Uncomplicated MI Approach

Uncomplicated MI Approach..

Here is my management for an uncomplicated MI:

So->presentation of chest pain suggestive for MI:
P/E-chest,abdomen,extremities=3 minutes
1)Aspirin chewing
2)O2 mask
3)IV line
4)ECG 12 lead
5)ECG monitoring
6)vitals monitoring
7)cardiac enzymes(CPK-MB,cTnT)
8)pulseoxymetry monitoring
9)Morphine sulphate i.v.
other Labs:CBC with diff
ABG's
Lytes
Chem 7
PT&aPTT
blood type &crossmatching
LFT's
Urinalysis,creatinine,BUN
glucose serum
TSH
imagistic:
CXR
abd plain films
cardiac ECHO

if no inferior MI/no hypotension->nitroglycerin iv

Look for CI to thrombolysis->if no CI->heparin iv
then tpa bolus
if CI to thrombolysis->stenting PTCA call interventional cardio

the patient is stabilised->transfer in ICU
d/c oxygen
adm.methoprolol iv
continue monitoring for 3 days
Diet liquid
Psyllum cysapride to prevent constipation
2'nd day
Tc scintigram-evaluation of affected miocardum
complete P/E
3'rd day continue measures- early ambulation (go to the bathroom)
4'th day non-stress submaximal effort test
discontinuation of monitoring,
transfer in ward room
5'th day D/c of iv medication
propranolol p.o.(chose because of lowcost)
cord-pulmon examination
look for patient immunisation status
if no influenza&pneumo
advise patient to stop smoking &drinking
6'th day begin solid alimentation
7'th day again submaximal treadmill test
discharge
Final recomandations:
diet low salt low cholesterol
continue aspirin indefintite
come back to control in one month
rest at home for 3 months

that cisapride has been disapproved by the FDA. So pick something else, like misoprostol

A 60-year-old white female is scheduled to have a total abdominal hysterectomy. She is currently in good health, but the general surgeon is concerned because the patient had a pulmonary embolus 10 years ago.

Which one of the following is most effective for prevention of another embolus?


a.No prophylaxis necessary
b.Impedance plethysmography, 36 and 72 hours after surgery
c.Aspirin prophylaxis
d.Full heparinization after surgery
e.Subcutaneous heparin prophylaxis

E

This patient is considered at high risk for a venous thromboembolism because of general surgery, age greater than 40, and previous history of a pulmonary embolus. In numerous clinical trials, heparin, 5000 U subcutaneously 2 hours prior to surgery, followed by 5000 U subcutaneously every 8 to 12 hours until the patient is ambulatory, has statistically reduced the incidence of deep vein thrombosis. Full heparin therapy is not necessary. Aspirin is not effective, and impedance plethysmography would not prevent thrombosis.

A 25-year-old white male comes to see you for evaluation of a 'white lesion' which he found several days ago with toothbrushing. The lesion is located on the mucosa of the right cheek, close to the first lower molar. The patient denies any bleeding or pain. He has smoked an average of 2 cigarettes a day for the last 10 years. He now works as a nursing aide in a hospital. There is no family history of malignancy involving the oral cavity. Inspection shows a circular 4 mm lesion that appears as a thin, white, and translucent film on the normal mucous membrane.

At this time, you should

a.refer the patient to an oral surgeon
b.consult with an otorhinolaryngologist
c.perform a biopsy
d.palpate the lesion digitallyA 25-year-old white male comes to see you for evaluation of a 'white lesion' which he found several days ago with toothbrushing. The lesion is located on the mucosa of the right cheek, close to the first lower molar. The patient denies any bleeding or pain. He has smoked an average of 2 cigarettes a day for the last 10 years. He now works as a nursing aide in a hospital. There is no family history of malignancy involving the oral cavity. Inspection shows a circular 4 mm lesion that appears as a thin, white, and translucent film on the normal mucous membrane.

At this time, you should

a.refer the patient to an oral surgeon
b.consult with an otorhinolaryngologist
c.perform a biopsy
d.palpate the lesion digitally

D

The characteristics of the lesion do not suggest malignancy. At this stage, digital palpation of the lesion will probably not reveal any thickening. Even though the four options presented are 'acceptable routes of management,' the physician should take a good history, perform a thorough physical examination-particularly a digital palpation of the lesion in this case-and formulate a clinical impression which will dictate the next logical step of action.
In the absence of thickening of the lesion on palpation, this thin, early lesion requires only a warning and a biopsy is not necessary. Close follow-up observation is however recommended. This aspect of continuity of care cannot be overemphasized for the family physician.

