CASE 1 A 48-year-old male presents to the clinic because of concerns about heart disease.

He reports that his father died from a heart attack at age 46, and his older brother has also had a heart attack at age 46 but survived and is on medications for elevated cholesterol. The patient reports chest pain occasionally with ambulation around his house and is not able to climb stairs without significant chest pain and shortness of breath. The physical exam is normal, and the physician orders an electrocardiogram (ECG), exercise stress test, and blood work. The patients cholesterol result comes back as 350 mg/dL (normal 200). The physician prescribes medication, which he states is directed at the ratelimiting step of cholesterol biosynthesis. What is the rate-limiting step of cholesterol metabolism? What is the class of medication prescribed?
Seorang pria 48-tahun pergi ke klinik karena kekhawatiran tentang penyakit jantung. Dia melaporkan bahwa ayahnya meninggal karena serangan jantung pada usia 46, dan kakaknya juga mengalami serangan jantung pada usia 46 tetapi selamat dan ada di obat untuk kolesterol tinggi. Pasien melaporkan nyeri dada kadang-kadang dengan ambulasi sekitar rumahnya dan tidak mampu menaiki tangga tanpa nyeri dada yang signifikan dan sesak napas. Pemeriksaan fisik normal, dan perintah dokter elektrokardiogram (EKG), uji latihan stres, dan kerja darah. Hasilnya kolesterol pasien kembali sebagai 350 mg / dL (normal 200). Dokter meresepkan obat, yang menyatakan diarahkan pada langkah ratelimiting apa yang terjadi Apa obat yang diresepkan? biosintesis pada metabolisme kolesterol. kolesterol?

CASE 2 Lofata Burne is a 16-year-old girl. Since age 14 months she has experienced recurrent episodes of profound fatigue associated with vomiting and increased perspiration, which required hospitalization. These episodes occurred only if she fasted for more than 8 hours. Because her mother gave her food late at night and woke her early in the morning for breakfast, Lofatas physical and mental development had progressed normally.On the day of admission for this episode, Lofata had missed breakfast, and by noon she was extremely fatigued, nauseated, sweaty, and limp. She was unable to hold any food in her stomach and

was rushed to the hospital, where an infusion of glucose was started intravenously. Her symptoms responded dramatically to this therapy. Her initial serum glucose level was low at 38 mg/dL (reference range for fasting serum glucose levels _ 70100). Her blood urea nitrogen (BUN) level was slightly elevated at 26 mg/dL (reference range _ 825) as a result of vomiting, which led to a degree of dehydration. Her blood levels of liver transaminases were slightly elevated, although her liver was not palpably enlarged. Despite elevated levels of free fatty acids (4.3 mM) in the blood, blood ketone bodies were below normal. What happened with Lofata Burne? Lofata Burne adalah seorang gadis 16-tahun. Sejak usia 14 bulan dia telah mengalami gagngguan berulang kelelahan mendalam terkait dengan muntah dan keringat meningkat, yang diperlukan rawat inap. Episode ini terjadi hanya jika ia berpuasa selama lebih dari 8 jam. Karena ibunya memberi makanannya larut malam dan bangun awal di pagi hari untuk sarapan, pengembangan Lofata fisik dan mental telah berkembang normally.On hari masuk untuk episode ini, Lofata telah melewatkan sarapan, dan pada tengah hari dia sangat lelah, mual, berkeringat, dan lemas. Dia tidak mampu menahan makanan di perutnya dan dilarikan ke rumah sakit, infus glukosa dimulai intravena. Gejalanya menanggapi secara dramatis untuk terapi ini. Tingkat glukosa serum awal-nya rendah pada 38 mg / dL (referensi jangkauan untuk puasa kadar glukosa serum _ 70-100). Nitrogen urea darah nya (BUN) tingkat yang sedikit lebih tinggi pada 26 mg / dL (referensi kisaran _ 8-25) sebagai akibat dari muntah, yang menyebabkan tingkat dehidrasi. Darahnya tingkat transaminase hati yang sedikit lebih tinggi, meskipun hatinya tidak dgn jelas diperbesar. Meskipun peningkatan kadar asam lemak bebas (4,3 mM) dalam darah, darah badan keton berada di bawah normal. Apa yang terjadi dengan Lofata Burne?

CASE 3 A 63-year-old female presents to the clinic with recurrent midepigastric pain over the last 3 months. She reports some relief shortly after eating, but then the discomfort returns. She has tried various over-the-counter medications without relief. She also reports feeling tired and has had to increase the amount of ibuprofen needed for relief of her arthritis. She denies nausea, vomiting, and diarrhea. On exam she is found to have mild midepigastric tenderness and guaiac positive stool. A CBC revealed a microcytic anemia and normal white blood cell count, consistent with iron deficiency. The patient was referred to a gastroenterologist who performed an upper GI endoscopy that identified gastric ulcers. He stated that he suspected that the ibuprofen, a nonsteroidal antiinflammatory drug (NSAID) was the causative agent and suggested switching from ibuprofen to a coxib, such as celecoxib. What is the likely biochemical etiology of the disorder?

