Diabetic foot ulcer-gangrene right toe.

1. PHARMACOTHERAPEUTICS-I
CASE PRESENTATION
BY
SRI SHARIKA.A
II-PHARM.D

2. DIABETIC FOOT INFECTION -GANGRENE GREAT
TOE RIGHT FOOT

3. CASE SUMMARY
• A 59 years old male was admitted in KMCH hospital on 23rd October 2018 with
the complaints of discoloration of right great toe (right foot infection).patient has
a past medical history of Diabetes mellitus type 2 and Hypertension for
10years,Acute pancreatitis (treatment since 2011), coronary artery disease on
treatment . Past surgical history of wound debridement right foot (24.8.2009),4th
toe amputation done on (14.9.2009) ,left above knee amputation done on
2010.Past medication includes Tab. GlycometGP2,Tab.Lasix(40mg) and Tab.
Ecospirin (75mg) .Laboratory investigations shows Hb-10.1g/dL, Blood Glucose
Fasting-107mg/dL and Glycosylated HbA1c-6.7% .Urine Analysis shows Presence
of Albumin,Plenty of Pus cells are seen.
• Patient was diagnosed with gangrene on right great toe .patient was treated with
surgical procedure called Amputation(removal of an entire affected body part
here its toe) and Drugs used for infection is cephalosporin antibiotics .other drugs
include Inj. Magnex forte(3gm) ,Inj.Cebanex forte (3gm),Tab.Lasix(40mg),
Tab.Glycomet. Gp(2500/2mg),Tab.Isolazine (T.ID)(37.5mg),
Tab.Arkamine(100mg),Tab.Cardivas.CR(20mg),Tab.Ivabrad(5mg)
,Tab.Ecospirin(75mg) ,Inj.Paracetamol(1gm),Inj.Heparin(2500units)

4. PATIENT’S PROFILE
• Patient details:
Name:Mr.R.Jayaraj
Age:59yrs old
Sex:Male
Reg no/Ip no:501226/E67880(8)
Primary Consultant:Thomas K.Abraham
This patient was admitted in KMCH hospital on 23rd October 2018 with
the complaints of Discoloration of right great toe(right foot infection).

5. MULTIPLE MEDICAL CONDITIONS :
Type II Diabetes Mellitus
Gangrene on Right great toe
Diabetic foot infection
MEDICAL HISTORY:
Type II Diabetes Mellitus (since 2008)
Hypertension (for10 yrs)
Acute pancreatitis (treatment since 2011)
Coronary artery disease on treatment.
PERSONAL/FAMILY HISTORY:
Nill
SOCIAL STATUS:
Married
KNOWN DRUG ALLERGIES:
Nil
PRESENT SURGERY DONE
Amputation right great toe(on 24.10.18)

6. SUBJECTIVE FINDINGS

7. VITALS OBSERVED VALUES NORMAL RANGE
RESPIRATORY
RATE
20 12-20 breaths/min
SPO2 96 94-99%
BP 140/80 120/80
HEART RATE 72 72 Beats /min
VITALS ON ADMISSION

8. DATE HEART
RATE
RESPIRATORY
RATE
BP SPO2%
24/10/18 78 20 130/80 99%
25/10/18 84 20 100/60
110/80
99%
26/10/18 88 20 110/70 98%
VITALS ON HOSPITALISATION

9. OBJECTIVE FINDINGS

10. LAB INVESTIGATIONS
TEST OBSERVED VALUE NORMAL RANGE
Hb 10.1 12-15g/dL
Tc 6800 4000-11300cells/cumm
Platelet count 295000 150000-450000cells/uL
Urea 62mg/dL 10-50mg/dL
Creatinine 2.8mg/dL 0.7 to 1.2 mg/dL
WBC 6800 4000-11300cells/cumm
eGFR 23ml/min/1.73m2
Serum sodium 137 meq/L 133 to 145meq/L
Potassium 5.4meq/L 3.7 to 5.4 meq/L

11. DIABETIC CHART
• 23/10/18
Blood glucose fasting:107mg/dL
• 24/10/18
Glycosylated HbA1c:6.7%.
As per the WHO statement HbA1c more than 6.5%indicates diabetes.

