Types of diabetes

- caused by an autoimmune reaction that stops your body from making insulin.

-5-10% of the people

- an impairment in the way the body regulates and uses sugar (glucose) as a fuel       

- 90-95% of people

-pregnant women 

What diabetes is experienced by patients and why?

Patient have type 2 diabetes. 

Reason: elderly,smokers as research stated that smokers are 30 to 40 percent more likely to develop type 2 diabetes than nonsmokers.

List antidiabetic drugs

mechanism of action

pharmacodynamic

pharmacokinetic

drug group

Mechanism of action

Pharmacodynamic

Pharmacokinetic

drug group

inc

The adverse drug reaction of aspirin is severe bleeding as it blocks the platelet aggregation and might cause blood loss for the body. Furthermore, aspirin also can cause rapid breathing because it blocks production of prostaglandin-E2 (PGE2) which responsible for smooth muscle relaxation. Low amount of PGE2 cause muscle contraction in bronchus thus trigger bronchoconstriction which resulting in low inhaled oxygen volume. This further causing body lacks oxygen, then further trigger the respiratory mechanism to increase respiratory rate which finally increase the respiratory rate and hyperventilation (rapid breathing) occur. Besides that, ADR of aspirin can cause stomach pain due to inhibiting the prostaglandin-I2 (PGI2). PGI2 function to increase the gastric mucous secretion in the stomach. If the PGI2 production is inhibited, gastric mucous production will be inhibited thus causing no protection of stomach lining then causing inflammation which finally gastritis occurs.

People at age more than 60 or with history of gastrointestinal (GI) disease or infection has higher risk for serious GI bleed. It is due to anti-coagulant reaction of aspirin that cause blood leakage cannot be blocked in the GI if any bleeding occurs either from infection or hard stool. In people with asthma, taking aspirin can cause acute asthma attack or can aggravate asthma symptom due to COX inhibition. It is because over amount of arachidonic acid will enter the 5-lipoxygenase pathway and finally produce leukotriene C4 which will increase the hyperresponsiveness in asthma patient.

Acetylsalicylate also can cause nephrotoxicity. It is due to decrease PGE2 that function vasodilator. Decreasing in PGE2 will cause vasoconstriction. In kidney, vasoconstriction of glomerular capillary at afferent artery can cause decrease in glomerular filtration rate (GFR) which will resulting in less filtration and secretion of waste product form body. This can cause azotaemia (creatinine and blood urea in blood) due to low filtration of glomeruli. Moreover, aspirin can lead to gout as it can inhibit the tubular uric acid secretion. This will lead to increase uric acid in blood (hyperuricemia) which further causing gout. Lastly for children, aspirin can cause Reye’s syndrome in children if aspirin is used to treat the children.

Differential diagnosis due to chest pain classified below

1. Cardiac

2. Pulmonary

3. Vascular

However, once the patient rested, the pain subsided. Pt display symptoms of stable angina.

Stable angina is most often due to a fixed stenosis caused by an atheroma.

Since Pt’s age is 63 years old male, it is one of the non-modifiable risk factors for atherosclerosis. Patient also smoked 2 packs of cigarettes a day for the last 40 years, one of the modifiable risk factors for atheroma. 

This factors predisposes the pt to have decrease myocardial oxygen supply d/t decreased luminal diameter in the presence of atherosclerostic lesion. There will be decrease in the SPO2 causing hypoxemia. Pt’s SPO2 is 80% whereas the normal range is 95-100%

Clopidogrel also have its adverse effects. If the symptom of the side effect are severe, the patient must immediately contact the doctor. The effects can be varied such as fatigue, headache, nausea, vomiting and stomach pain. For some cases, it will also develop hives, fever, and rash.

For some patients, clopidogrel is contraindicated to them because they have hypersensitivity to clopidogrel. Other than that, patient with severe bleeding such as GI tract bleeding, intracranial bleeding and bleeding form surgery are not recommended to consume clopidogrel as it functions to inhibit platelet aggregation. It will make the other disease become worsen.

            However, nitroglycerin also have its side effect. It is because this medication is a foreign substance to the body so the body need to adjust for the drug. The side effects are headache, dizziness, lightheadedness, nausea . Nitroglycerin did not have very serious adverse effect so many doctor recommend the patient to use the drug.

