Mrs. X, a 55-year-old female, was admitted to the hospital for diabetic neuropathy symptoms including leg pain and difficulty rising from sitting. She has a history of type 2 diabetes for 7 years. Physical examination and tests confirmed diabetic neuropathy and anemia. She was prescribed medications including gabapentin and metformin to control blood sugar and neuropathy symptoms. The patient was counseled on lifestyle modifications like diet, exercise and foot care to manage her condition and prevent further complications.

1. PRESENTED BY
RA1522281010017
DEPARTMENT OF PHARMACY PRACTICE
SRM COLLEGE OF PHARMACY, SRM INSTITUTE OF SCIENCE & TECHNOLOGY,
KATTANKULATHUR
CASE STUDY ON
DIABETIC NEUROPATHY

2. SUBJECTIVE EVIDENCE
2
NAME Mrs. X
AGE 55 years
GENDER Female
WEIGHT / HEIGHT 64 kg / 160 cm
BMI 21
MARITAL STATUS Married
OCCUPATION House wife
DEPARTMENT General Medicine
DATE OF ADMISSION 03-01-19
DATE OF DISCHARGE 14-01-19
TOTAL STAY IN HOSPITAL 11 Days

3. REASON FOR
ADMISSION
C/O radiating pain in both legs
C/O severe pain in hip and thigh
C/O Difficulty in rising from sitting position since 1 week
H/O ear pain
H/O pain in the right half of the abdomen
H/O loss of consciousness
H/O loss of appetite
PAST MEDICAL
HISTORY
K/C/O Type 2 diabetes for past 7 years
PAST MEDICATION
HISTORY
T.Neurobion plus 1-0-0
C. Pregabalin 75mg
Tab . Glycomet 250 mg
PERSONAL HISTORY Mixed diet
Disturbed sleep pattern
Allergies – Nil
MENSTRUAL
HISTORY
Menopause at 42 years (10 years back)
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4. 4
GENERAL EXAMINATION PHYSICAL EXAMINATION
Temperature : 98.6 F
BP : 120/80 mm Hg
PR : 68 beats/min
RR : 22 cycle/min
SYSTEMIC EXAMINATION
CVS : S1S2 +
CNS : NFND
RS : NVBS
P/A : distended(+),tenderness
INVESTIGATIONS DONE •Complete blood count
•Liver function test
•Renal function test
•Urine test
•ECG
•Doppler test
•Monofilament test

5. HEMATOLOGICAL TEST
Hb 11.8 g/dl 13-17 g/dl
PCV 36 % 40-50 %
MCV 81 fl 83-101 fl
MCH 26 pg 27-32 pg
Total RBC 3.0 millions/cumm 3.8-4.8 millions/cmm
WBC 10,300 cells/cumm 4000-10000 cells/cumm
Neutrophil 72% 40-80%
Platelet count 4.0 lakhs/cumm 2.0-4.0 lakhs/cumm
ESR 40 mm/hr 0-20 mm/hr
RBS 152 mg/dl 70-140 mg/dl
FBS 121mg/dl 70-110 mg/dl
HbA1C 9.3 mg/dl 4.5-6.0 mg/dl
5
OBJECTIVE EVIDENCE

6. 6
LIVER FUNCTION TEST
Total bilirubin 1.2 mg/dl 0.5-1.0mg/dl
Direct bilirubin 3.3 mg/dl Upto 0.3mg/dl
Protein 7.9 mg/dl 6.0-8.0mg/dl
Albumin 3.7 mg/dl 3.5-5mg/dl
Globulin 3 g/dl 2.5-3.0g/dl
SGPT 38 U/L 5-35U/L
SGOT 49 U/L 8-40U/L
ALP 130 U/L 40-125U/L
RENAL FUNCTION TEST
Creatinine 1mg/dl 0.6-1.2mg/dl
Urea 7mg/dl 7-20mg/dl

7. 7
04/01/19 DOPPLER –
ARTERIAL SYSTEM
MONOFILAMENT
TEST
URINE TEST
PERIPHERAL
BLOOD SMEAR
Ankle brachial index shows normal
blood circulation in both the legs.
Protective sensation partially present
Pale yellow color
Glucose ++
Pus cells – 4 to 6 present.
Other Parameters Normal.
RBCs are reduced in number and small
in size
Hypochromic anemia

8. ASSESSMENT
FINAL DIAGNOSIS :
Diabetes Amyotrophy
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9. PLAN
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THERAPEUTIC GOALS
• To maintain the normal blood sugar levels.
• To enable the patient symptoms free.
• To prevent the progression of the disease and its complications.
• To improve the quality of life of the patient.

