GANGRENE ON LEFT

GREAT TOE, DIABETES

MELLITUS 2 AND

HYPERTENSION

Amarnath Mullapudi

14PPM2037

NIPER-Mohali1

Chief complaints

2

Wound on left great toe x 1 month

Pain of left foot x 2 month

Bleeding of left great toe x 1 month

Past history

3

K/C/O of colitis and gastric bleeding

Diabetes mellitus type 2

Hypertension

Chronic kidney disease

Patient details

4

Age : 81 years

Sex : Female

Weight : 68 kgs

BP : 140/90 mmHg

HR : 80 beats/minute

RR : 22/minute

Laboratory investigations

5

Lab investigation - 1

6

PARAMETER DAYS

Hb

12-18 gm%

D1 D3 D5 D7 D8

10.1 9.0 - 8.1 -

D9 D10 D12 D14 D15

8.8 8.1 - 9.7 -

Platelets (×103)

1.5-4lakhs/µl

D1 D3 D5 D7 D8

523 477 - 494 -

D9 D10 D12 D14 D15

581 588 - 602 -

Lab investigation - 2

7

PARAMETER DAYS

Prothrombin

time

(Control 13 secs)

D1 D3 D5 D7 D8

18 17 - 15 17

D9 D10 D12 D14 D15

- 17 - - 17

PT Index (%)

D1 D3 D5 D7 D8

72 76 - 86 76

D9 D10 D12 D14 D15

- 76 - - 76

Lab investigation - 3

8

PARAMETER DAYS

INR

0.8-1.4

D1 D3 D5 D7 D8

1.35 1.3 - 1.16 1.3

D9 D10 D12 D14 D15

1.3 - - - 1.28

TLC (×102)

4-10.5 k/mm3

D1 D3 D5 D7 D8

114 145 - 131 -

D9 D10 D12 D14 D15

122 120 - 101 -

Lab investigation - 4

9

PARAMETER DAYS

Na+

135-145mEq/L

D1 D3 D5 D7 D8

132 130 136 137 137

D9 D10 D12 D14 D15

136 137 130 - 130

K+

3.5-5.2mEq/L

D1 D3 D5 D7 D8

4.2 4.1 3.9 3.7 4.0

D9 D10 D12 D14 D15

3.9 3.9 4.2 - 4.5

Lab investigation - 5

10

PARAMETER DAYS

Cl-

95-105mEq/L

D1 D3 D5 D7 D8

97.7 98 98 93.9 97.8

D9 D10 D12 D14 D15

116 100.1 98 - 99

Urea

10-50mg%

D1 D3 D5 D7 D8

31.9 31.9 26 19.7 17.7

D9 D10 D12 D14 D15

16 15.9 18 - 19

Lab investigation - 6

11

PARAMETER DAYS

Creatinine

0.6-1.2mg%

D1 D3 D5 D7 D8

3.3 3.3 3.2 3.2 2.8

D9 D10 D12 D14 D15

2.5 3.3 1.7 2.4 2.8

Ca++

8.5-10.5mg/dl

D1 D3 D5 D7 D8

9.6 9.8 8.9 9.2 9.5

D9 D10 D12 D14 D15

10.2 9.6 9.1 9.8 9.5

Lab investigation - 7

12

PARAMETER-- DAYS

Albumin

3.4-4.8gm/dl

D1 D3 D5 D7 D8

2.9 3.7 3.0 3.1 3.3

D9 D10 D12 D14 D15

- 3.1 - - -

Protein (T)

6.4-8.3gm/dl

D1 D3 D5 D7 D8

- 7.27 6.7 6.85 6.89

D9 D10 D12 D14 D15

- 6.96 - - -

Diagnosis

13

Gangrene on left toe with pain and bleeding

Diabetes mellitus type 2

Hypertension

Medication charts

14

Medication chart - 1

15

Drug ROA Dose Freq. Days

CefuroximePO 500mg OD D1-D6

Amoxicillin + Clavulinic

acid PO 625mg

12

hourlyD1-D15

Cefprozil PO 500mg BD D1-D6

Atrovostatin PO 20mg OD D1-D15

Valerian PO 40mg BD D1-D15

Medication chart - 2

16

Drug ROA Dose Freq. Days

Amlodipine PO 2.5mg OD D1-D15

Alprazolam PO 0.25mg TDS D4-D15

Telmisartan +

hydrochlorothiazidePO

40 &

12.5mgOD D4-D12

Erythropoietin SC 10,000

IU

weekly D1&D8

Tramadol + paracetamol PO37.5 &

325mgBD D6-D15

Medication chart - 3

17

Drug ROA Dose Freq. Days

Cilostazol PO 50mg TDS D3-D15

Acetaminophen + codeine PO650mg +

30mg8 hourly D1-D6

Metoprolol PO 12.5mg OD D1-D15

Becosule PO 1 cap OD D1-D15

Insulin R SC 15 U TDS D1-D15

Pharmaceutical issues

18

Drug duplication

Cefprozil and Cefuroxime two drugs of the same class are

administered.

Contraindication

Patient has a past history of colitis and gastric bleeding. Cefuroxime

and Cefprozil are contraindicated in this case.

Suggestion: Replace Cefuroxime with Clindamycin in the dose of

300mg BD. Clindamycin can be administered to the patients who has

severe skin and subcutaneous infections.

Source : Micromedex

Summary

19

A 81 years old female was admitted into the hospital

with the following complaints:

Pain and gangrene on the left great toe with bleeding.

She has history of DM-2 and hypertension.

She was diagnosed with gangrene on left great toe.

She was administered antihypertensives, antibiotics,

NSAIDs, anticoagulant, insulin and alprazolam.

Summary cont…

20

Pharmaceutical issues

Drug duplication of cephalosporin antibiotics

Contraindication; administration of cefprozil and

cefuroxime to the patient suffering from colitis.

References

21

Viswanathan V. Epidemiology of diabetic foot and

management of foot problems in India. Int J Low Extrem

Wounds. 2010;9:122–6.

Gadepalli R, Dhawan B, Sreenivas V, Kapil A, Ammini AC,

Chaudhry R. A clinico-microbiological study of diabetic foot

ulcers in an Indian tertiary care hospital. Diabetes

Care. 2006;29:1727–32.

Pendsey SP. Understanding diabetic foot. Int J Diabetes Dev

Ctries 2010 Jun;30(2):75–79.