The patient, a 70-year-old male, presented with a 2x2 cm ulcer on his right foot and pain in both limbs for 2 years. He was diagnosed with lower limb cellulitis and NSAID-induced acute kidney injury. He received IV antibiotics, insulin, salbutamol and calcium gluconate to treat the cellulitis, hyperkalemia and kidney injury. His renal function and potassium levels improved by days 3 and 5 respectively. He was counselled about cellulitis, medications, lifestyle changes and avoiding NSAIDs to prevent further kidney damage.

1. Lower limb Cellulitis with NSAID’s
induced Acute Kidney Injury
Monday, 20 March 2023 1
DR AYESHA JAMAL
PHARM D
FAROOQIA COLLEGE OF PHARMACY

2. Monday, 20 March 2023 2
IP no. 258257
UNIT Surgery 1
AGE 70 yrs
SEX Male
WEIGHT 72 Kgs

3. Reasons for admission :
c/o: Ulcer on Right foot since 10 days
c/o: Pain in both limbs since 2 years
10 days back got injured on right leg due to
thorn prick and developed into an ulcer 2x2 cm
PMHx: Not a k/c/o HTN, DM, TB
SHx: NS
Monday, 20 March 2023 3

4. General Examination
• Elderly male patient
• Conscious oriented
• BP: 170/100 mmHg
• Pulse: 85 BPM
• Pallor +
• Cataract +
• Swelling of Rt Lower
limb from knee to toes
• Small ulcer +
• Discharge +
• Left leg normal
• CVS: S1S2 +
• RS: B/L NVBS +
Monday, 20 March 2023 4

5. DAY 1
• BP : 170/100 mm Hg
• RBS: 117 mg/dl
• Imp: Rt Leg Cellulites
• Investigations: Hb, TC, DC, ESR, Plt, INR, CT, BT,
RBS, RBS, U/C, SE, HIV, HBS Ag, ECG
• ADV: Limb elevation, Physician opinion,
Anesthetic opinion
Monday, 20 March 2023 5
Provisional Diagnosis: ? Diabetic Foot

6. LAB REPORTS :
Monday, 20 March 2023 6
HEMATOLOGY
Hb 9.4 g%
WBC 7000 Cells/ cumm
DLC N: 87 % , L: 11 %, M: 02 %
E: 00 %, B: 02 %
PLT 4.82 L/ cumm
BT 3 min
CT 6 min
ELECTROLYTES
Sodium 144 mmol/l
Potassium 6.5 mmol/l
Chloride 115 mmol/l
BIOCHEMISTRY
RBS 117 mg/dl
Urea 57 mg/dl
S. Cr 2.5 mg/dl
MICROBIOLOGY
AFB: -ve
HIV: -ve
HBS Ag: -ve
GFR: 28 ml/min
Urine Culture
Pus cells +
Gram –ve bacilli +

7. • Physician opinion:
Not a k/c/o DM, HTN
CVS: S1S2 +, Tachycardia
ECG: Tachycardia, mild LVH
C- X-ray Pul. Edema
IMP: Cellulitis with AKI with Hyperkalemia
ADV: salbutamol neb, Rpt U/C, HbA1C, USG abdomen,
Fundoscopy
• Anesthetic opinion:
In view of BP, Hyperkalemia & ECG, it is advisable to take
to surgery after controlling parameters
If surgery is necessary then it should be done after the
consent of the patient.
Monday, 20 March 2023 7

8. TREATMENT CHART
DRUG DOSE R F 1
Inj. Ceftriaxone 1 g IV 1-0-1 +
Inj. Metronidazole 500 mg IV 1-1-1 +
Inj. pantoprazole 40 mg IV 1-0-0 +
Salbutamol 100 mcg INH 4 hrly +
Calcium Gluconate PO 6hrly +
Monday, 20 March 2023 8

9. DAY 2
BP :130/90mm Hg PULSE :90 BPM
Nephrologists' opinion: H/O NSAID’s Abuse since 6
months
CVS/ RS: NAD
IMP: Cellulitis with Hypertension with ? NSAID
Induced CKD
ADV: 2 pints of NS at 75 ml/hr
Avoid NSAIDS, Rpt U/C, USG abdomen + KUB,
Low potassium diet, salbutamol, Calcium gluconate,
H. actrapid 8 units with 25% dextrose
Monday, 20 March 2023 9