A young male is brought to the emergency department after having been submerged for a prolonged period in a nearby pond. Cardiopulmonary resuscitation was performed at the scene. The patient is being ventilated by mask and bag upon arrival in the emergency department. A brief examination reveals that the patient has no obvious sites of trauma and is conscious but not communicative. His blood pressure is 90/60, pulse is 120, temperature is 36C (96.8F), and respiratory rate is 30. Cardiac rhythm reveals sinus tachycardia. Pulse oximetry reveals oxygen saturation of 83 percent. Which of the following is the best method to reverse the patient's apparent hypoxemia?

A Administration of sodium bicarbonate
B Administration of acetazolamide
C Administration of supplemental oxygen
D Application of continuous positive airway pressure and administration of supplemental oxygen
E Administration of supplemental oxygen and endotracheal suction to remove aspirated fluid

The answer is D
Ninety percent of drowning patients aspirate fluid; however, the vast majority aspirate less than 22 mL/kg. Although aspiration of fresh water can produce acute hypervolemia with dilutional hyponatremia and possibly even hemolysis, these are rare occurrences. Aspiration of seawater can cause hypovolemia with ensuing hypernatremia. In the absence of documentation of such an electrolyte problem, no specific therapy is required. Aspiration of water of any type leads to considerable venous admixture (i.e., ventilation-perfusion abnormalities), which can produce hypoxemia. The most important therapeutic maneuvers, after resuscitation on the scene, are to provide supplemental oxygen, intravenous access, and transportation to a hospital where the patient can be evaluated for adequacy of ventilation, cardiac function, and blood volume. The best way to reverse drowning-associated hypoxemia consists of the application of continuous positive airway pressure (CPAP). CPAP may be combined with mechanical inflation of the lung as needed; mechanical inflation may be particularly effective in those who have aspirated fresh water, which leads to a change in the surface-tension characteristics of pulmonary surfactant. Correction of severe metabolic acidosis with bicarbonate is controversial. Finally, the universal need for corticosteroid therapy and antibiotics is no longer accepted.

which is the cost effective screenig for DM in high
risk patients?
oral 50g glucose test
GTT
oral 75g glucose test.


2. baby born from mother with GDM is more likely to have
which one as a longtrem complication
1. obesity
2. glucose intolerenc
3.type2 diabetes in adolescent period
4.hypoglycemia




3. Which of the following is NOT used in the initial
management of GDM?

A. proper diet

B. exercise

C. insulin

D. oral hypoglycemics


4. What is the incidence of gestational diabetes
mellitus (GDM) in pregnancy?

A. <1%

B. 3% to 5%

C. 5% to 10%

D. 12% to 15%



5. Which group of women is least likely to develop
GDM?

A. Native Americans

B. African Americans

C. Latinos

D. Whites



6 The pathologic defect in GDM is summarized as:

A. a diminished compensatory response to the increased
insulin resistance commonly associated with pregnancy.


B. a significantly faster first phase response of
insulin release in the presence of glucose.

C. answers A and B are both correct

D. answers A and B are both false



7. Which maternal risk factor is an important
predictor of GDM?

A. younger than age 25

B. previous pregnancies

C. obesity

D. no family history of diabetes mellitus



8. The American College of Obstetrics and Gynecology
recommends that pregnant women at low risk for GDM
undergo a modified glucose tolerance test:

A. when pregnancy is confirmed.

B. at the beginning of each trimester.

C. between weeks 24 and 28.

D. between weeks 30 and 34.



9.Which of the following is a neonatal complication of
GDM?

A. lowbirth-weight infants

B. 90% chance of neonatal hyperglycemia

C. increased instance of hyperbilirubinemia and
polycythemia

D. a decreased risk of congenital malformation



10. What percent of women with GDM will ultimately
develop DM?

A. 25%

B. 50%

C. 75%

D. 100%

1-1, 2-1, 3-D, 4-B, 5-B, 6-D, 7-C, 8-C, 9-A, 10-B

Gestational diabetes(GDM) is defined as glucose intolerance of variable degree with onset or first recognition during the present pregnancy. It can be screened by drawing a 1-hour glucose level following a 50-g glucose load, but is definitively diagnosed only by an abnormal 3-hour OGTT following a 100-g glucose load.


Importance

The growth and maturation of the fetus are closely associated with the delivery of maternal nutrients, particularly glucose. This is most crucial in the third trimester and is directly related to the duration and degree of maternal glucose elevation. Thus, the negative impact is as highly diverse as the variety of carbohydrate intolerance that women bring to pregnancy.

For the mother with GDM there is a higher risk of hypertension, preeclampsia, urinary tract infections, cesarean section, and future diabetes. Many of the problems associated with overt diabetic pregnancies can be seen in infants of gestational diabetic pregnancies, such as macrosomia, neural tube defects, neonatal hypoglycemia, hypocalcemia, hypomagnsemia, hyperbilirubinemia,birth trauma, prematurity syndromes, and subsequent childhood and adolescent obesity.


