19 Important Causes Of Chest Pain
Chest pain is a common symptom associated witha variety of underlying causes. It is estimated that more than six million people visit hospital energy departments in the United States annually because of chest pain. It is the second most frequently reported principal reason for visiting the emergency unit, only abdominal pain is more common ( 1 ). The cause of chestpain in outpatients may vary fromlife-threatening conditions to those that are relatively harmless. The most common causesof chest pain are musculoskeletal (30-50%) and gastrointestinal conditions (10-20%). Examples of life-threatening conditions that may cause chest pain and call for immediate medical attentionare; acute coronary syndrome (ACS), pulmonary embolism, tension pneumothorax, pericardial tamponade, and esophageal rupture. It is practical to classify the underlying conditions causing chest pain into; gastrointestinal (caused by digestive disorders) Nowadays, all chest pain is regarded as suspected coronary artery diseaseuntil proven otherwise. Most emergency departments have chest pain units, a fast-track service for patients with chest pain, relying to a large extent on blood testing, electrocardiogram, exercise testing and imaging techniques. History Is a Key Factor in Determining the Cause of Chest Pain History and physical examination are of crucialimportancewhen it comes to assessthe probability of different causes of chest pain and determine the need for further testing. The character or quality of the pain is important. Chest pain may be only a vague discomfort, or itmay be sharp, ripping, tearing, or a feeling of pressure, fullness or tightness in the chest. The localization of the pain may help determine its origin. Pain due to coronary artery diseasemay radiate to the neck, jaw, and arms. Continue reading >>
Type 1 Diabetes Complications
Type 1 diabetes is complicated—and if you don’t manage it properly, there are complications, both short-term and long-term. “If you don’t manage it properly” is an important if statement: by carefully managing your blood glucose levels, you can stave off or prevent the short- and long-term complications. And if you’ve already developed diabetes complications, controlling your blood glucose levels can help you manage the symptoms and prevent further damage. Diabetes complications are all related to poor blood glucose control, so you must work carefully with your doctor and diabetes team to correctly manage your blood sugar (or your child’s blood sugar). Short-term Diabetes Complications Hypoglycemia: Hypoglycemia is low blood glucose (blood sugar). It develops when there’s too much insulin—meaning that you’ve taken (or given your child) too much insulin or that you haven’t properly planned insulin around meals or exercise. Other possible causes of hypoglycemia include certain medications (aspirin, for example, lowers the blood glucose level if you take a dose of more than 81mg) and alcohol (alcohol keeps the liver from releasing glucose). There are three levels of hypoglycemia, depending on how low the blood glucose level has dropped: mild, moderate, and severe. If you treat hypoglycemia when it’s in the mild or moderate stages, then you can prevent far more serious problems; severe hypoglycemia can cause a coma and even death (although very, very rarely). The signs and symptoms of low blood glucose are usually easy to recognize: Rapid heartbeat Sweating Paleness of skin Anxiety Numbness in fingers, toes, and lips Sleepiness Confusion Headache Slurred speech For more information about hypoglycemia and how to treat it, please read our article on hy Continue reading >>
Euglycemic Diabetic Ketoacidosis: An Easily Missed Diagnosis
SESSION TITLE: Critical Care Student/Resident Case Report Posters I SESSION TYPE: Student/Resident Case Report Poster INTRODUCTION: A 47 year-old woman with type 1 diabetes presented with euglycemic diabetic ketoacidosis (DKA) that initially went undiagnosed. Recognition and treatment with insulin resulted in rapid resolution of her clinical condition. CASE PRESENTATION: A 47 year-old woman presented to our hospital with four days of fever, abdominal pain, diarrhea, nausea, vomiting, lethargy and malaise. She had a history of type 1 diabetes mellitus managed with an insulin pump. Her blood pressure was 88/51. She was disoriented with a diffusely tender but soft abdomen. Laboratory studies revealed blood glucose of 109 mg/dL, bicarbonate of 15 mmol/L, anion gap of 27 mmol/L, lactic acid of 2.4 mmol/L, and a