Primary Diagnosis and ICD-10 Code:
I20.8- Angina Pectoris
E78.5- Hyperlipidemia
R94.39- Abnormal result of other cardiovascular function study (Nuclear
... [Show More] Stress test)
93000- Electrocardiogram, routine ECG with at least 12 leads: with interpretation and report
85025- CBC with differential
80061- Lipid panel
80048- BMP
83036- Hemoglobin (Hb) A1c
Additional Laboratory and Diagnostic Tests: Consider a Computerized Tomography Coronary
Angiography if pain continues or worsens.
Consults: Angina is stable, no consult or referral is needed at this time.
Therapeutic Modalities: Treatment is targeted at symptom relief and decrease disease progression
to lessen event occurrence that could result in a myocardial infarction or even death (Alaeddini,
2018). Pharmacological management will include:
1. Aspirin 81 mg one tab daily (Johnson, 2018).
2. Simvastatin 40 mg daily at bedtime (Johnson, 2018).
3. Nitro stat 0.4 mg, 1 sublingual tablet dissolved under the tongue as needed for angina.
May repeat every 5 minutes if needed for 15 minutes, a maximum of 3 doses (Johnson,
2018).
Non-pharmacological management will include:
1. Advise patient to quit smoking to decrease the development of atherosclerosis (Alaeddini,
2018).
2. Participate in an exercise program to better control blood pressure and weight, such as
joining a gym, taking walks or biking (Osborn, 2020).
3. Advise patient on the importance of a heart-healthy diet to decrease the “bad” cholesterol
and improve the “good” cholesterol. Diet changes may include eating more fruits and
veggies; eat more healthy fats such as chicken and fish; increase fiber and omega-3 such
as beans, salmon and walnuts (Osborn, 2020).
Health Promotion: Mr. MacIntyre has many factors that place him at risk for developing a
myocardial infarction or early death. Non-Modifiable risk factors include age, race, gender and
ethnicity. Modifiable risk factors include smoker, hypertension, and new diagnosis of
hyperlipidemia. Mr. MacIntyre has a history of CAD, is smoker with high blood pressure and has
had episodes of angina; it is suggested he participate in the following screenings:
Abdominal aortic aneurysm one-time screening- he is approaching the age of 65 and currently
possess most of the risk factors associated with the development of an abdominal aortic aneurysm.
1. Cholesterol screening- his cholesterol was elevated during this visit; therefore he will
need frequent monitoring, especially since medication has been added to control the
cholesterol.
2. Lung cancer screening- Mr. MacIntyre is 62 years old with a history of smoking 50
packs/year and currently cutting back to 1 pack/day; therefore placing him a risk for
development of lung cancer (Healthcare.gov, 2020). [Show Less]