10. MEDICATION CHART
1. T.NEUROTIN
T.Gabapentin
300mg Oral 1-1-1 Day 1- 10
2. INJ.RENERVE PLUS
Mecobalamin +inisitol
Alpha lipoic acid + folic acid
1ml IV 0-0-1 Day 1- 10
3. T.ELAVIL
T.Amitriptyline
10mg Oral 0-0-1 Day 6- 10
4. T.GLUMETZA
T.Metformin
500mg Oral 1-0-1 Day 1- 10
5. T.LIPITOR
T.Atorvastatin
20mg Oral 1-0-1 Day 1- 10
6. T.ZANTAC
T.Ranitidine
150mg Oral 1-0-1 Day 4- 10
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11. PHARMACIST INTERVENTION
• FREQUENCY ERROR
As per the given prescription, T.Atorvastatin was given two times a day but it
should be taken once daily.
• MISSED DRUG
The hb levels of patient is low and patient has microcytic iron deficiency anemia.
So iron supplements is suggested for the patient.
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6. T.LIPITOR
T.Atorvastatin
20mg Oral 1-0-1 Day 1- 10

12. •DRUG INTERACTIONS :
[ Minor ]
1.Atorvastatin + Amitriptyline
Atorvastatin will increase the level or effect of amitriptyline by
p-glycoprotein efflux transporter.
Modification : Administer amitriptyline half an hour before
atorvastatin.
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13. DISCHARGE SUMMARY
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1. T.NEUROTIN 300mg 1-1-1
2. C.RENERVE PLUS 1 Capsule 0-0-1
3. T.ELAVIL 10 mg 0-0-1
4. T.GLUMETZA 500mg 1-0-1
5. T.LIPITOR 20mg 0-0-1
6. T.ZANTAC 150mg 1-0-1
NEXT REVIEW : AFTER ONE WEEK IN GENERAL MEDICINE DEPARTMENT

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15. DISEASE COUNSELING
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1. Diabetes neuropathy is a nerve damage due to uncontrolled high blood
sugar in the body.
2. Most common and serious complication of type 2 diabetes mellitus.
3. Depending upon the affected nerves , symptoms can range from pain and
numbness in legs and feet to problems with digestive system , urinary
tract , blood vessels and heart.
4. Following a healthy diet with low glycemic index can prevent progression
of the disease.
5. To prevent the complication of the disease, good foot care is essential.
Patient should inspect their feet every day for injuries or sores.

16. DRUG COUNSELING
• Follow 4S in drug meditation : Do not share , stop, skip and sum the doses of the
prescribed drugs.
• A pill organizer or pill container is best way for medication adherence
and keeping alarm can help patient to take medications at correct time.
• T.Metformin should be taken after food to avoid stomach and bowel side effects.
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17. • C.Renerve plus should be taken at fixed time and correct interval of
time. Take the missed tablet as soon as you remember.
• Avoid antacids with T.gabapentin as it may interfere with the
absorption of the drug.
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18. DIET COUNSELING
• To combat the dawn phenomenon, eat high fiber and low fat snack before
going to bed like wheat crackers or an apple.
• Diabetes Neuropathy can lead to low hemoglobin concentration. Therefore
eat foods rich in Iron content- dates,greens,broccoli and dry fruits.
• Eat foods with heart healthy fats : olive oil and tuna fish(soorai) and salmon
fish(sankara)
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19. • Limit foods and drinks that includes saturated fats,high in
sodium, beverages with added sugars.
• Make every meal well balanced :The key for eating
diabetes is to eat a variety of heathy foods from all food
groups,
• Vegetables – Starchy : potatoes , corn.
• Non starchy : carrot ,greens, peppers.
• Fruits : orange, lemon , berries, bananas.
• Grains : wheat , rice ,oats.
• Protein : fish , eggs , dried peas.
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20. 20
Plate method
• Use a nine inch plate.
• Fill half of the plate with non-starchy foods.
• Fill one quarter of plate with whole grain or starchy foods and
remaining quarter with lean protein foods.
• Patient can also have one glass of milk and few parts of fruits in bowl.

21. TO PREVENT FROM PAIN
• Rest or activity modification: Limiting strenuous activity like lifting heavy
objects or using better posture while driving or sitting might provide
relief.
• Soak in a warm bath : It helps to relax and boost circulation throughout
the body.
• Ice or heat therapy to the painful areas : It helps to reduce
inflammation and pain . Make sure to have a layer that prevents direct
contact with skin.
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LIFESTYLE MODIFICATION

22. TO PREVENT FURTHER COMPLICATIONS :
• Candy in a pocket : Whenever there is giddiness , eat a candy to overcome it.
• Protect feet : To help prevent foot problems, wear comfortable and
supportive shoes or chappal.
• Pay attention : Foot sores and cuts may silently become severely infected
and turn into ulcer. Take necessary treatment don’t leave it carelessly.
• Infection free foot : Avoid soaking feet it may encourage fungal growth and
cut toe nails regularly.
• Vision test : A comprehensive eye exam should be taken to check the
functioning of eyes and to avoid cataract and other vision problems.
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23. • Sleep at right time : If amount of sleep decreases, blood sugar level increases.
So sleep for 8-10 hours for normal functioning of body and also for the
production of RBCs.
• Coconut a week : It maintains blood sugar and A1c and its a good source of
magnesium which may increase insulin sensitivity and reduce blood sugar
level.
• Get body hydrated : Drink enough water to keep body hydrated and it helps
body in eliminating excess of glucose from the body .
• Manage stress : when you are stressed or anxious find ways to relieve –
through deep breathing
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TO CONTROL SUGAR and Hb LEVEL :

24. REFERENCE
For drug dose , drug interactions and patient counseling :
Secondary source:
Pharmacotherapy handbook – 9th edition by Joseph.T.Dipiro
BNF 76
Teritary source :
• www.mayoclinic.org
• www.micromedex.com
• www.wemmd.com
• www.healthline.com
• www.medscape.com
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