Nitroglycerin is contraindicated to a patient with anemia, methemoglobinemia, hemorrhage in the brain and low blood pressure. Nitroglycerin also can be used for many purposes. One of them is to hinder and cure angina or chest pain due to cardiovascular disease, then to treat peri-operative hypertension or induce intra-operative hypotension. Nitroglycerin is indicated to treat pain caused by anal fissures when converted into ointment. The transdermal form is applied directly to the skin to prevent acute anginal attacks.

Heart Valve: Prevent the backflow of the blood through the heart.

Heart Wall: consist 4 walls

Complications of a coronary angiogram

Results

An angiogram shows what's wrong with patients' blood vessels. 

High blood pressure, also called hypertension, is blood pressure that is higher than normal which is above 120/80 mmHg.

1. Sphygmomanometer

2. Digital blood pressure monitor

In this case, the patient stated that he has hypertension, which means that his blood pressure is above 120/80 mmHg.

1. Approximately 10% of myocardial infarcts occur in people younger than age 40
2. 45% occur in people younger than age 65
3. It frequently rises progressively with increasing age
4. Strongly correlates with genetic and behavioural predisposition to atherosclerosis
4. Male gender increases the relative risk of MI

It is the result of diseases that affect internal organs within the thorax (heart, lungs, esophagus, stomach, gallbladder, pancreas, and liver)

It caused by disease of the chest wall (abnormalities of muscle, bone, cartilage, and skin) 

Other than that, pain and tightness can also radiate in other areas of the body including arm, upper abdomen, shoulder, back, neck/throat, teeth or jaw

12-16 breath per min is the normal respiratory rate. Since pt’s respiratory rate is high. Patient starts to hyperventilate.

Due to the nature of the symptoms that may arise during hyperventilation, the differential is broad and may include:

Agonal breathing or gasping for air can occur when someone has gone into cardiac arrest. Unlike a heart attack — which happens when one or more arteries narrow and stop blood from reaching the heart muscle — cardiac arrest is an electrical problem. During cardiac arrest, the heart stops beating effectively. This is known as an arrhythmia, or pattern of irregular heartbeats.

Blood continues to flow briefly in the brain and other organs, which can cause gasps for a few minutes after the heart stops. If cardiac arrest is the cause of agonal breathing, the labored breaths may only last a few minutes. Having had a heart attack due to MI makes it more likely to have cardiac arrest.

Another common cause of agonal breathing is cerebral ischemia, or a reduction in blood flow to the brain. This can be caused by a ministroke due to a blood flow blockage within a brain blood vessel. It can also be caused by a hemorrhagic stroke due to a bleeding blood vessel within the brain. Either can lead to a condition called cerebral hypoxia, which is insufficient oxygen supply to the brain regardless of the cause. The brain can have permanent damage if it’s deprived of oxygen for too long.

Since our differential diagnosis overlaps with MI, we should run more tests to confirm the diagnosis.

1. Light smokers: <1-5 cigarettes per day 
2. Moderate smokers: 6-10 cigarettes per day
3. Heavy smokers: >11 cigarettes per day

Before moving on, we need to understand the purpose of intubation and when is the appropriate time a patient needs to be intubated. Intubation is given to those who cannot maintain their airway, cannot breathe on their own without assistance. This is common when patients are undergoing general anesthesia which is a drug given prior to surgery or a medical procedure to put them in a sleep-like state and in accordance with Mr Ahmad’s case, a coronary angiogram was performed. Although an angiogram requires one to lie awake on the table they will still need to be mildly sedated. General anesthesia acts as a drug to paralyze the muscle of the body including the diaphragm which makes it impossible for a patient to inhale air without using a ventilator. Hence, general anesthesia can hold down your own breathing, making Mr Ahmad unable to breathe on his own during the procedure and with intubation it lets the machine do the breathing for us.

Besides, intubation is also done to those who have any injury or illness that makes it hard to breathe. As breathing provides oxygen to every cell in our body and if one doesn't get enough it can lead to passing out, brain damage or even death. Ventilation also helps us to breathe out the air accumulated by getting rid of the carbon dioxide so that it does not build up in our blood. This can cause the blood to be more acidic which would result in unwanted health problems such as respiratory acidosis. As Mr Ahmad had arrived the hospital in an unconscious state would also be one of the reasons as to why he might need to be intubated. He could possibly have an injury or illness that can weaken the reflexes in his airway. Furthermore, his vital signs showed low oxygen saturation level which is 80% and this was also an indication for him to be intubated to allow more oxygen to enter the lungs.

To put it simply, patients who require intubation have at least one of the following five indications:

Intubation Procedure 

1) Typically a patient is sedated or is in an unconscious state due to injuries that relaxes both the mouth and airway. The patient would lie flat on their backs with the person in charge of inserting the tube standing at the head of the bed.

2) The patient's mouth is  opened gently by using a lighted instrument in order to move the tongue out of the way providing a visible opening to the throat, the tube is then guided in the throat furthering into the trachea

3) There is a small balloon around the tube that is inflated to prevent the tube from moving and to keep air from escaping.Once said balloon is inflated, the tube is securely placed by taping it at the mouth.

3) To check whether the placement is correct, it is first listened to the lungs with a stethoscope and verified with a chest X-ray. In comparison in the operating room, a device that measures carbon dioxide is only present if the tube was in the lungs, rather than in the esophagus. This used to confirm that it was rightfully positioned.

Underlying health conditions:

Due to the myocardial perfusion pattern from epicardium to endocardium, ischemia is most pronounced in the subendocardium; thus, irreversible injury of ischemic myocytes occurs first in the subendocardial zone

Since the atheroma cause blockage of coronary blood flow, irreversible cell death occur due to ischaemia. 

Once myocyte membrane damage, cell enzymes/proteins leak into blood.

Cardiac markers elevated such as Troponin I indicates there is cardiac muscle injury.

Troponin I is the cardiac marker in acute coronary syndromes and in heart failure.

Differential diagnosis of elevation would be 

Having a result higher than 0.40 ng/ml showing the underlying cardiac injury is MI. Since Pt’s troponin I is 12.90 ng/ml. This can confirms that the Pt has MI after seeing his ECG results also shows an ST- segment elevation.

D-dimer normal level is below 0.25 ug/ml. D-Dimer, an expression of ongoing thrombus formation and lysis, is a marker of substantial incremental value for the early diagnosis of acute coronary syndromes presenting with chest pain. This ticks the box since the patient also presents with chest pain. It adds independent information to the traditional assessment for myocardial infarction. D-Dimer can be incorporated into clinical decision models in the ED to find the definitive diagnosis.

- Unfractionated heparin (UFH)
- Low molecular weight heparin (LMWH)
- Synthetic heparin 

The symptoms of having LADA stenosis:

Sure Afrina! Thank you for your question. 

As for additional informations, there are some differences between UFH and LMWH 

In this case, the patient’s renal profile is normal, which means that the patient has a fully functioning kidney.

Liver function tests also have been done to measure how well the patient’s liver performs its normal functions of producing protein and clearing bilirubin (blood waste product). Elevated levels of bilirubin might indicate liver damage or disease or certain types of anaemia. Normal values of liver function tests are generally around 7 to 20 mg/dL (2.5 to 7.1 mmol/L).

The patient shows a normal liver function test reading, which indicates that the patient's liver is functioning normally.

Because the transmural depth of necrosis cannot be precisely determined clinically, infarcts are usually classified as STEMI or NSTEMI by the presence or absence of ST-segment elevation or Q waves on the ECG.

Non–ST-segment elevation myocardial infarction (NSTEMI, subendocardial MI) is myocardial necrosis (evidenced by cardiac markers in blood; troponin I or troponin T and CK will be elevated) without acute ST-segment elevation. ECG changes such as ST-segment depression, T-wave inversion, or both may be present.

ST-segment elevation myocardial infarction (STEMI, transmural MI) is myocardial necrosis with ECG changes showing ST-segment elevation that is not quickly reversed by nitroglycerin. Troponin I or troponin T and CK are elevated.

PATIENT HAVE STEMI OR TRANSMURAL MYOCARDIAL INFARCTION DUE TO ST ELEVATION THAT CAN BE SEEN ON THE ECG RESULTS

As for treatment and post management, Hariz will help me to give a brief discussion about it. 

It can be seen in the figure above and each phase is determined by the electrical signal in cardiac cycles.

 The main parts of an ECG are P wave, QRS complex and T waves.

The electrical signal in the cardiac cycle is shown in ECG by P wave,QRS complex,T wave and U wave.

ECG is used to determine or detect:

Full blood count (FBC) = complete blood count (CBC) = blood test that is used to assess overall health and diagnose a variety of illnesses such as anaemia, infection, and leukaemia.