Type-2 DM with ulcer over right foot
A 48-year-old female patient with Type-2 Diabetes Mellitus and Essential Hypertension presents with an ulcer over her right foot. This case delves into her medical history, chief complaints, laboratory investigations, and diagnosis, highlighting the complexities of managing diabetes in combination with hypertension and foot ulcers.
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Presentation Transcript
Case presentation on Type-2 DM with ulcer over right foot with Essential hypertension.
SENARIO: Here is a 48 years old female patient hospitalized for 10days. 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 4 150/100 140/90 142/88 130/90 120/80 130/80 136/80 130/80 130/80 140/80 BP Puls e 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 positive Ciprofloxacin-500mg 1-0-1 DIAGNOSIS: 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 Dosage Type-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. 0.5-1mg/day -Biguanides Metformin: it enhances insulin sensitivity of both hepatic and peripheral (muscle) tissues.it allows increased uptake of glucose into these insulin sensitive tissues 500mg BD Or 850mg OD -insulin 0.7-2.5units/kg/day
Problem Goals of treatment Drugs & MOA Dosage Hypertension -Blood pressure should be controlled -ARB blockers: Telmisartan: these inhibits the binding of AT-1 & AT-2 receptors there by inhibiting release of angiotensin. 20-80mg/day Ulcer on foot -to prevent infection and to promote wound healing -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. Amoxicillin-500mg BD Metronidazole 500mg BD Ceftriaxone 1gm TID
Plan: s. no T.name G.name dose 26 27 28 29 30 31 1 2 3 1. T.Triglimesta 1-0-1 Glimipride+m etformin+piog litazone 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+cl avulanic 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 interaction Increase 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 3.T.Ciplox 0-1-1x 15 days. Rablet should be added in discharge drugs. 1-0-1x15 days. 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 months 8.Never skip meals and if hypoglcemia occurs symptoms are sweating,weakness,confusion,palpitation and giddiness. Then have a fruit juice or a chocolate 9.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.
