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Case No. 23

Case No. 23. Lin, I-Chen(Tina). A 30 y/o female, frail looking , pale came in stretcher borne with chief complaint of weakness and vomiting . An hour PTC (prior to consultation), she was noticed to be uncomfortable with cold clammy perspiration immediately after breakfast .

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Case No. 23

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  1. Case No. 23 Lin, I-Chen(Tina)

  2. A 30 y/o female, frail looking, pale came in stretcher borne with chief complaint of weakness and vomiting. An hour PTC (prior to consultation), she was noticed to be uncomfortable with cold clammy perspiration immediately after breakfast. • BP-80/60, RR-24/m • Diabetic for 5 years, on insulin: 20”u”NPH at 6am, 15”u”NPH at 6pm • ECG showed: ST elevation anteroseptal and lateral areas.

  3. Diagnosis: Acute Myocardial infarction & Hypoglycemia • ID: Acute myocardial infarction (MI) is defined as death or necrosis of myocardial cells. MI means that part of the heart muscle suddenly loses it's blood supply. • This accelerated form of atherosclerosis occurs regardless of whether a patient has insulin-dependent or noninsulin-dependent diabetes. • The proportion of painless AMI is great in patient with diabetes mellitus and it increase with age. • May present as sudden-onset breathlessness which may progress to pulmonary edema.

  4. Signs and Symptoms • Chest pain described as a pressure sensation, fullness, or squeezing in the midportion of the thorax • Radiation of chest pain into the jaw/teeth, shoulder, arm, and/or back • Associated dyspnea or shortness of breath • Associated epigastric discomfort with or without nausea and vomiting • Associated diaphoresis or sweating • Syncope or near-syncope without other cause • Impairment of cognitive function without other cause

  5. Laboratory examination • 1.Electrocadiogram(ECG):The first test is the ECG, which may demonstrate that a MI is in progress or has already occurred • 2.Blood Tests:Blood tests can be performed to detect evidence of myocardial cell death. a.creatine phosphokinase (CK) b.MB isoenzyme of CK (CKMB) c.cardiac-specific troponin T (cTnT) d.cardiac-specific troponin I (cTnI) • 3.Echocardiography: The echocardiogram can be helpful in identifying which portion of the heart is affected by a MI, and which of the coronary arteries is most likely to be occluded.

  6. Management pharmacologic regimen: • 1.antithrombotic agents • 2.beta-adrenoceptor blockers • 3.angiotension-converting enzyme inhibitor (ACEI) • 4.other agent: Nitrates

  7. 1.antithrombotic agents Platelet inhibitor: Aspirin • MOA: inhibits synthesis of thromboxane A2 Anticoagulant: Heparin • MOA: inhibitor antithrombin III Fibrinolytics: tPA • MOA: lyze thrombus by formation of serine proteose plasmin Glycoprotein IIb/IIIa Antagonists: Abviximab • MOA: inhibit of fibrinogen Adverse effect: bleeding, GIT symptom

  8. 2.beta-adrenoceptor blockers Ex: Metoprolol, Atenolol, Esmolol • MOA: inhibit Beta-1 receptor • adverse effect: bradycardia, hypotension 3.angiotension-converting enzyme inhibitor (ACEI) ACEI: Captopril, Enalapril • MOA: inhibit angiotension-converting enzyme • adverse effect: Dry cough

  9. 4.other agent: Nitrates Ex: Nitroglycerine route: Sublingual tablet, Spray, Transdermal or paste, Intravenous • MOA: releases Nitric Oxide→↑cGMP→relaxation • adverse effect: throbbing headache, flushing of the face, dizziness, postural hypotension

  10. 5) Tx hypoglycemia

  11. non-pharmacologic regimen: 1.Supplemental Oxygen: Supplemental oxygen should be administered to patients with symptoms and/or signs of pulmonary edema or pulse oximetry reading less than 90% blood oxygen saturation. 2.Control blood pressure 3.Eat a low fat diet 4.more fruit and vegetable diet 5.Control DM 6.Exercise daily to improve heart fitness.

  12. thank you

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