1. Case presentation on Type-2 DM with ulcer over right foot with Essential hypertension.

2. SENARIO:
Here is a 48 years old female patient hospitalized for
10days.
CHIEF COMPLAINTS:
Ulcer over right foot since 2 months
C/o pain on sole of right foot
Loss of sensation over sole of both feet.
History of present illness:
Patient got a prick on sole of right foot by piece of glass
before 2 months and pain on the sole of right foot.

3. PAST MEDICATION HISTORY:
PAST MEDICAL HISTORY:
K/c/o Type-2 Diabetes mellitus from 20 years.
k/c/o Hypertension since 4years
PAST MEDICATION HISTORY:
Tb. Metformin + voglibose + Glimipride regularly.
Tb.Amlodipine
LABORATORY INVESTIGATIONS:
CBC
Values
ESR
100 mm/hr
MCV
78.2 fl
MCH
24.8 g/dl
MCHC
31.7 g/dl Na
129meq/lt
Sugar (urine)
1.5%

4. Other investigations: ECG- sinus tachycardia culture sensitivity- enterococcus sensitivity (positive) ciprofloxacin 500mg
Date
26/1 27 28 29 30 31 1 2 3 4 BP
150/100
140/90
142/88
130/90
120/80
130/80
136/80
140/80
Pulse 84 85 86 72 78
122 82 80
R.B.S
268
369
172
180
132
107 92 98 89

5. SOAP NOTE:
SUBJECTIVE: Here is a 48 years old female patient presenting complaints of ulcer over right foot since 2months, pain on sole of right foot . Loss of sensation over sole of both feet.
OBJECTIVE:
BP on the day of admission was 150/100mm hg
Increase in BP indicates hypertension.
R.B.S. On the day of admission is 268 mg/dl.
Increased it indicates hyperglycemia.
CBC:
ESR-100 mm/hr. increased., due to infection or inflammation.
MCV-78.2 fl decreased usually occurs in iron deficiency anemia.
MCHC-24.8 decreased due to iron deficiency anemia.

6. Hyponatremia is due to osmotic losses due to polyuria.
ECG: Sinus tachycardia.
Culture sensitivity: Enterococcus sensitive – positive
Ciprofloxacin-500mg 1-0-1
DIAGNOSIS:
Type-2 DM with essntial hypertension with ulcer over right foot.
ASSESSMENT:
Problem lists:
Type-2 DM:
It is due to the insulin resistance and relative insulin deficiency.

7. Essential hypertension:
Hyperinsulinemia occurs in type -2 Diabetes due to peripheral insulin resistance this may be associated with excess of sodium conservation in the body predisposing hypertension
it is due to increase in sodium renal tubular absorption and increase in osmolarity in uncontrolled state of diabetes.
Ulcer on foot:
This is due to injury by glass piece which was infected.

8. Problem
Goals of treatment
Drugs & MOA
Dosage
Type-2 Diabetes Mellitus
-To ameliorate symptoms of hyperglycemia, reduce the onset and progression of microvascular & macrovascular complications
-reduce mortality.
-sulfonylureas
Glimepride: it exerts hypoglycemic action by stimulating pancreatic secretion of insulin.
-Biguanides
Metformin: it enhances insulin sensitivity of both hepatic and peripheral (muscle) tissues.it allows increased uptake of glucose into these insulin sensitive tissues
-insulin
0.5-1mg/day
500mg BD
Or 850mg OD
units/kg/day

9. Problem
Goals of treatment
Drugs & MOA
Dosage
Hypertension
Ulcer on foot
-Blood pressure should be controlled
-to prevent infection and to promote wound healing
-ARB blockers:
Telmisartan: these inhibits the binding of AT-1 & AT-2 receptors there by inhibiting release of angiotensin.
-Antibiotics:
Staphylococcus is the commonest organism & hence penicillinase resistant antibiotics are the drug of choice.for gram –ve ampicillin, cephalosporins are given, for anaerobic infections Metronidazole.
20-80mg/day
Amoxicillin-500mg BD
Metronidazole 500mg BD
Ceftriaxone 1gm TID

10. Plan: s.no T.name G.name dose 26 27 28 29 30 31 1 2 3 1. T.Triglimesta
1-0-1
Glimipride+metformin+pioglitazone
2mg+8mg+7.5 y 2.
T.Telmikind
1-0-0
telmisartan
40mg 3.
Mixtars S/C
H.insulin
30/70 4.
T.Accuclav
1-1-1
Amoxicillin+clavulanic
625mg 5.
T.Rantac
rantidine
150mg 6.
T.Tramadan
tramadol
50mg 7.
T.Neurolac
0-0-1
multivitamin 8.
T.Ciplox
ciprofloxacin
500mg

11. Drug interactions: 1. Antibiotic is not indicated for foot ulcer.
2.metformin/pioglitazone +rantidine =Moderate interaction
Increase in metformin plasma concentraion. (hypoglycemia)
2.Ciprofloxacin+anti-diabetic (triglimestar)= major interaction
Change in glucose level (hypoglycemia/ hyperglycemia).
3.pioglitazone+insulin- Contraindicated in UK because of reports of cardiac
failure.
If pioglitazone 15mg is given the dose of insulin to be reduced by 10-25%
Discharge drugs:
1.T.Amlong – x 15 days.
2. T.triglimestar x15 days.
3.T.Ciplox x 15 days.
Rablet should be added in discharge drugs.
Patient counselling:
1.Take high fiber diet.
2.Avoid foods rich in sugars,fats.

12. 3. Monitor your blood glucose and blood pressure levels regularly. 4
3.Monitor your blood glucose and blood pressure levels regularly. 4.Strict medication adherence should be followed. 5.Regular exercise aerobic exercise for 30 min atleast 5 times a week 6.Salt restriction up to 2g/day 7. Eye checkup for every 6 months 8.Never skip meals and if hypoglcemia occurs symptoms are sweating,weakness,confusion,palpitation and giddiness. Then have a fruit juice or a chocolate 9.Restrict calorie intake , maintain ideal body weight. Drug counselling: 1.Amlodipine should be taken in the morning after breakfast. 2.Triglimestar to be taken 30min before meals. 3.Ciprofloxacin should be taken after food. 4.Avoid milk.