DM Mrs. Emma Taffey is a right-handed 73-year-old women who comes from a small outp ort in Newfoundland.

She is married to a retired fishery worker. Mrs. Taffey has a grade eight education. She is a native-English speaker who has never worked o utside of the home. She has raised 12 children, seven of whom still live in the vicinity. The Taffey home is a two-storey wooden house with a shanty (i.e., outhouse) atta ched to the back porch. There is a water pump in the kitchen and a wood burning stove for heat. Mrs. Taffey enjoys canning, knitting, needlepoint, and quilting. She has a small income from her knitting and quilting work. She has a sizeable social support s ystem that includes her children, her husband, and many friends. Medical Information Mrs. Taffey is overweight and has insulin-dependent diabetes mellitus (IDDM). In conjunction with being a brittle diabetic, she has peripheral neuropathy with p aresthesias of her fingers and feet, vision problems (diabetic retinopathy), bil ateral sensorineural hearing loss (SNHL), and peripheral vascular disease. Mrs. Taffey also smokes, on average, one package of cigarettes daily. back2top_e0.gif Presenting Problem Mrs. Taffey's physician(s) has recommended the amputation of her right leg, belo w the knee. Pressure sores on the left foot require monitoring and may lead to a nother amputation. The cost of a prosthesis is relatively high, given the limite d family income. The outport in which the family resides is very isolated from S eptember to May. Mrs. Taffey must be discharged within eight-to-ten weeks in ord er to catch the coastal supply boat to her home town, or else she may be strande d in St. John's for the winter. Chronic renal failure ( case scenario) A 56 years old malay housewife from melaka, admitted to the hospital with ge neralized body weakness and fatigue for 2 days. She is a known to have diabtes mellitus for past 13 years and hypertension f or 1 year. She was told to have low Hb level and 3 packs of blood have been transfused. She also gave history of frothy urine. No history of oliguria, hematuria. Patie nt also give history of pedal edema for past 2 months. No history of breathlessness, dyspnea on exertion. There is history of polyuria. She is on insulin for the past 6 months. She is also on treatment for hypert ension. On examination, patient s vitals sign are stable. She is alert and cooperative . There is no pallor, JVP not raised, there is anarsaca. CVS examination is norm al. RS examination also normal. Diagnosis: chronic renal failure Discussion: Blood pressure in this patient should be maintain below 135/85mmHg. ACE inhi bitors or angiotensin receptor blocker are drug of choice. Blood glucose level should be well controlled. Insulin therapy will be the d rug of choice. Higher dose might be required. Oral hypoglycemic drug should be a

voided. Associated diabetic retinopathy tends to progress rapidly. Therefore, freque nt ophthalmic supervision required. She should be follow up regularly. MI John Smith comes into the ER complaining of chest pain. His blood pressure is 72 /48, pulse 32. He is in a sinus rhythm. Mr. Smith is a 52 year old executive who is a diabetic and slightly overweight. He reports that he smokes 1 pack per day. He states that the chest pain began su ddenly and feels like "an elephant is sitting on his chest". He is pale, diaphor etic, and has cyanotic lips. He states that he has also had some nausea. What wo uld be the pathophysiologic reason for his nausea? 3 What predisposing factors place Mr. Smith at risk for a myocardial infar ction?