About the patient with Diabetes mellitus and ketoacidosis with abscess, his treatment plan, goals of treatment, monitoring parameters, drug interactions, patient counseling, precautions

1. Gluteal Abscess with
Diabetes Mellitus and
Diabetic Ketoacidosis
By
Goutham Kondeti
611271602008

2. Patient profile form:
Name: K.Srinivas
Gender:
Male
Age: 32
Unit: General Medicine M1
RegdNo: 110472
DOA: 24/12/12

3. Complaint:
Swelling on Right side gluteal region, pain in gluteal
region.
Past Medical History:
Known Diabetes Melllitus Type-ii Since 5 Years on
Insulin

4. Pharmaceutical care Plan :
Subjective Evidence:
Swelling on right side Gluteal region, Pain in Gluteal region and known
Diabetes mellitus Type-II since five years.
Objective Evidence:
Ketonuria, Blood Urea, SerumCreatinine, HIV,HPS,HCV and Random Blood
Sugar Test

5. Lab Reports:
Urine ketone bodies-+ve Haemoglobin-9gm% Totalcount-7200
Differential count: P-51% L-42% E-0.7% ESR-40ml/hr
Serum creatinine:0.7mg/dl Blood Urea:35mg/dl RBS-317mg/dl
HIV: -ve hPS:-ve HCV :-ve

6. Gluteal Abscess with Diabetes Mellitus
and Diabetic KetoAcidosis

7. About Disease
Gluteal Abscess:
An abscess is a collection of pus, a thick fluid which contains white blood cells, dead tissue and bacteria. On
appearance, an abscess will be a hard lump surrounded by inflamed tissue. They can develop any where on the body,
but commonly occur under the skin close to the anus – known as a gluteal abscess.
Therefore a gluteal abscess does not grow in the anus itself (a perianal abscess) but below it. To be precise, they
form under the skin on the subcutaneous plane of the gluteal muscle. This usually occurs when the glands in the
perianal area become infected. However, a gluteal abscess may also arise from the necrosis of fat in the buttock, which
is caused by repeated trauma to the tissue(for example,from frequent injections).

8.  Pain around the buttocks
 Red, inflamed tissue around the buttocks which is hot
to touch
 An upset stomach
 Diarrhoea and vomiting
 Fever.
Symptoms of Gluteal Abscess

9. Diabetes mellitus Type-2 :
Diabetes Mellitus is a Chronic disorder that disrupts the way our uses glucose
All the cells in our body needs sugar to work normally . Sugar enters in to cells with help of harmone called Insulin. If there is
not enough insulin or if body stops responding to insulin, sugar builds up in the blood . In type-2 Diabetes, the pancreas doesnot
make enough insulin, the body becomes resistant to normal or high levels of insulin or both. It can be diagnosed by Random
blood sugar test, Fasting blood sugar test, Haemoglobin A1C test , Oral glucose tolerance test.
It leads to acute complications like Diabeticketoacidosis and chronic complications like Atherosclerosis,Coronary heart
diseases, DiabeticRetinopathy, DiabeticNeuropathy, Cataract, DiabeticNephropathy

10. Diabetic Ketoacidosis:
When there is no insulin in the body, glucose (sugar) cannot be used and the body breaks
down fat for energy. When fat breaks down, acids (ketones) build up in the blood. Very
high levels of glucose and high levels of acids lead to severe loss of body fluids
(dehydration) and other dangerous chemical changes. This stresses your vital organs and
can cause coma or death.
Symptoms
Tiredness (fatigue), Weight loss, Excessive thirst, Ketones in the urine, Lightheadedness, Fruity
or sweet smell on your breath, Excessive urination, Visual changes, Confusion or irritability,
Feeling sick to your stomach (nauseous) or vomiting, Rapid breathing, Stomachache or belly
(abdominal) pain,Hypotensiom,Tachycardia.

