The patient, an 81-year-old female, presented with complaints of pain, gangrene and bleeding in her left great toe for one month. She has a history of type 2 diabetes mellitus and hypertension. Laboratory tests were performed. She was diagnosed with gangrene in her left great toe. Medications prescribed included antibiotics, antihypertensives, NSAIDs, anticoagulant and insulin. However, there were some issues with drug duplication and contraindications noted.

1. GANGRENE ON LEFT
GREAT TOE, DIABETES
MELLITUS 2 AND
HYPERTENSION
Amarnath Mullapudi
14PPM2037
NIPER-Mohali
1

2. 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

3. Past history
3
 K/C/O of colitis and gastric bleeding
 Diabetes mellitus type 2
 Hypertension
 Chronic kidney disease

4. Patient details
4
 Age : 81 years
 Sex : Female
 Weight : 68 kgs
 BP : 140/90 mmHg
 HR : 80 beats/minute
 RR : 22/minute

5. Laboratory investigations
5

6. 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 -

7. 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

8. 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 -

9. 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

10. 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

11. 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

12. 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 - - -

13. Diagnosis
13
 Gangrene on left toe with pain and bleeding
 Diabetes mellitus type 2
 Hypertension

14. Medication charts
14

15. Medication chart - 1
15
Drug ROA Dose Freq. Days
Cefuroxime
PO 500mg OD D1-D6
Amoxicillin + Clavulinic
acid
PO 625mg
12
hourly
D1-D15
Cefprozil PO 500mg BD D1-D6
Atrovostatin PO 20mg OD D1-D15
Valerian PO 40mg BD D1-D15

16. Medication chart - 2
16
Drug ROA Dose Freq. Days
Amlodipine PO 2.5mg OD D1-D15
Alprazolam PO 0.25mg TDS D4-D15
Telmisartan +
hydrochlorothiazide
PO
40 &
12.5mg
OD D4-D12
Erythropoietin SC 10,000
IU
weekly D1&D8
Tramadol + paracetamol PO
37.5 &
325mg
BD D6-D15

17. Medication chart - 3
17
Drug ROA Dose Freq. Days
Cilostazol PO 50mg TDS D3-D15
Acetaminophen + codeine PO
650mg +
30mg
8 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

18. 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

19. 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.

20. Summary cont…
20
Pharmaceutical issues
 Drug duplication of cephalosporin antibiotics
 Contraindication; administration of cefprozil and
cefuroxime to the patient suffering from colitis.

21. 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.