 Why do coxibs generally have a lower incidence of upper GI problems than other NSAIDs? What is the major difference between aspirin and other NSAIDs with regard to platelet function?
seorang perempuan 63th pergi ke klinik dengan rasa sakit midepigastric berulang selama 3 bulan terakhir. Ia melaporkan beberapa bantuan segera setelah makan, tapi kemudian kembali ketidaknyamanan. Dia telah mencoba berbagai over-the-counter obat tanpa bantuan. Dia juga melaporkan merasa lelah dan telah meningkatkan jumlah ibuprofen diperlukan untuk menghilangkan radang sendinya. Ia menyangkal mual, muntah, dan diare. Pada ujian ia ditemukan memiliki kelembutan midepigastric ringan dan tinja positif guaiac. CBC Sebuah mengungkapkan anemia mikrositik dan normal jumlah sel darah putih, konsisten dengan kekurangan zat besi. Pasien dirujuk ke seorang pencernaan yang melakukan suatu endoskopi GI atas yang diidentifikasi tukak lambung. beralih dari dengan fungsi trombosit? Dia menyatakan bahwa dia ke menduga coxib, kemungkinan bahwa ibuprofen, obat antiinflamasi nonsteroid (OAINS) merupakan agen penyebab dan menyarankan dari ibuprofen etiologi biokimia seperti gangguan celecoxib. tersebut? lainnya? Apakah

Mengapa coxib umumnya memiliki insiden lebih rendah dari masalah GI atas NSAID Apakah perbedaan utama antara aspirin dan NSAID lainnya sehubungan

CASE 4 Diana, a 27-year-old woman with type 1 diabetes mellitus, had been admitted to the hospital in a ketoacidotic coma a year ago. She had been feeling drowsy and had been vomiting for 24 hours before that admission. At the time of admission, she was clinically dehydrated, her blood pressure was low, and her breathing was deep and rapid (Kussmaul breathing). Her pulse was rapid, and her breath had the odor of acetone. Her arterial blood pH was 7.08 (reference range, 7.367.44), and her blood ketone body levels were 15 mM (normal is approximately 0.2 mM for a person on a normal diet). What happened with Diana? Diana, seorang wanita 27-tahun dengan diabetes mellitus tipe 1, telah dirawat di rumah sakit dalam keadaan koma ketoacidotic tahun lalu. Dia telah merasa mengantuk dan telah muntah selama 24 jam sebelum masuk itu. Pada saat pendaftaran, ia secara klinis dehidrasi, tekanan darahnya rendah, dan napasnya dalam dan cepat (pernapasan Kussmaul). Denyut nadinya cepat, dan napas memiliki bau aseton. PH darah arteri nya adalah 7.08 (referensi kisaran,

7,36-7,44), dan kadar keton tubuhnya adalah 15 mM (normal adalah sekitar 0,2 mM untuk orang pada diet normal). Apa yang terjadi dengan Diana?

CASE 5 Since her admission to the hospital for an acute myocardial infarction, Ann Jeina has been taking the bile salt sequestrant cholestyramine and the HMG-CoA reductase inhibitor pravastatin to lower her blood cholesterol levels. She also takes 160 mg acetylsalicylic acid (ASA; aspirin) each day. At her most recent visit to her cardiologist, she asked whether she should continue to take aspirin because she no longer has any chest pain. She was told that the use of aspirin in her case was not to alleviate pain but to reduce the risk of a second heart attack and that she should continue to take this drug for the remainder of her life unless a complication, such as gastrointestinal bleeding, occurred as a result of its use. What happened with Ann Jeina? Sejak masuk ke rumah sakit untuk infark miokard akut, Ann Jeina telah mengambil garam empedu cholestyramine sekuestran dan HMG-CoA reduktase inhibitor pravastatin untuk menurunkan kadar kolesterol darahnya. Dia juga mengambil 160 mg asam asetilsalisilat (ASA; aspirin) setiap hari. Pada kunjungannya yang terakhir ke ahli jantung, dia ditanya apakah dia harus terus minum aspirin karena dia tidak lagi memiliki rasa sakit dada. Dia diberitahu bahwa penggunaan aspirin dalam kasusnya tidak untuk mengurangi rasa sakit tetapi untuk mengurangi risiko serangan jantung kedua dan bahwa ia harus terus mengambil obat ini selama sisa hidupnya kecuali komplikasi, seperti pendarahan gastrointestinal, terjadi sebagai akibat dari penggunaannya. Apa yang terjadi dengan Ann Jeina?

CASE 6 hospitalization Emma Wheezer has done well with regard to her respiratory function since her earlier for an acute asthmatic attack. She has been maintained on two puffs of triamcinolone acetonide, a potent inhaled corticosteroid, three times per day, and has not required systemic steroids for months. The glucose intolerance precipitated by high intravenous and oral doses of the synthetic glucocorticoid dexamethasone during her earlier hospitalization resolved after this drug was discontinued. She has come to her doctor now because she is concerned that the low-grade fever and cough she has developed over the last 36 hours may trigger another acute asthma attack. What happened with Emma Wheezer?
Emma wheeze menjalani rawat inap, berkaitan dengan fungsi pernapasan sejak awal dia untuk serangan asma akut. Dia telah dipertahankan pada dua

gumpalan triamcinolone acetonide, sebuah inhalasi kortikosteroid kuat, tiga kali per hari, dan tidak diperlukan steroid sistemik selama berbulan-bulan. Para intoleransi glukosa dipicu oleh dosis intravena dan oral tinggi dari deksametason glukokortikoid sintetik selama rawat inap sebelumnya dia sembuh setelah obat ini dihentikan. Dia telah datang ke dokter sekarang karena ia khawatir bahwa demam ringan dan batuk dia telah berkembang selama 36 jam terakhir dapat memicu serangan asma akut. Apa yang terjadi dengan Emma Wheezer?