11. Goals of Treatment:
 The primary goal to be achieved is to maintain the normal blood glucose levels.
 To decrease pain in the gluteal region ,inflammation.
 To maintain B.P values at 130/80
.
 To decreasebreak down of fatty acids.
 To avoid complications like Hypoglycemia, Cardio vascular diseases,DiabeticNeuropathy, Diabetic
Nephropathy, Diabetic Retinopathy,Diabetic Foot e.t.c

12. Treatment Options:
Antibiotics:
 Ceftriaxone
 Nalidixic Acid
 Doxycycline
 Rifampin
 Cefperazone
 Amikacin
 Levofloxacin
 Linezolid
 Metronidazole

13. Anti Inflammatory drugs:
 Serratiopeptidase
 Paracetamol
Anti Ulcerative drugs:
 Pantoprazole
 Fluid Replacement therapy
 Electrolyte Replacement Therapy
Tramadol

14. There are six types of pills and non insulin medicines routinely used to treat type 2 diabetes:
Metformin:
Pills that reduce sugar productionfrom the liver
Thiazolidinediones (glitazones):
Pills that enhancesugar removal from the blood stream
Insulin releasing pills (secretagogues):
Pills that increaseinsulin releasefrom the pancreas
Starch blockers
Pills that slow starch (sugar) absorption from the gut
Incretin based therapies:
Pills and injectionsthat reduce sugar production in the liver and slow the absorptionof food
Non-insulin Treatment for Type 2 Diabetes –
Amylin analogues:
Injectionsthat reduce sugar productionin the liver and slow the absorption of food
insulin also may be used to treat type 2 diabetes:

15. Drug Class Drug Name Brand Name Mechanism of Action
Biguanides Metformin Glucophage Inhibit glucose production by liver
Sulfonyl ureas Glimepiride
Glipizide
Glyburide
Amaryl
Glucotrol
Diabeta
Glynase Pres Tab
Micronase
Increase insulin secretion by
pancreatic beta cells
Meglitinides Repaglinide
Nateglinide
Prandin
Starlix
Increase insulin secretion by
pancreatic beta cells
Thiazolidinediones(
TZDs)
Pioglitazone
Rosiglitazone
Actos
Avandia
Increase glucose uptake by
skeletal muscle
Alpha-glucosidase
inhibitors
Acarbose
Miglitol
Precose
Glyset
Inhibit carbohydrate absorption in
the small intestine

16. Insulin Therapy:
Short-term use:
 Acute illness,surgery, stress and emergencies
 Pregnancy
 Breast-feeding
 Insulin may be used as initialtherapy in type 2 diabetes
 in marked hyperglycaemia
 Severe metabolicdecompensation (diabetic ketoacidosis,hyperosmolar nonketotic coma, lactic acidosis,severe
hypertriglyceridaemia)
Long-term use:
 If targetshave not been reached after optimal dose of combination therapy or BIDS,consider change to multi-doseinsulin
therapy. When initiatingthis,insulinsecretagogues should be stopped and insulinsensitiserse.g. Metforminor TZDs,can be
continued.

17. Rapid acting Insulins:
 Insulin Lispro
 Insulin Glulisine
Short acting Insulin:
 Regular Insulin
Intermediate acting Insulin:
 Lente insulin
Long acting Insulin:
 Ultralente Insulin
 Insulin Aspart
 Isophane insulin
 Insulin Glargine

18. Insulin type/action (appearance) Brand names
(generic name in
brackets)
Basal/bolus Dosing shedule
Rapid –acting analogue(clear)
Onset:10-15minutes
Peak:60-90minutes
duration:4-5hours
Humalog
(insulin lispro)
NovoRapid
(Insulin aspart)
Bolus Usually taken right before eating or to
lower high blood glucose
Short-acting (clear)
Onset:0.5-1hour
Peak:2-4hours
Duration:5-8hours
Humulin-R
Novolin ge Toronto
Bolus Taken about 30 minutes before
eating, or to lower high blood glucose
Intermediate-acting (cloudy)
Onset:1-3hours
Peak:5-8hours
Duration: up to18hours
Humulin-N
Novolin ge NPH
Basal Often taken at bedtime, or twice a
day (morning and bed time)
Extended long acting analogue (clear and
colourless)
Onset:90minutes
Peak: none
Duration:24hours
Lantus
(insulin glargine)
Levemir
(insulin detemir)
Basal Usually taken once or twice a day
Premixed(cloudy)
A single vial contains a fixed ratio of insulins
(the numbers refer to the ratio of rapid-or
fast-acting to intermediate-acting insulin in
the vial)
Humalog Mix 25
Humulin (20/80,30/70)
Novolin
ge(10/90,20/80,30/70,40/6
0,50/50)
Combination of
basal and bolus
insulins
Depends on the combination

19. Assessment:
1. Here Antibiotics are preferred as the patient is
presented with infection in gluteal region
2.Here Anti Inflammatory drugs are preferred to
reduce the inflammation caused in Gluteal region.
3.Anti Ulceratives are preferred as the other
medications may cause GI disturbances
4.Fluid replacement is preferred to replace the
fluid due to DKA and also to dilute the blood
glucose concentration.