10. LAB REPORTS :
Monday, 20 March 2023 10
ELECTROLYTES
Sodium 134 mmol/l
Potassium 5.6 mmol/l
Chloride 106 mmol/l
BIOCHEMISTRY
RBS 96 mg/dl
HbA1C 5.2 g%
Urea 55 mg/dl
S. Cr 3.0 mg/dl
GFR: 23.5 ml/min

11. TREATMENT CHART
DRUG DOSE R F 1 2
Inj. Ceftriaxone 1 g IV 1-0-1 + +
Inj. Metronidazole 500 mg IV 1-1-1 + +
Inj. pantoprazole 40 mg IV 1-0-0 + +
Salbutamol 100 mcg INH 4 hrly + +
Inj. INSULIN with 25% Dextrose 8 U IV +
K check powder PO 6hrly + +
Monday, 20 March 2023 11

12. DAY 3
BP: 130/90 mmHg PULSE : 90BPM
O/E:
Pain in foot
CVS/RS: NAD
Surgery conducted
Monday, 20 March 2023 12

13. LAB REPORTS :
Monday, 20 March 2023 13
ELECTROLYTES
Sodium 138 mmol/l
Potassium 3.3 mmol/l
Chloride 88 mmol/l
BIOCHEMISTRY
Urea 53 mg/dl
S. Cr 3.0 mg/dl
GFR: 23.5 ml/min

14. TREATMENT CHART
DRUG DOSE R F 1 2 3
Inj. Ceftriaxone 1 g IV 1-0-1 + + +
Inj. Metronidazole 500 mg IV 1-1-1 + + +
Inj. pantoprazole 40 mg IV 1-0-0 + + +
Inj. Tramadol 50 mg IV 1-1-1 +
Salbutamol 100 mcg INH 4 hrly + + +
K check powder PO 6hrly + + +
Monday, 20 March 2023 14

15. DAY 4
BP:130/90 mmHg PULSE: 90 BPM
O/E: No fresh complains
Ophthalmologist opinion:
RE: Leucomatous opacity, No view
LE: Normal
IMP: No DR, Hypertensive retinopathy
Monday, 20 March 2023 15

16. TREATMENT CHART
DRUG DOSE R F 1 2 3 4
Inj. Ceftriaxone 1 g IV 1-0-1 + + + +
Inj. Metronidazole 500 mg IV 1-1-1 + + + +
Inj. pantoprazole 40 mg IV 1-0-0 + + + +
Inj. Tramadol 50 mg IV 1-1-1 + +
Salbutamol 100 mcg INH 4 hrly + + + +
K check powder PO 6hrly + + + +
Monday, 20 March 2023 16

17. DAY 5
BP : 130/90 mmHg PULSE :80 BPM
Nephrologists opinion: No edema
CVS/ RS: NAD
RFT: improving
ADV: Rpt U/C after 5 days
Monday, 20 March 2023 17

18. LAB REPORTS :
Monday, 20 March 2023 18
ELECTROLYTES
Sodium 140 mmol/l
Potassium 4.8 mmol/l
Chloride 100 mmol/l
BIOCHEMISTRY
Urea 34 mg/dl
S. Cr 2.0 mg/dl
GFR: 35 ml/min

19. TREATMENT CHART
DRUG DOSE R F 1 2 3 4 5
Inj. Ceftriaxone 1 g IV 1-0-1 + + + +
Inj. Metronidazole 500 mg IV 1-1-1 + + + + +
Inj. pantoprazole 40 mg IV 1-0-0 + + + + +
Inj. Tramadol 50 mg IV 1-1-1 + + +
Salbutamol 100 mcg INH 4 hrly + + + +
K check powder PO 6hrly + + + + +
Inj Cefoperazone + Sulbactum 1.5 g IV 1-0-1 +
Monday, 20 March 2023 19

20. DAY 6
BP: 130/90 mm Hg PULSE: 90 BPM
• O/E : No fresh complains
• Ortho opinion: Physiotherapy
Monday, 20 March 2023 20