12.  URINE ANALYSIS
MACROSCOPY MICROSCOPY
OBJECTIVE OBSERVATION
Colour straw
Appearance clear
Specific gravity 1.015
Reaction Acidic
Albumin ++
Sugar Not detected
Acetone -ve
Bile salts -ve
Bile pigments -ve
Urobilinogen Slightly increased
OBJECTIVE OBSERVATION
Pus cells plenty
RBC 2-3cell/HPF
Epithelial 2-3cell/HPF
Bacteria Nil
Crystals Nil
Cast Nil
Flagellates Nil
others Nil

13. PHARMACIST’S ASSESMENT

14. • As per the physical examination, vitals and lab findings ,the patient’s
health condition is summarized as follows
Diabetic foot infection –gangrene right great toe
severity leads to the surgical procedure - AMPUTATION
Anemia-patient is anemic nature due to diabetes
Elevated levels of albumin shows the presence of complications of
diabetes ,such as diabetic neuropathy and also leads to diabetic
nephropathy .

16. DIABETIC FOOT INFECTION
• DEFINITION:
The American Diabetes Association defines the diabetic foot
as the anatomical area below the malleoli in a person with diabetes
mellitus. The diabetic foot may be defined as a group of syndromes in
which neuropathy, ischaemia and infection lead to tissue breakdown,
resulting in morbidity and possible amputation (World Health
Organization ,1995).2
Gangrene is a form of necrosis of tissue with superadded
putrefaction.Diabetes may unknowingly develop wet gangrene after
experiencing a minor toe or foot injury.

17. PHYSICIAN’S PLAN

18. DRUG CHART
DRUG
(DOSE/ROUTE/FREQ
)
TIME 23/10 24/10 25/10 26/10
CEPHALOSPORIN ANTIBIOTICS
INJ.CEBANEX FORTE
(3g)/IV/BD
6am
6pm

 .
 .
 .
 .
 .
stopped
INJ.MAGNEX FORTE
(3G)/IV/BD
6am
6pm
 .
 .
ANTIPLATELET DRUG
TAB.ECOSPIRIN
(75mg/oral/OD)
2pm  .  .  .  .
INJ.HEPARIN
25000units/IV/BD
2am
2pm
 .
 .
 .
 .
 .
 .
ANALGESICS/ANTIPYRETICS
INJ.PARACETAMOL
(1gm)/IV/BD
6am
6pm
 .
 .
 .
 .

19. ANTI DIABETIC DRUG 23/10 24/10 25/10 26/10
TAB.GLYCOMET.GP
( 2500/2MG/BD)
6am
6pm
 .
 .
stopped
VASODILATORS
TAB.ISOLAZINE
(37.5mg/oral/TID)
5am
11am
5pm
11pm
 .
 .
 .
 .
NPO  .
 .
 .
 .
 .
 .
 .
 .
ANTIHYPERTENSIVE AGENTS
TAB.ARKAMINE
(100mg/oral/TID)
5am
11am
5pm
11pm
 .
 .
 .
 .
NPO  .
 .
 .
 .
 .
 .
 .
 .
TAB.CARDIVAS.CR
(20mg/oral/HS)
9pm  .  . NPO  .

20. ANTI ANGINAL TIME 23/10 24/10 25/10 26/10
TAB.IVABRAD
(5mg/oral/OD)
 .  .  .  .
DIURETICS
TAB.LASIX
(40mg/oral/BD)
4am
4pm
 .
 .
 .
 .
 .
 .
 .
 .
PROTON PUMP INHIBITORS
NEXPRO RD
(40mg/oral/OD)
6am  .
INFUSIONS
INFUPAR
(100ml)
 .
FEVRIDOL
(100ml)
 .

21. Pre and post operative medications
DRUGS 23/10/18 24/10/18 25/10/18 26/10/18
INJ. ZOSTUM
(3mg)
 .  .  .  .
Water for injection
.amanta
(10ml)
 .  .
INJ.BUPRIGESIC
(2ml)
 .
INJ.SENSORCAINE
HEAVY
(4ml)
 .
BETADINE
15gm(ointment)
 .  .  .
INJ.TROPINE
(1ml)
 .
INJ. EFIPRES  .

