Pathophysiology
Precipitating/Modifiable Sedentary Lifestyle Smoker since 19 (3sticks/day) for 30 yrs Diet (high in fats & sweets) Pre-obese (BMI= 27.49) Predisposing/Nonmodifiable Age (58 y/old) Father (DM Type 2
Insulin Resistance Exhaustion of beta cells Decrease insulin production of beta cells
Decrease absorption of glucose by cell Glucogenolysis
Cell starvation
Stimulation of hunger mechanism via hypothalamus Polyphagia
Increase glucose production by the liver
Increase serum glucose level (HbA1C= 10.9) Osmotic diuresis Increase serum osmolarity
Polyuria & albuminuria (U/A + Albumin)
F&E imbalance Increase blood viscosity Loss of Na & K (Na: 129mmol/L; + K : 3.0mmol/L) Intracellular dehydration Sluggish blood circulation Decrease circulatory blood volume 12 (RBC 2.66x10 /L; HGB 79g/L; Hct .237; ESR 70mm/hr)
Tissue dehydration
Decrease blood flow to organs and extremities
Polydipsia
+Dry mouth; generalized weakness; dizziness; Increase RR (32breaths/min)
Impaired delivery of blood component (RBCs &WBCs) Inadequate nutritional support
Hypovolemia (A/G ratio: 0.40) Delayed wound healing Decrease perfusion of major organs
Disrupted skin integrity Bacteria enters and adheres to cell of liver (Liver Biopsy Result) Gram Positive cocci occurring singly: some Gram Positive bacilli: few Leukocytes: some
Decrease myocardial contractility Decrease cardiac output
Decrease Glomerular Filtration Rate Decrease urine output (5cc/hr)
Inflammatory response initiated by 9 Kupffer cells (WBC= 32.8x10 /L; ESR 70mm/hr)
Histamine
Kinin
Progstaglandin Contraction of smooth muscles
Increase capillary permeability
Blood vessels Dilation
+Edema (Albumin 15g/L)
+Redness, heat o (fever = 38.8 C)
Chemotaxis
Neutrophils initiate phagocytosis
Platelet adheres to damaged site Platelet plug/white thrombus forms
Macrophages aid in phagocytosis Anchored platelets release serotonin to go into vasospasm
Coagulation events B
B Gram (-) bacteria releases endotoxins & exotoxins (Klebsiella pneumoniae: light growth)
Endotoxins further activates inflammatory response and increase the activity of fibrinolysis inhibitor by releasing plasminogen activator inhibitor Formation intravascular clots Hepatic artery obstruction Decrease blood flow to liver Decrease blood flow to right thigh Decrease oxygen and nutrient supply to tissues Increase multiplication and growth anaerobic bacteria causing further inflammatory activation + calf pain (homans sign) Clots dislodged and travels into deep vein in right thighs
Abscess formation
Poor liver function: 1. Poor bacterial clearance *presence of gram + cocci and gram + bacilli 2. Low Albumin Albumin: 175 G/L CT Scan result minimal ascites and grade 2 edema on both lower extremities 3. Hepatomegaly 4. Decreased formation coagulation factors bleeding PT: 24.2 secs (prolonged) Decrease RBC (2.66 12 x 10 /L); Decrease Hgb (79g/L) Hypotension (70/40mmHg) 5. Decrease production thrombopoietin 9 (Plt 17 x 10 /L)
Elevated SGPT SGOT: 64U/L SGPT: 59 U/L
Tissue ischemia Tissue Necrosis CT Scan Result: Gangrene, right thigh
Endothelial damage
Inflammation
Attract inflammatory cells (monocytes, macrophages)
Macrophage ingest lipids
Release biochemical substance
Can further damage endothelium
Attracts plts and initiate clotting
Formation of fibrous cap by smooth muscle
Formation of plaque
Dec. coronary tissue perfusion
Coronary Ischemia
Dec. myocardial oxygenation
M.I Old Infarct
C Activation of complement cascade
Hyperdynamic state
Increase Cardiac Output HR= 120s
Decrease peripheral resistance BP= 70/40mmHg
Production of chemical mediators
Marked capillary permeability and third space loss
Hypovolemia