bandemia of 11%. Rapid flu test was positive. She was admitted to the intensive care unit, resuscitated with intravenous fluid, and started on oseltamivir, cefepime and vancomycin. Hemodialysis was initiated soon thereafter. The patient received no insulin due to her euglycemia. Influenza A was detected by PCR on the second hospital day and antibiotics were discontinued. Her gastrointestinal symptoms improved but her mental status remained poor. Furthermore, while her lactate normalized and blood glucose remained under 120 mg/d, her anion gap persisted at 23-36 mmol/L and her bicarbonate remained low at 15-17 mmol/L. Beta hydroxybutyrate was found to be 4.88 mmol/L. An insulin infusion was started, along with dextrose 5% in water, and her mental status rapidly improved as her acidemia and anion gap normalized. DISCUSSION: Euglycemic DKA is a rare condition that can easily go undiagnosed. It has been previously described in the context of critical illness.1 The pathoge Continue reading >>
The Silent Heart Attacks That Can Strike Diabetics Without Warning
Property consultant Michael Green was adamant that his type 2 diabetes was nothing to worry about. 'It's the non-serious type,' he'd say dismissively. Michael's laid-back attitude is in some ways understandable. The father-of-one had never suffered any obvious ill-effects from the condition he'd lived with for 28 years, and he'd been diagnosed not as a result of any troubling symptoms, but by chance following a routine blood test. Compared to a family friend who had type 1 diabetes, he was lucky, he insisted. At least he didn't have to monitor his blood sugar levels every few hours, and inject insulin. Then one night, two years ago, he went to sleep and never woke up. At just 53, he'd suffered a 'silent heart attack' - a little-known complication of diabetes. A silent attack is almost symptomless and occurs without any of the chest pain normally associated with a heart attack. Yet they can be just as dangerous - if not more so - as a normal heart attack. They're also surprisingly common. It is estimated that around a quarter of the 175,000 heart attacks in the UK each year are the silent type - and people with diabetes are at greatest risk. This is because the nerve damage linked to their condition can prevent warning signals being transmitted in the usual way. This, in turn, can lead to a delay in seeking treatment and result in damage to the blood vessels and heart muscle that make the heart attack more lethal. Heart attacks occur when there is a blockage in the artery supplying blood to the heart. Normally, this is as a result of a fatty plaque breaking off from the artery wall, triggering a blood clot. When the blood supply to the heart is reduced, the body produces chemicals that affect nerves and trigger pain. Often, people describe the pain of a heart attack as a Continue reading >>
Diabetic Ketoacidosis (dka)
Diabetic ketoacidosis is an acute metabolic complication of diabetes characterized by hyperglycemia, hyperketonemia, and metabolic acidosis. Hyperglycemia causes an osmotic diuresis with significant fluid and electrolyte loss. DKA occurs mostly in type 1 diabetes mellitus (DM). It causes nausea, vomiting, and abdominal pain and can progress to cerebral edema, coma, and death. DKA is diagnosed by detection of hyperketonemia and anion gap metabolic acidosis in the presence of hyperglycemia. Treatment involves volume expansion, insulin replacement, and prevention of hypokalemia. Diabetic ketoacidosis (DKA) is most common among patients with type 1 diabetes mellitus and develops when insulin levels are insufficient to meet the body’s basic metabolic requirements. DKA is the first manifestation of type 1 DM in a minority of patients. Insulin deficiency can be absolute (eg, during lapses in the administration of exogenous insulin) or relative (eg, when usual insulin doses do not meet metabolic needs during physiologic stress). Common physiologic stresses that can trigger DKA include Some drugs implicated in causing DKA include DKA is less common in type 2 diabetes mellitus, but it may occur in situations of unusual physiologic stress. Ketosis-prone type 2 diabetes is a variant of type 2 diabetes, which is sometimes seen in obese individuals, often of African (including African-American or Afro-Caribbean) origin. People with ketosis-prone diabetes (also referred to as Flatbush diabetes) can have significant impairment of beta cell function with hyperglycemia, and are therefore more likely to develop DKA in the setting of significant hyperglycemia. SGLT-2 inhibitors have been implicated in causing DKA in both type 1 and type 2 DM. Continue reading >>