20. 5.Electrolyte replacement is preferred as
the insulin is low electrolytes will be low.
6.Here non insulin and insulin
medications are preffered as the patient is
presented with Diabetes Mellitus and
Diabetic Ketoacidosis.
7.Insulin therapy is used until our blood
sugar value falls below 240mg/dl.

21. Day:1
 Patient is conscious or coherent
 PulseRate: 78/min
 RBS: 306mg/dl
 P/A:Soft
 Urine Ketone Bodies+ve
 Monitor RBS 8th hourly
 BloodPressure: 130/90
10:50pm-RBS:144mg/dl
 CVS:S1S2+
 RS: BAE+

22. Day-2
 Patient is concsious and coherent
 Pulse rate:98/min
 RS:NVBS
 CNS:B/L Pupils:NSRL
 Right Gluteal Abscess drained+ve
 Afebrile
 Blood pressure:120/80
 P/A:Soft
 Advised Daily dressing
 Monitor RBS 6th hrly

23. Day-3
 Patient is conscious and coherent Afebrile
 Pulse rate:n98/min Tongue dry
 CVS:S1S2+ RS:NVBS,BAE+
 P/A:Soft CNS:B/L Pupils:NSRL
 Right Gluteal Abscess Advice Daily dressing
 Urine ketone bodies+ve Monitor RBS 6th hrly

24. Day-4
 Patient is conscious and coherent
 Pulse rate:100/min B.P:130/80
 CVS:S1S2+ Lungs:clear
 P/A:Soft CNS:NFND
 Abscess on Right Gluteal region
RBS:291mg/dl

25. Day-5
 Patient is conscious and coherent C/O: Low fever
 No pain in the thigh Pulse rate:100/min
 Blood pressure:110/70 Afebrile P/A:Soft
 Swelling on the right thigh CVS:S1S2+

26. Day-6
 Patient is conscious or coherent Pulse rate:72/min
 Blood pressure:110/70 CVS:S1S2+
 RS:NVBS RBS:273mg/dl
 Advise Regular dressing

27. Day-7
 Patient is conscious and coherent
 Pulse rate:78/min Blood pressure:130/80
 RS:BAE+ CNS:NFND
 Urine ketone bodies +ve

28. Day-8
 Urine output adequate Pulse rate:78/min
 Blood pressure:120/70 CVS:S1S2+
 Lungs:B/L VBS+ P/A:Soft
 At 10:30am RBS-151mg/dl
 At 2:15pm RBS-375mg/dl

29. Day-9
 Patient is conscious or coherent Afebrile
 Pulse rate:82/min Blood pressure:110/70
 CVS:S1S2+ RS:NVBS
 CNS:B/L Pupils:NSRL
 P/A:Soft

30. Day-10
 Patient is conscious and coherent Afebrile
 Pulse rate:82/min Blood pressure:110/70
 CVS:S1S2+ RS:NVBS
 P/A:Soft

31. Inj,Plain Insulin100 IV stat
Inj.Plain Insulin 30units in 1 bottle NS @ 30drops/min
Inj.Ceftriaxone 500mg TID
Inj.Pantop 40mg IV OD
IV fluids
Inj.Plain Insulin SC TID
Inj.Metrogyl 100ml IV TID
Inj.Levofloxacin 500mg IV BD
Inj.Plain Insulin 30 units in 1 bottle NS @25drops/min
Inj.Sulbacef 1.5gms IV BD
20/20/16
Treatment Regimen:

32. IVF NS 3quarters 6drops/min
Inj.Pantop 40mg IV OD
Tab.Paracetamol 500mg TID
Inj.Amikacin 500mg IV BD
Tab. Tramadol 1 BD
Tab Paracetamol 1 BD
Tab Serratiopeptidase 1 TID
Inj.Plain Insulin 10 units in 1 bottle DS@8drops/min
Inj.Plain Insulin 30 units in 1 bottle NS@30drops/min
Inj.Plain Insulin SC TID
Tab.Serax Forte BD
18/18/15

