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