Diabetic Ketoacidosis Clinical Presentation
History Insidious increased thirst (ie, polydipsia) and urination (ie, polyuria) are the most common early symptoms of diabetic ketoacidosis (DKA). Malaise, generalized weakness, and fatigability also can present as symptoms of DKA. Nausea and vomiting usually occur and may be associated with diffuse abdominal pain, decreased appetite, and anorexia. A history of rapid weight loss is a symptom in patients who are newly diagnosed with type 1 diabetes. Patients may present with a history of failure to comply with insulin therapy or missed insulin injections due to vomiting or psychological reasons. Decreased perspiration is another possible symptom of DKA. Altered consciousness in the form of mild disorientation or confusion can occur. Although frank coma is uncommon, it may occur when the condition is neglected or if dehydration or acidosis is severe. Among the symptoms of DKA associated with possible intercurrent infection are fever, dysuria, coughing, malaise, chills, chest pain, shortness of breath, and arthralgia. Acute chest pain or palpitation may occur in association with myocardial infarction. Painless infarction is not uncommon in patients with diabetes and should always be suspected in elderly patients. A study by Crossen et al indicated that in children with type 1 diabetes, those who have had a recent emergency department visit and have undergone a long period without visiting an endocrinologist are more likely to develop DKA. The study included 5263 pediatric patients with type 1 diabetes. [15] Continue reading >>
Heart Attack And Stroke A Result Of Diabetic Drug Invokana?
Invokana, a relatively new drug used to treat Type 2 diabetes has recently come under fire for a number of potential risks associated with the drug. While much of the bad press regarding Invokana has to do with ketoacidosis, a potentially life-threatening condition, there are other issues associated with Invokana. There is also evidence that manufacturers Johnson & Johnson and Janssen, as well as the FDA, were aware of these issues, in particular the risk of heart attack and stroke linked to Invokana, yet failed to warn consumers. Doctors Disagree with Janssen’s Claim That Invokana is Safe In January, 2013, representatives from Janssen Pharmaceuticals presented information to the FDA on the increase of Type 2 diabetes in the United States and the benefits associated with their new drug, Invokana. During the question and answer session, Dr. Sidney Wolfe raised some questions about the safety of Invokana. The most pressing concern voiced by Wolfe was blood clots which could lead to heart attacks. In studies presented by Janssen, thirteen patients who were taking Invokana suffered cardiovascular events. Further, Wolfe demonstrated that the heart attack risk (measured by increase in hematocrit) for Invokana (canagliflozin) users was as much as one and a half times greater than those in the gliflozin group. Hematocrit is the concentration of red bloods cells. In women, the normal concentration of hematocrit is 40 percent and the normal concentration in men is 45 percent. Any levels higher than this increase the risk of a blood clot which, in turn, causes a heart attack or stroke. Wolfe believed that a full one-quarter of Invokana users would develop a hematocrit of 47 percent—a “very dangerous range.” FDA biostatistician Dr. Mat Soukop testified before the panel rega Continue reading >>
Pheochromocytoma Masquerading As Diabetic Ketoacidosis
Pheochromocytoma Masquerading as Diabetic Ketoacidosis Author information Article notes Copyright and License information Disclaimer Jeffrey Stephen Hedley, MD, Emory University School of Medicine, 100 Woodruff Circle, Suite 327 School of Medicine Building, Atlanta, GA 30303-3073, USA. Email: [email protected] Received 2016 Jan 27; Revised 2016 Mar 23; Accepted 2016 Mar 24. Copyright 2016 American Federation for Medical Research This article is distributed under the terms of the Creative Commons Attribution 3.0 License ( ) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( ). This article has been cited by other articles in PMC. Diabetic ketoacidosis is a routinely encountered diagnosis in medicine. Physicians are trained early on to look for precipitants. Most clinicians assess for medication compliance, infection, ischemia, and the like. We present a case of pheochromocytoma presenting as diabetic