Case presentation on Type-2 DM with ulcer over right foot with Essential hypertension. - PowerPoint Presentation

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Case presentation on Type-2 DM with ulcer over right foot with Essential hypertension.

SENARIO: Here is a 48 years old female patient hospitalized for10days.

CHIEF COMPLAINTS:

Ulcer over right foot since 2 months

C/o pain on sole of right foot

Loss of sensation over sole of both feet.

History of present illness:

Patient got a prick on sole of right foot by piece of glass

before 2 months and pain on the sole of right foot.

PAST MEDICAL HISTORY:K/c/o Type-2 Diabetes mellitus from 20 years. k/c/o Hypertension since 4years

PAST MEDICATION HISTORY

:

Tb. Metformin + voglibose + Glimipride regularly.Tb.Amlodipine LABORATORY INVESTIGATIONS:

CBC

Values

ESR

100 mm/hr

MCV

78.2 fl

MCH

24.8 g/dl

MCHC

31.7 g/dl

Na

129meq/

lt

Sugar (urine)

1.5%

Other investigations:ECG- sinus tachycardia

culture sensitivity-

enterococcus

sensitivity (positive) ciprofloxacin 500mg 1-0-1

Date

26/1

27

28

29

30

31

1

2

3

4

BP

150/100

140/90

142/88

130/90

120/80

130/80

136/80

130/80

130/80

140/80

Pulse

84

85

86

72

78

122

82

82

80

84

R.B.S

268

369

172

180

132

122

107

92

98

89

SOAP NOTE:SUBJECTIVE: Here is a 48 years old female patient presenting complaints of ulcer over right foot since 2months, pain on sole of right foot . Loss of sensation over sole of both feet.

OBJECTIVE:

BP on the day of admission was 150/100mm hg

Increase in BP indicates hypertension. R.B.S. On the day of admission is 268 mg/dl.Increased it indicates hyperglycemia.CBC:ESR-100 mm/hr. increased., due to infection or inflammation.

MCV-78.2 fl decreased usually occurs in iron deficiency

anemia

.

MCHC-24.8 decreased due to iron deficiency

anemia

.

Hyponatremia is due to osmotic losses due to polyuria

.

ECG: Sinus tachycardia.

Culture sensitivity: Enterococcus sensitive – positiveCiprofloxacin-500mg 1-0-1DIAGNOSIS:Type-2 DM with essntial hypertension with ulcer over right foot.

ASSESSMENT:

Problem lists:

Type-2 DM:

It is due to the insulin resistance and relative insulin deficiency.

Essential hypertension:Hyperinsulinemia occurs in type -2 Diabetes due to peripheral insulin resistance this may be associated with excess of sodium conservation in the body predisposing hypertension

it is due to increase in sodium renal tubular absorption and increase in

osmolarity

in uncontrolled state of diabetes.Ulcer on foot:This is due to injury by glass piece which was infected.

Problem

Goals of treatment

Drugs & MOA

DosageType-2 Diabetes Mellitus-To ameliorate symptoms of hyperglycemia

, reduce the onset and progression of

microvascular

&

macrovascular

complications

-reduce mortality.

-

sulfonylureas

Glimepride

: it exerts

hypoglycemic

action by stimulating pancreatic secretion of insulin.

-

Biguanides

Metformin: it enhances insulin sensitivity of both hepatic and peripheral (muscle)

tissues.it

allows increased uptake of glucose into these insulin sensitive tissues

-insulin

0.5-1mg/day

500mg BD

Or 850mg OD

0.7-2.5units/kg/day

Problem

Goals of treatment

Drugs

& MOADosageHypertension

Ulcer on foot

-

Blood pressure should be controlled

-to

prevent infection and to promote wound healing

-ARB

blockers:

Telmisartan: these inhibits the binding of AT-1 & AT-2 receptors there by inhibiting release of angiotensin.

-Antibiotics:

Staphylococcus is the commonest organism & hence

penicillinase

resistant antibiotics are the drug of

choice.for

gram –

ve

ampicillin

, cephalosporins are given, for anaerobic infections

Metronidazole

.

20-80mg/day

Amoxicillin-500mg BD

Metronidazole

500mg BD

Ceftriaxone 1gm TID

Plan:

s.no

T.name

G.namedose

26

27

28

29

30

31

1

2

3

1.

T.Triglimesta

1-0-1

Glimipride+metformin+pioglitazone

2mg+8mg+7.5

y

y

y

y

y

y

y

y

y

2.

T.Telmikind

1-0-0

telmisartan

40mg

y

y

y

y

y

y

y

y

y

3.

Mixtars

S/C

15-0-10

H.insulin

30/70

y

y

y

y

y

y

y

y

y

4.

T.Accuclav

1-1-1

Amoxicillin+clavulanic

625mg

y

y

y

y

y

5.

T.Rantac

1-1-1

rantidine

150mg

y

y

y

y

y

y

y

y

6.

T.Tramadan

1-0-1

tramadol

50mg

y

y

y

y

y

y

y

y

7.

T.Neurolac

0-0-1

multivitamin

y

y

y

y

y

y

y

y

8.

T.Ciplox

1-0-1

ciprofloxacin

500mg

y

y

y

Drug interactions:1. Antibiotic is not indicated for foot ulcer.

2.metformin/

pioglitazone

+rantidine =Moderate interactionIncrease in metformin plasma concentraion. (hypoglycemia)2.Ciprofloxacin+anti-diabetic (

triglimestar

)= major interaction

Change in glucose level (

hypoglycemia

/

hyperglycemia

).

3.pioglitazone+insulin- Contraindicated in UK because of reports of cardiac

failure.

If

pioglitazone

15mg is given the dose of insulin to be reduced by 10-25%

Discharge drugs:

1.T.Amlong – 1-0-0 x 15 days.

2.

T.triglimestar

1-0-1x15 days.

3.T.Ciplox 0-1-1x 15 days.

Rablet should be added in discharge drugs.

Patient counselling:

1.Take high

fiber

diet.

2.Avoid foods rich in

sugars,fats

.

3.Monitor your blood glucose and blood pressure levels regularly.4.Strict medication adherence should be followed.

5.Regular exercise aerobic exercise for 30 min atleast 5 times a week

6.Salt restriction up to 2g/day

7. Eye checkup for every 6 months8.Never skip meals and if hypoglcemia occurs symptoms are sweating,weakness,confusion,palpitation and giddiness. Then have a fruit juice or a chocolate9.Restrict calorie intake , maintain ideal body weight.

Drug counselling:

1.Amlodipine should be taken in the morning after breakfast.

2.Triglimestar to be taken 30min before meals.

3.Ciprofloxacin should be taken after food.

4.Avoid milk.