Venous ulcer
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Transcript of Venous ulcer
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Case presentation on Venous Ulcer with Heart Failure with Type 2 DM With AKI
By : Abhimanyu Parashar Pharm D Intern
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I.P No. 262406
UNIT Surgery 1
AGE 56 years
SEX Male
WEIGHT NAS
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Reasons for admission :
• c/o Pain in Left lower leg since 15 days•Itching is present throughout the day.•Aggravated while walking, Relived on taking rest.•Also gives a H/O Ulcer on the Left Leg associated with swelling of the surrounded tissue
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PMHx
• K/C/O T2DM, HTN, IHD, Varicose Veins (Both lower limbs with SFJ and SPJ incompetence)
• Diabetic and Hypertensive since 18 Years
• IHD since 7 months and on Rx• Operate 3 times for Varicose
veins in last 20 years• Chronic smokers + Alcoholic left
5 years back
Competent Venous system
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Incompetence
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General Examination
• Adult male• Overweight• Conscious oriented• Afebrile• Mild pallor +• PA: soft and non tender• CVS: s1s2+, no Murmurs• RS: B/L NVBS +
• B/L Pitting edema +• No Cyanosis, Clubbing,
lymphadenopathy• 3 Ulcers + on the Left leg
7x5 cm, 3x4 cm, 2x2 cm• Skin is Darkly Pigmented
Below the Knee up to Ankle
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PROVISIONAL DIAGNOSIS
Chronic Venous Ulcer, Type 2 DM, Hypertension and IHD
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DAY 1
BP: 160/90 mm Hg PULSE: 86 BPM Plan – DebridementADV: Hb, TC, DC, PLT, RBS, U/C, SE, HIV, HBS-Ag, CXR-PA View,
ECG, USG – Left Lower Limb Doppler & CREPE BANDAGE
Drug Dose R Freeq
Tab. Carvedilol 3.125 mg PO 1-0-1
Tab. Ramipril 1.25 mg PO 1-0-1
Tab. Glimpiride 2 mg PO 1-0-0
Tab. Metformin 500 mg PO 1-0-1
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LAB REPORTS :
Biochemistry
RBS 180 mg/dl
Urea 42 mg/dl
S.Cr 1.7 mg/dl
GFR 41.9 ml/min
Electrolytes
Sodium 134 mmol/L
Potassium 5.3 mmol/L
Chloride 102 mmol/L
Hematology
Hb 12.9 g%
TC 12400 cells/cumm
DC N- 73%; L-26%; E-1%
PLT 4.05 L/cumm
ESR 40 mm/hr
PT 17 sec
INR 1.30
CXR-PA View Cardiomegaly
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DAY 2
BP: 170/100 mmHg PULSE : 84 BPMFCBG: 157 mg/dl
C/O Pain in Left Lower Limb, Difficulty in passing urineO/E: FebrileADV: physician Opinion, Fundoscopy, USG KUB, Diet Counseling,
CST
HIV Negative
HBS Ag Negative
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Drug Dose R Freeq
Tab. Carvedilol 3.125 mg PO 1-0-1
Tab. Ramipril 1.25 mg PO 1-0-1
Tab. Glimpiride 2 mg PO 1-0-0
Tab. Metformin 500 mg PO 1-0-1
Tab. Tramadol 100 mg PO 1-0-1
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DAY 3
BP: 190/110 mmHg PULSE : 86 BPMFCBG: 108 mg/dlO/E Febrile, C/O pain in lower limbCVS, RS: NADADV: CST, ECHO
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DAY 4
BP: 160/90 mmHg PULSE : 84 BPMFCBG: 115 mg/dlCVS/RS: NADADV: CSTC/S/B Ophthalmologist :Imp- Grade II Hypertensive retinopathy changes in both eyesADV: Fundoscopy every 6 months
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• HTR Grade III & IV are only considered as end organ damage• Grade I & II will be asymptomatic
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Fundoscopic differences Between Hypertensive & Diabetic Retinopathy
Hypertensive Retinopathy Diabetic Retinopathy
Retina Dry Wet
Hemorrhages Few Multiple
Edema Rare Extensive
Exudates Rare Multiple
Cotton wool spots Multiple Few
Flame shaped Hemorrhages
Common Rare
Visually abnormal blood vessels in retina
Arteries Veins
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DAY 5 BP: 150/90 mmHg PULSE : 82 BPMFCBG: 129 mg/dlUSG-KUB:• Mild Prostatomegaly• Small Renal calculi.ADV: Urologists opinion, CST
