes, n.d.).
Laboratory/Diagnostic Tests
Necessary tests
ECG (applicable for all differential diagnoses): is aimed to measure electrical activity of the heart and reveal if the heart muscle is injured.
Blood test (applicable for all differential diagnoses): special attention should be paid to creatine phosphokinase (CK), CK-MB fraction, and troponin I and T levels.
Supplementary tests
Stress test (physical exercises): to evaluate heart responses to stress.
Chest X-ray: can help to assess the size of the heart and blood vessels. It is also informative in case of fluid in the lungs.
Cardiac computerized tomography (CT) or magnetic resonance imaging (MRI): can be applied for a more precise diagnosis of heart problems, and assess damage from heart attacks.
Evidence of ST Depression
ST depression is evident from office ECG.
Secondary Diagnoses to Address
Obesity and hypertension should be addressed together with myocardial infarction treatment.
Rationale and Reference for the Diagnoses
The rationale for the selected diagnosis is as follows. First of all, St depression is a typical sign of myocardial infarction. Secondly, the patient demonstrates certain risk factors for heart diseases in general and infarction in particular. Thus, the man is obese. Despite the initiation of lifestyle changes, he still has this problem. Also, his age and the fact that he has been diagnosed with hypertension are additional risk factors (Sullivan, 2017).
Application of JNC 8 Guidelines and Recommendations
According to JNC 8 hypertension algorithm (n.d.), the patient can be considered hypertensive.
Among black population, the primary pharmacological treatment for hypertension should consist of a thiazide diuretic or calcium channel blocker (JNC 8 Guidelines, 2014). In case there still is a necessity to reach the target blood pressure, it is possible to increase the dosage of the initial medication. Also, it is possible to add another drug, such as thiazide diuretic, calcium channel blocker, ACE inhibitor, etc. It is essential to monitor blood pressure. In the case of the patient, this scenario is the best choice because Larry M. is an African American and his blood pressure was above normal limits three days ago.
Plan for the Primary Diagnosis
The plan for the primary diagnosis includes conservative treatment with the following medication. Aspirin may not be necessary because the patient is not in an acute condition. Thrombolytics should be administered to dissolve a blood clot and avoid blocking blood flow. Other blood-thinning medications can be also used, for example, heparin. Pain relievers are usually used to stop pain and keep patient calm. Nitroglycerin can be prescribed for chest pain and blood flow improvement. Beta blockers that are also prescribed are aimed to relax the heart muscle. In case of necessity, surgical procedures such as coronary angioplasty and stenting or coronary artery bypass surgery can be performed. According to the research by Cherlin et al. (2013), it is also important to plan discharge. The patient will be given recommendations regarding medication and lifestyle change after discharge. Also, the patient should show up to cardiologist two weeks after discharge for control.
Further Diagnostic Work-Up
- Discover complications of myocardial infarction (early or late);
- Define the patient’s prognosis;
Education
Patient education is crucial in case of myocardial infarction because patient’s survival depends on his actions and behavior of his family. Thus, educational interventions include lifestyle change information, safety measures, necessary daily routines for heart support, and actions in case of emergency before the patient can be delivered to hospital.
References
Cherlin, E., Curry, L., Thompson, J., Greysen, S., Spatz, E., Krumholz, H., & Bradley, E. (2012). Features of high quality discharge planning for patients following acute myocardial infarction. Journal of General Internal Medicine, 28(3), 436-443.
ICD-10-CM Codes. (n.d.).
JNC 8 Guidelines for the management of hypertension in adults. (2014). Web.
JNC 8 hypertension algorithm. (n.d.). Web.
Sullivan, D. (2017). Acute myocardial infarction. Web.