Prevalence

The prevalence of GDM varies worldwide and among different racial and ethnic groups within a country. The variability is partly because of the different criteria and screening regimens(i.e., not all pregnant women are screened). Studies using a 100-g 3-hour OGTT and either the criteria of the National Diabetes Data Group(NDDG) or of Carpenter and Coustan have found prevalence rates of 1.4% to 12.3% in the United States, respectively.


Pathophysiology

Gestational diabetes is pathophysiologically similar to type II diabetes. Approximately 90% of the persons identified have a deficiency of insulin receptors(prior to pregnancy) or a marked increase in weight that has been placed on the abdominal region. The other 10% have deficient insulin production and will proceed to develop mature-onset insulin-dependent diabetes.

HPL blocks insulin receptors and increases in direct linear relation to the length of pregnancy. Insulin release is enhanced in an attempt to maintain glucose homeostasis. The patient experiences increased hunger due to the excess insulin release as a result of elevated glucose levels. This insulin release further decreases insulin receptors due to elevated hormonal levels.


Diagnostic Criteria and Screening Procedures

The traditional method of screening for GDM is to assess risk factors: age, prepregnancy weight, family history of diabetes in a first-degree relative, previous large baby, and previous perinatal loss. Unfortunately, screening based solely on risk factors will only identify approximately 50% of women with GDM.

Glucosuria is a common finding in pregnancy due to increased glomerular filtration and is therefore unreliable as a diagnostic finding.

The ADA(American Diabetes Association) recommend that all pregnant women, who have not been identified with glucose intolerance earlier in pregnancy, be screened with a 50-g 1-hour GCT between 24 and 28 weeks of pregnancy. Such test can be performed at anytime of the day and with disregard to previous meal ingestion. A value equal to or above 140mg/dL should be used as the threshold level and indicates the need for a 100-g 3-hour OGTT. For the OGTT, the patient is fasting and receives 100-g of glucose after a fasting glucose level is obtained. A blood sample is taken every hour for 3 hours. The patient is advised to sit quietly during the test to minimize the impact of exercise on glucose levels.

The glucose values used to detect gestational diabetes were first determined by OSullivan (1964) in a retrospective study designed to detect risk of developing type II diabetes in the future. The values were set using venous whole blood and required 2 values reaching or exceeding the value to be positive. Subsequent information has led to alteration in OSullivans criteria. For example: when methods for blood glucose determination changed from the use of whole blood to venous plasma samples, the criteria for GDM were also changed once whole blood glucose values are lower than plasma levels due to glucose uptake by hemoglobin (NDDG,1979).

Since the adoption of the NDDG criteria, more specific glucose oxidase or hexokinase tests for glucose determination have replaced older methods, and new threshold values have been calculated by Carpenter and Coustan. Sacks and co-workers also have shown that correction of the OSullivans cutoffs may be necessary and suggested new cutoff values in 1989

If one abnormal value is seen during the 100-g 3-hour OGTT it is recommended that the test be repeated approximately 1 month later. There is growing evidence that 1 abnormal value is sufficient to make an impact on the health of the fetus and is now the criterion used by most clinicians to initiate treatment. In a study of 106 women with one abnormal value on the OGTT, 34% were diagnosed with GDM when the test was repeated 1 month later, emphasizing the importance of repeat testing when only one abnormal value is found.

OBS.: If GDM and fetal macrosomia begin to develop in the first trimester, then a diagnostic test to identify women at risk for GDM and to predict infants at risk for macrosomia should be accurate in the first trimester.


Medical Management

The reason for lowering the glucose level to a normoglycemic one is to prevent diabetic complications. The goal of medical management of women with GDM, therefore, is to prevent perinatal morbidity and mortality by normalizing the level of glycemia and other metabolites(i.e., lipids and amino acids) to the levels of nondiabetic pregnant individuals.

Dietary Therapy

Nutritional counseling is the mainstay of therapy for the gestational diabetic woman. The optimal dietary prescription would be one that provides the calories and nutrients necessary for maternal and fetal health, results in normoglycemia, prevents ketosis, and results in appropriate weight gain.

One of the difficulties with dietary prescription for women with GDM is the difference between lean and obese women. Obese women with GDM may benefit from a low calorie diet and weight reduction to reverse the metabolic disturbances, but proper nutrition is needed to assure fetal growth and development.

Jovanovic and Peterson found the following diet to result in euglycemia: 30kcal/kg/24h present pregnant weight for normal-weight women, 24kcal/kg/24h for overweight women (120%-150% ideal body weight ), 12 to 15 kcal/kg/24h for morbidly obese women ( >150% ideal body weight ), and 40kcal/kg/24h for underweight women( <80% ideal body weight ). They recommend that the diet be composed of 40% to 50% carbohydrate, 20% to 25% protein, and 30% to 40% fat ( polyunsaturated).