21. TREATMENT CHART
DRUG DOSE R F 1 2 3 4 5 6
Inj. Ceftriaxone 1 g IV 1-0-1 + + + +
Inj. Metronidazole 500 mg IV 1-1-1 + + + + + +
Inj. pantoprazole 40 mg IV 1-0-0 + + + + + +
Inj. Tramadol 50 mg IV 1-1-1 + + + +
Salbutamol 100 mcg INH 4 hrly + + + +
Calcium Gluconate PO 6hrly + + + + + +
Inj Cefoperazone + Sulbactum 1.5 g IV 1-0-1 + +
Monday, 20 March 2023 21

22. DAY 7
BP: 130/80 mm Hg PULSE: 84 BPM
O/E : No fresh complains
CVS/ RS: NAD
Afebrile
ADV: CST
Monday, 20 March 2023 22

23. TREATMENT CHART
DRUG DOSE R F 1 2 3 4 5 6 7
Inj. Ceftriaxone 1 g IV 1-0-1 + + + +
Inj. Metronidazole 500 mg IV 1-1-1 + + + + + +
Inj. pantoprazole 40 mg IV 1-0-0 + + + + + +
Inj. Tramadol 50 mg IV 1-1-1 + + + + +
Salbutamol 100 mcg INH 4 hrly + + + +
Calcium Gluconate PO 6hrly + + + + + +
Inj Cefoperazone + Sulbactum 1.5 g IV 1-0-1 + +
Tab. Cefoperazone + Sulbactum 1.5 g PO 1-0-1 +
Tab. Pantoprazole 40 mg PO 1-0-0 +
Monday, 20 March 2023 23

24. PHARMACEUTICAL CARE
PLAN (SOAP)
Monday, 20 March 2023 24

25. SUBJECTIVE EVIDENCE
• Ulcer on Right foot since 10
days
• Pain in both limbs since 2
years
• H/O NSAID’s abuse
OBJECTIVE EVIDENCE
• Elevated Serum creatinine
• Elevated Blood Urea levels
• Elevated Potassium Levels
• ECG: Tachycardia, Mild LVH
Monday, 20 March 2023 25

26. FINAL DIAGNOSIS
Based on subjective and objective evidence the
patient was diagnosed as Lower limb Cellulitis
with NSAID’s induced Acute Kidney Injury
Monday, 20 March 2023 26

27. GOALS OF TREATMENT
• To prevent Progression of kidney disease and
further insult to kidneys..
• To treat Hyperkalemia and prevent cardiac
morbidity.
• To treat cellulitis and retain mobility.
Monday, 20 March 2023 27

28. TREATMENT OPTIONS
CELLULITIS:
• Beta lactam Antibiotics
• Macrolides
• Clindamycin
• Vancomycin
HYPERKALEMIA:
• Insulin
• Salbutamol
• Hemodialysis (in rare cases)
Monday, 20 March 2023 28

29. GOALS ACHIEVED
• Patient’s potassium levels were brought to
normal by day 3
• Patient’s Renal function was brought to
normal by day 5
• Patient was symptomatically better by day 6
Monday, 20 March 2023 29

30. PROBLEMS IDENTIFIED
• Untreated indication LVH.
• Monitoring error: continues use of salbutamol
even after potassium levels came to normal.
Monday, 20 March 2023 30

31. MONITORING PARAMETERS
• Serum electrolytes
• Renal function test
• ECG
• Blood pressure
• Tissue culture
Monday, 20 March 2023 31

32. PATIENT COUNSELLING
Monday, 20 March 2023 32

33. About Disease
• What is cellulitis?
• What are the symptoms?
• How do you get cellulitis?
• How can you prevent cellulitis?
Monday, 20 March 2023 33

34. About Medications
– Name and purpose
– Dose and frequency
– Medication adherence
– Possible adverse effects
– Missed dose
– Avoid use of OTC drugs (NSAID’s)
Monday, 20 March 2023 34

35. About Life style medications
• Take good care of your skin. Keep it clean, and
use lotion to prevent drying and cracking.
• Check your feet and legs often.
• Treat any skin infection right away.
• Drink plenty of water.
Monday, 20 March 2023 35

36. Monday, 20 March 2023 36