22. Drug Date {23/10/18} Date {24/10/18}
T.Neksium RD . .
T.Perinorm (10mg) , .
Rupatch 5mg /hr .

23. PHARMACIST’S WORK UP OF
DRUG THERAPY
(PWDT)

24. REASONABLE OUTCOMES
MORTALITY OUTCOMES:
To avoid diabetes and cardiovascular related PROGRESSION.
MORBIDITY OUTCOMES:
a) DISEASE RELATED
To reduce morbidity resulting from uncontrolled blood glucose,anaemia,bacterial
infection .
Close monitoring for hypoglycemia symptoms such as sweating ,pale skin,dizziness,etc,,.
To control blood pressure without missing dose of antihypertensive agents .

25. • b) DRUG RELATED
To prevent ,manage or minimize drug related morbidity
-Monitoring any side effects or toxicity.
-Monitoring any drug-drug ,drug-disease or drug-food interactions.
 BEHAVIOURAL OUTCOMES
• Adhere to medication regimen.
• Obtain annual eye check ups
• Get routine and timely medical examinations and laboratory tests.
• Avoid any stimulants and OTC drugs that may affect blood glucose, and blood circulation.
 PHARMACOECONOMIC OUTCOMES
• Keep drug and treatment costs within patients resources .
• Make cost effective and efficient use of health care services.

26. PHARMACIST INTERVENTIONS
The prescribed drugs are rational .
DRUG DUPLICATION:Nil.
DRUG-DRUG INTERACTION CHART :
Drug Interacting
drug
Severity Risk Rectifications
aspirin heparin moderate cause bleed more easily dose adjustment needed according
with the testing of prothrombin
time
cefaperazone
sodium
heparin moderate cause bleed more easily dose adjustment needed

27. DRUG -FOOD INTERACTION
DRUGs INTERACTING FOOD CLINICAL RESULTS
paracetamol alcohol Alcohol Paracetamol Syndrome –
hepatotoxity occur from the
ingestion of therapeutic doses of
paracetamol in moderate to heavy
drinkers of alcohol.
metformin alcohol Slows the action of oral
hypoglycemic agent(8 to 12hrs)

28. DRUG – DISEASE INTERACTION
Drug Disease Clinical result
aspirin anemia GI blood loss, causes damage in
mucosal layer in GI.
CLASS OF DRUGS PRESENT LAB VALUES TARGET VALUE
ANTI ANAEMIC DRUG
Inj.cebanex forte (3gm)
10.1gm/dL 12-15gm/dL
ANTI PLATELET DRUGS
Tab.ecospirin(75mg)
295000cells/microliter >295000cells/microliter
THERAPEUTIC END POINT

29. PATIENT ON DISCHARGE
His post operative recovery was uneventful.he was managed post
operatively with INJ.Heparin ,TAB.Ecospirin ,IV antibiotics and analgesics
and daily dressings done.
MEDICATIONS DOSAGE MORNING AFTERNOON EVENING NIGHT A/B FOOD DURATION
TAB.CIFRAN 500mg 1 0 0 1 A 7DAYS
TAB.CLOPILET A 75mg 1 0 0 0 A 14DAYS
TAB.STILOZ 50mg 1 0 0 1 A 14DAYS
CAP.OMEZ 20mg 1 0 0 1 B 7DAYS

30. PATIENT POST OPERATIVE CONDITION
His post op recovery was uneventful .He was managed post operatively
with Inj.Heparin ,Tab.Ecospirin ,I.V Antibiotics and Analgesics and daily
dressing done.
Discharge –stable condition -27/10/18
Follow up review on 5/11/2018

31. PATIENT COUNSELLING
BASED ON DIET
• Eating an unhealthy diet high in fat will make any existing atherosclerosis worse and increase your risk of
developing gangrene.
• Continuing to eat high-fat foods will cause more fatty plaques to build-up in your arteries. This is because
fatty foods contain cholesterol.
• There are 2 types of fat – saturated and unsaturated. Avoid foods that contain saturated fats because they
increase levels of "bad cholesterol" in your blood.

32. PATIENT EDUCATION
BASED ON LIFESTYLE MODIFICATION
Smoking
Smoking can cause your arteries to become blocked, resulting in a loss of blood supply to your
arms or legs. This is known as peripheral arterial disease (PAD). Which may also cause
gangrene
So that You must give up the smoking to reduce the risk of gangrene
Alcohol
Drinking excessive amounts of alcohol will cause your blood pressure to rise, and also raise the
level of cholesterol in your blood. Which may also block the artery and that may cause
gangrene
Men and women are advised not to drink more than 14 units a week. 14 units is equivalent to
6 pints of average-strength beer or 10 small glasses of low-strength wine.