ketoacidosis. The case serves as an example for broadening the differential diagnosis for patients with similar presentations. Additionally, the case helps inform our understanding of the so-called stress reactions that are commonly invoked in clinical rationale. Keywords: pheochromocytoma, diabetic ketoacidosis, DKA, stress hyperglycemia, stress response A 62-year-old Caucasian gentleman presented to the emergency department complaining of palpitations. The patient, an avid ice hockey player, was participating in a game the evening prior to admission. After a long stretch of play, he began to experience headache, lightheadedness, and palpitations. The patient reported feeling shaky and weak, and although he is was not a known diabetic, he postu Continue reading >>
Kussmaul Breathing - An Overview | Sciencedirect Topics
Nicholas J. White, in Manson's Tropical Infectious Diseases (Twenty-third Edition) , 2014 Hyperventilation or Kussmaul's breathing (sometimes termed respiratory distress) is a poor prognostic sign in malaria. In the tachypnoea associated with high fever, breathing is shallow compared with the ominous laboured hyperventilation associated with metabolic acidosis, pulmonary oedema or bronchopneumonia. Acute pulmonary oedema (acute respiratory distress syndrome) may develop at any time in severe falciparum malaria. It is particularly common in pregnant women, but rare in children. In some cases malaria ARDS may be difficult to distinguish clinically from pneumonia. The heart sounds are normal. The central venous pressure and pulmonary artery occlusion pressures are usually normal, the cardiac index is high and systemic vascular resistance is low. This points to an increase in capillary permeability (unless the patient has been overhydrated). The chest radiograph shows increased interstitial shadowing and a normal heart size. Julian L. Seifter, in Goldman's Cecil Medicine (Twenty Fourth Edition) , 2012 Symptoms include nausea, vomiting, anorexia, polydipsia, and polyuria. Patients often exhibit Kussmaul respirations and volume depletion. Neurologic symptoms include fatigue and lethargy with depression of the sensorium. CSF exhibits a change in acid-base status with treatment of diabetic ketoacidosis. Even without bicarbonate administration, CSF pH falls as a result of the ventilatory response to the correction of acidosis and the sudden rise in Pco2. However, no correlation between decreased CSF pH and depression of sensorium has been established. Ketoacidosis is also seen in cases of starvation, in which it is generally mild and not associated with hyperglycemia. Ketoacids Continue reading >>
Ketoacidosis: A Complication Of Diabetes
Diabetic ketoacidosis is a serious condition that can occur as a complication of diabetes. People with diabetic ketoacidosis (DKA) have high blood sugar levels and a build-up of chemicals called ketones in the body that makes the blood more acidic than usual. Diabetic ketoacidosis can develop when there isn’t enough insulin in the body for it to use sugars for energy, so it starts to use fat as a fuel instead. When fat is broken down to make energy, ketones are made in the body as a by-product. Ketones are harmful to the body, and diabetic ketoacidosis can be life-threatening. Fortunately, treatment is available and is usually successful. Symptoms Ketoacidosis usually develops gradually over hours or days. Symptoms of diabetic ketoacidosis may include: excessive thirst; increased urination; tiredness or weakness; a flushed appearance, with hot dry skin; nausea and vomiting; dehydration; restlessness, discomfort and agitation; fruity or acetone smelling breath (like nail polish remover); abdominal pain; deep or rapid breathing; low blood pressure (hypotension) due to dehydration; and confusion and coma. See your doctor as soon as possible or seek emergency treatment if you develop symptoms of ketoacidosis. Who is at risk of diabetic ketoacidosis? Diabetic ketoacidosis usually occurs in people with type 1 diabetes. It rarely affects people with type 2 diabetes. DKA may be the first indication that a person has type 1 diabetes. It can also affect people with known diabetes who are not getting enough insulin to meet their needs, either due to insufficient insulin or increased needs. Ketoacidosis most often happens when people with diabetes: do not get enough insulin due to missed or incorrect doses of insulin or problems with their insulin pump; have an infection or illne Continue reading >>
Jaime Moo-young, Md