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DAY 6
BP: 130/70 mm Hg PULSE : 74 BPMFCBG: 122 mg/dlO/E No fresh complainsAfebrileCVS, RS: NADADV: PhysiotherapyPhysician opinion: ECG- T wave inversion in II avF,
v5-v6
ECHO- • IHD• Mod. LV Systolic
Dysfunction• LV Diastolic Dysfunction +• EF: 34 %
Urea 33 mg/dl
S.cr 1.4 mg/dl
GFR 52.4 ml/min
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Drug Dose R Freeq
Tab. Carvedilol 3.125 mg PO 1-0-1
Tab. Ramipril 1.25 mg PO 1-0-1
Tab. glimpiride 2 mg PO 1-0-0
Tab. Aspirin + Clopidogrel + Atorvastain
75/75/10 mg PO 0-1-0
Tab. Cilnidipine 10 mg PO 1-0-0
Tab. Tramadol 100 mg PO 1-0-1
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DAY 7 BP: 162/98 mm Hg PULSE: 84 BPMO/E: Pt FebrileRBS: 180 mg/dlFBS: 129 mg/dlADV: Physician opinion, Plastic surgeonPhysician opinion:CVS: S1s2 +, No murmursRS: B/L NVBS +ADV: CST
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Drug Dose R Freeq
Tab. Carvedilol 3.125 mg PO 1-0-1
Tab. Cardace 1.25 mg PO 1-0-1
Tab. glimpiride 2 mg PO 1-0-0
Tab. Aspirin + Clopidogrel + Atorvastain 75/75/10 mg PO 0-1-0
Tab. Cilnidipine 10 mg PO 1-0-0
Tab. Tramadol 100 mg PO 1-0-1
Enzoheal (Trypsin+ Bromelin + Rutaside) 48+90+100 mg PO 1-1-1
Tab. Paracetamol 650 mg PO 1-0-1
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DAY 8BP: 150/80 mm Hg PULSE: 86 BPMFCBG: 145 mg/dl• C/S/B Plastic Surgeon- O/E AfebrileContraction band 15 cm over the ankle jointB/L Lower limb varicositis +ADV: Release of contraction - fasico cutaneous flapBut the chance of failure Explained in view of DM and HTN
• C/S/B Urologist: Grade III Prostatomegaly (Benign) Plan- Evaluation of prostate after circumcision
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Grading for Prostate Enlargement
Intravesical protrusion of the prostate ( Using USG):• <5mm: Grade 1• >5mm to 10mm: Grade 2• >10mm: Grade 3
The IPP is more important than the prostate volume in prediction of the degree of obstruction as it is related to the size of the prostate as well as the presence of median lobe enlargement.
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• Fasciocutaneous flaps are tissue flaps that include skin, subcutaneous tissue and the underlying fascia
• Use fasciocutaneous flaps to provide coverage when a skin graft or random skin flap is insufficient for coverage (eg, in coverage over tendon or bones)
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Drug Dose R Freeq
Tab. Carvedilol 3.125 mg PO 1-0-1
Tab. Ramipril 1.25 mg PO 1-0-1
Tab. glimpiride 2 mg PO 1-0-0
Tab. Aspirin + Clopidogrel + Atorvastain 75/75/10 mg PO 0-1-0
Tab. Cilnidipine 10 mg PO 1-0-0
Tab. Tramadol 100 mg PO 1-0-1
Tab. Enzoheal (Trypsin+ Bromelin + Rutaside) 48+90+100 mg PO 1-1-1
Tab. Paracetamol 650 mg PO 1-0-1
Inj. tramadol 50 mg IV 1-0-1
Tab. Cefditoren Pivoxitil 200 mg PO 1-0-1
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DAY 9
• BP: 146/80 mm Hg Pulse: 84 BPM• FCBG: 232 mg/dl• O/E Afebrile• No fresh complains• CVS/ RS: NAD• ADV: CST, Physiotherapy
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Drug Dose R Freeq
Tab. Carvedilol 3.125 mg PO 1-0-1
Tab. Ramipril 1.25 mg PO 1-0-1
Tab. glimpiride 2 mg PO 1-0-0
Tab. Aspirin + Clopidogrel + Atorvastain 75/75/10 mg PO 0-1-0
Tab. Cilnidipine 10 mg PO 1-0-0
Tab. Tramadol 100 mg PO 1-0-1
Tab. Enzoheal 48+90+100 mg PO 1-1-1
Tab. Paracetamol 650 mg PO 1-0-1
Tab. Cefditoren Pivoxitil 200 mg PO 1-0-1
Inj. Ceftriaxone 1 gm IV 1-0-1
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DAY 10
• BP: 140/80 mm Hg Pulse: 76 BPM• FCBG: 160 mg/dl• O/E: Afebrile• CVS/RS: NAD• ADV: CST and Physiotherapy
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Drug Dose R Freeq
Tab. Carvedilol 3.125 mg PO 1-0-1
Tab. Ramipril 1.25 mg PO 1-0-1
Tab. glimpiride 2 mg PO 1-0-1
Tab. