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.

5. 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

6. 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.

7. Normal Values of Blood Tests to Detect Myocardial Infarction
Analysis
Normal Range
Total creatinine phosphokinase (CK)
U/L
CK, MB fraction
ng/mL
CK, MB fraction percent of total CK
0-4%
CK, MB2 fraction
< 1 U/L
Troponin I
ng/mL
Troponin T
ng/mL   

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

9. 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

10. 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

11. 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

12. 5) Tx hypoglycemia

13. 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.

14. thank you