Diabetic Ketoacidosis (DKA) Pathogenesis · Insufficient insulin for a given carbohydrate load decreased cellular metabolism of glucose · Increased gluconeogenesis, glycogenolysisHyperglycemia · Increased breakdown of free fatty acids as alternative energy source ketone and ketoacid accumulation · Hyperglycemiaserum hyperosmolality osmotic diuresis dehydration and electrolyte derangements (dehydration is most lethal!) · Seen almost exclusively in Type I diabetes; rarely in Type II Definition: Triad of 1. Hyperglycemia (usually between 500 – 800 mg/dL or 27.8-44.4 mmol/L) 2. Anion Gap Metabolic Acidosis (pH usually <7.30) 3. Ketonemia: -hydroxybutyrate, acetoacetate most significant ** Urine ketones do not make the diagnosis, but they can support it** Triggers (the “I’sâ€): Don’t forget to ask about these! · Insulin deficiency: insulin non-compliance, insufficient insulin dosing, new-onset Type I diabetes · Iatrognic: glucocorticoids, atypical antipsychotics, high-dose thiazide diuretics · Infection: UTI, pneumonia, TB · Inflammation: pancreatitis, cholecystitis · Ischemia/infarction: MI, stroke, gut ischemia · Intoxication: Alcohol, cocaine, other drugs Presentation · Symptoms · Polyuria, polydipsia, weight loss · Nausea, vomiting, abdominal pain · Fatigue, malaise · Associated trigger sx (fever/chills, chest pain, etc) · Signs · Volume depletion: skin turgor, dry axillae, dry mucus membranes, HR, BP · Altered mental status: stupor, coma · Kussmaul respirations: rapid, shallow breathing = hyperventilation to counteract metabolic acidosis · Fruity, acetone odor on breath Lab workup and findings · Hyperglycemia: > 250 mg/dL in serum, + glucose on urinalysis · Acidemia (pH <7. Continue reading >>
Diabetic Ketoacidosis
What is diabetic ketoacidosis? Diabetic ketoacidosis (DKA) is a life-threatening condition caused by a build-up of waste products called ketones in the blood. It occurs in people with diabetes mellitus when they have no, or very low levels of, insulin. DKA mostly occurs in people with type 1 diabetes, but it can also occur in some people with type 2 diabetes and pregnant women with gestational diabetes. Causes Glucose is an essential energy source for the body's cells. When food containing carbohydrates is eaten, it is broken down into glucose that travels around the body in the blood, to be absorbed by cells that use it for energy. Insulin works to help glucose pass into cells. Without insulin, the cells cannot absorb glucose to use for energy. This leads to a series of changes in metabolism that can affect the whole body. The liver attempts to compensate for the lack of energy in the cells by producing more glucose, leading to increased levels of glucose in the blood, also known as hyperglycaemia. The body switches to burning its stores of fat instead of glucose to produce energy. This leads to a build-up of acidic waste products called ketones in the blood and urine. This is known as ketoacidosis, and it can cause heart rhythm abnormalities, breathing changes and abdominal pain. The kidneys try to remove some of the excess glucose and ketones. However, this requires taking large amounts of fluid from the body, which leads to dehydration. This can cause: Increased concentration of ketones in the blood, worsening the ketoacidosis; Loss of electrolytes such as potassium and salt that are vital for the normal function of the body's cells, and; Signs and symptoms Symptoms of DKA can develop over the course of hours. They can include: Increased thirst; Increased frequency Continue reading >>
Cardiovascular Complications Of Ketoacidosis
US Pharm. 2016;41(2):39-42. ABSTRACT: Ketoacidosis is a serious medical emergency requiring hospitalization. It is most commonly associated with diabetes and alcoholism, but each type is treated differently. Some treatments for ketoacidosis, such as insulin and potassium, are considered high-alert medications, and others could result in electrolyte imbalances. Several cardiovascular complications are associated with ketoacidosis as a result of electrolyte imbalances, including arrhythmias, ECG changes, ventricular tachycardia, and cardiac arrest, which can be prevented with appropriate initial treatment. Acute myocardial infarction can predispose patients with diabetes to ketoacidosis and worsen their cardiovascular outcomes. Cardiopulmonary complications such as pulmonary edema and respiratory failure have also been seen with ketoacidosis. Overall, the mortality rate of ketoacidosis is low with proper and urgent medical treatment. Hospital pharmacists can help ensure standardization and improve the safety of pharmacotherapy for ketoacidosis. In the outpatient setting, pharmacists can educate patients on prevention of ketoacidosis and when to seek medical attention. Metabolic acidosis occurs as a result of increased endogenous acid production, a decrease in bicarbonate, or a buildup of endogenous acids.1 Ketoacidosis is a metabolic disorder in which regulation of ketones is disrupted, leading to excess secretion, accumulation, and ultimately a decrease in the blood pH.2 Acidosis is defined by a serum pH <7.35, while a pH <6.8 is considered incompatible with life.1,3 Ketone formation occurs by breakdown of fatty acids. Insulin inhibits beta-oxidation of fatty acids; thus, low levels of insulin accelerate ketone formation, which can be seen in patients with diabetes. Extr Continue reading >>
Diabetic Ketoacidosis
What is diabetic ketoacidosis? Diabetic ketoacidosis, or DKA, is a serious health problem that can happen to a person with diabetes. It happens when chemicals called ketones build up in the blood. Normally, the cells of your body take in and use glucose as a source of energy. Glucose moves through the body in the bloodstream. Insulin is a hormone that helps your cells take in the glucose from the blood. If you have diabetes, your cells can’t take in and use this glucose in a normal way. This may be because your body doesn’t make enough insulin. Or it may be because your cells don’t respond to it normally. As a result, glucose builds up in your bloodstream and doesn’t reach your cells. Without glucose to use, the cells in your body burn fat instead of glucose for energy. When cells burn fat, they make ketones. High levels of ketones can poison the body. High levels of glucose can also build up in your blood and cause other symptoms. Ketoacidosis also changes the amount of other substances in your blood. These include electrolytes, such as sodium, potassium, and bicarbonate. This can lead to other problems. Ketoacidosis happens most often in a person with type 1 diabetes. This is a condition where the body does not make enough insulin. In rare cases, ketoacidosis can happen in a person with type 2 diabetes. It can happen when they are under stress, like when they are sick, or when they have taken certain medicines that change how their bodies handle glucose. Diabetic ketoacidosis is pretty common. It is more common in younger people. Women have it more often than men do. What causes diabetic ketoacidosis? High levels of ketones and glucose in your blood can cause ketoacidosis. This might happen if you: Don’t know you have diabetes, and your body is breaking down Continue reading >>
Diabetic Ketoacidosis Causes, Symptoms, Treatment, And Complications
Diabetic ketoacidosis definition and facts Diabetic ketoacidosis is a life-threatening complication of type 1 diabetes (though rare, it can occur in people with type 2 diabetes) that occurs when the body produces high levels of ketones due to lack of insulin. Diabetic ketoacidosis occurs when the body cannot produce enough insulin. The signs and symptoms of diabetic ketoacidosis include Risk factors for diabetic ketoacidosis are type 1 diabetes, and missing insulin doses frequently, or being exposed to a stressor requiring higher insulin doses (infection, etc). Diabetic ketoacidosis is diagnosed by an elevated blood sugar (glucose) level, elevated blood ketones and acidity of the blood (acidosis). The treatment for diabetic ketoacidosis is insulin, fluids and electrolyte therapy. Diabetic ketoacidosis can be prevented by taking insulin as prescribed and monitoring glucose and ketone levels. The prognosis for a person with diabetic ketoacidosis depends on the severity of the disease and the other underlying medical conditions. Diabetic ketoacidosis (DKA) is a severe and life-threatening complication of diabetes. Diabetic ketoacidosis occurs when the cells in our body do not receive the sugar (glucose) they need for energy. This happens while there is plenty of glucose in the bloodstream, but not enough insulin to help convert glucose for use in the cells. The body recognizes this and starts breaking down muscle and fat for energy. This breakdown produces ketones (also called fatty acids), which cause an imbalance in our electrolyte system leading to the ketoacidosis (a metabolic acidosis). The sugar that cannot be used because of the lack of insulin stays in the bloodstream (rather than going into the cell and provide energy). The kidneys filter some of the glucose (suga Continue reading >>