The patient checks her glucose 4 times daily (eg., fasting,and 1-hour postprandial breakfast, lunch, dinner ). The desired values are a fasting of <90mg/dL and a 1-hour <130mg/dL. The average glucose levels should be~90. After she has obtained a good understanding of her diet and the glucose values are in the desired range, she can decrease the frequency of testing to 3 days per week chosen randomly.

Insulin Therapy

If diet is not successful in maintaining relative euglycemia, then insulin therapy is recommended. To identify the women who will require insulin, circulating glucose levels should be monitored at frequent intervals. The ADA and ACOG( American College of Obstetricians and Gynecologists ) recommend glucose measurements be taken both fasting and after meals to 1 to 2-week intervals. Insulin therapy should be initiated if the fasting glucose levels exceed 105mg/dL and/or if the 2-hour postprandial levels exceed 120mg/dL on two or more occasions within a 2-week interval.

Several centers, however, use the 1-hour time point because it reflects the peak glycemic response to a meal. Two studies have found that the 1-hour postprandial glucose level was a better predictor of infant birth weight than the fasting level. For this reason, when the fasting blood glucose level is 90mg/dL or more, or the 1-hour postprandial glucose is 120mg/dL or more on two or more glucose measurements within 1 or 2 weeks, then insulin therapy is initiated. Several regimens are possible for insulin therapy. Jovanovic and Peterson suggest the regimen.

Exercise Therapy


Cardiovascular conditioning or aerobic exercise has both acute and long-term effects on insulin sensitivity, insulin secretion, and glucose metabolism. Because exercise is associated with a decrease in blood glucose concentration both acutely and after a training program and exercise training with weight control or reduction is associated with lower fasting and postprandial insulin concentrations and apparent increases in insulin sensitivity, regular exercise may be useful in the treatment or prevention of GDM.

There are many other potential benefits of exercise training and increased cardiorespiratory fitness, such as improvement in cardiovascular risk factors and the prevention or reduction of cardiovascular complications in people with diabetes.

Recognizing the importance of physical activity, the Third International Workshop-Conference on Gestational Diabetes has recommended exercise as a treatment modality for GDM in women who do not have a medical or obstetric contraindication for an exercise program.


Obstetric Management

Antepartum Care

Surveillance for fetal well-being should begin between 28 and 32 weeks. Methods of fetal surveillance may include fetal kick counts, the nonstress test(NST), the contraction stress test (CST), and the biophysical profile. Signs of fetal compromise include the following: decreased fetal movement, a nonreactive NST, a positive CST and a poor biophysical profile.

The frequency and timing of fetal surveillance depend on the severity of the disease and the degree of glycemic control. Frequent ( every 4 to 6 weeks) ultrasound examinations to assess fetal growth should be performed.

In the case of abnormal fetal testing, the practioner should assess gestational age and, if the fetus is found to be mature, should proceed to delivery. If the fetus is intermediate in maturity, amniotic fluid assessment for pulmonary maturity may assist in the decision regarding whether delivery should be effected. If the fetus is immature, further testing such as contraction stress tests or hospitalization with continuous fetal heart rate monitoring is advised.

Preterm labor is increased in patients with diabetes and they should be treated with magnesium sulfate as the initial tocolytic agent because the beta mimetics markedly influence glucose control. Corticosteroids increase maternal glucose levels, and this therapy may consist of continuous insulin infusion in certain cases.

Intrapartum and Postpartum Management

Induction of labor is recommended at 38 weeks in patients with poor glucose control and macrosomia. Insulin-requiring diabetics should be induced at 40 weeks gestation if spontaneous labor has not occurred.

Induction of labor may be attempted if the fetus is not excessively large and if the cervix is capable of being induced( i.e., if the cervix is soft, appreciably effaced, and somewhat dilated).

The possibility of shoulder dystocia in the macrosomic infant of a mother with diabetes must be considered; cesarean section may be indicated to avoid the trauma of a delivering of a large infant(>4000g). Euglycemia should be maintained during labor.


Prognosis

Women diagnosed with gestational diabetes have an increased risk of developing diabetes mellitus in the future. If they require insulin for their pregnancy, there is a 50% risk of diabetes within 5 years. If dietary control has been sufficient, a 60% risk of developing diabetes mellitus within 10-15 years still persists.

For this reason, all gestationally diabetic patients should have a 75-g 3-hr glucose tolerance to evaluate for preexisting diabetes. If the 1-hr value is high, it represents decreased insulin capacity, whereas an elevated 3-hr value reflects decreased insulin receptors. In the former, limiting simple sugars in the diet should become a lifetime goal. In the latter, weight loss with increased abdominal musculature should significantly reduce the increased risk of diabetes.

according to blue print of obgy,
50 % of GDM during pregnancy will experience gdm in subsequent pregnancy and 25-35% will go on to develop overt dm within 5 years