33. About Drugs:
Inj.Plain Insulin: Plain Insulin is a short acting insulin starts working quickly in as little as
five minutes and wears off in 3 to 6 hours (sometimes longer). This type of insulin works well when taken
before a meal to bring your blood sugar quickly back to normal. It was given with normal saline when
RBS is more than 250mg/dl if it is less than that it was given with Dextrose 5% solution
Inj.Ceftriaxone: Ceftriaxone is an antibiotic used to treat a wide variety of bacterial infections. This
medication is known as a cephalosporin antibiotic .These inhibit bacterial cell wall synthesis. It is given
as 1 gm intravenously bis in a day. It is reconstituted with 9.6ml of NS or D5s and dilute with 50ml
of NS or D5s and given as infusion for 30 mins.

34. Inj.Amikacin: This medication is used to prevent or treat a wide variety of bacterial infections.
Amikacin belongs to a class of drugs known as aminoglycoside antibiotics. It works by stopping the growth
of bacteria by inhibiting bacterial protien synthesis.It is given as 500mg intravenously twice a day.It is
diluted by 100ml normal saline and given as 30mins infusion.
Tab.Tramadol: This medication is used to help relieve moderate to moderately severe
pain.Tramadol is similar to narcotic analgesics. It works in the brain to change how your body feels and
responds to pain.It is given orally twice in a day.Its recommended dose is 50-100mg

35. Tab.Serratio Peptidase: This medication is a proteolytic enzyme (protease), prescribed for
inflammation and swelling. It is given trice in a day.Its recommended dose is 5-10mg/day.
Tab.Paracetamol:It is an antipyretic has good analgesic activity and low use in anti inflammation
activity.itis given 500mg Thrice in a day.
IV fluids: IV fluids are prescribed to replace the fluid that is usually lost as a result of DKA. Fluid
replacement is also helpful in diluting the amount of sugar in your blood.

36. Goals Achieved:
 Gluteal abscess was drained.
 Relieve of pain in the gluteal region.
 Break down of fatty acids was decreased so there is
decrease in ketone bodies in urine.
 By controlling diabetic ketoacidosis further infections
are prevented.

37. Problems Identified:
 Amikacin and sulbacef are together prescribed so they
produce a major problem Nephrotoxicity.
 Hyperglycemia and hypoglycemia have been reported
in patients treated concomitantly with quinolones and
antidiabetic agents. Therefore, close monitoring of
blood glucose is recommended when these agents are
coadministered.

38. Monitoring Parameters:
 Random blood Sugar levels should be monitored at 8th hrly
 Patient should be monitored for diabetes leading to other
complications like kidney problems, change in vision,cardiac
problems.
 Blood pressure should be monitored regularly.
 Advise daily dressing.
 Insulin can cause hypoglycemia it should be monitored.

39. Patient Counselling:
1. Diet Therapy
 Avoid simple sugars like cakes and chocolates. Instead have
complex carbohydrates like rice, pasta, cereals and fresh fruits.

Do not skip or delay meals. It causes fluctuations in blood sugar
levels. Eat more fiber-rich foods like vegetables.
 Cut down on salt.
 Avoid alcohol. Dietary guidelines recommend no more than two
drinks for men and no more than one drink per day for women

40. 2.Regular exercise is an important part of diabetes control.
Daily exercise . . .
* Improves cardiovascular fitness
* Helps insulin to work better and lower blood sugar
* Lowers blood pressure and cholesterol levels
* Reduces body fat and controls body weight
Exercise at least 3 time a week for ate least 30 minutes each session. Always carry
quick sugar sources like candy or softdrink to avoid hypoglycemia (low blood sugar)
during and after exercise.

41. 3.To prevent loss of body fluids (dehydration), drink enough water and fluids to keep
urine clear or pale yellow.
4.Get your eyes checked regularly.
5.Have a yearly physical exam.
6.Have blood pressure checked.
7.Get blood and urine tested
9.Check feet for sores every night
8.Always take usual dose of insulin. If you cannot eat, or glucose is getting too low,
call the caregiver for further instructions.

42. 10.SMBG test (self-monitoring blood glucose).
Using a blood glucose monitor (meter) to do SMBG testing is an
easy way to monitor the amount of glucose in blood and can help
to improve control. The monitor will tell what blood glucose is at that very moment.
Every person with diabetes should have a blood glucose monitor and know how to use it.
The better to control the blood sugar on a daily basis, the better your A1c levels will be.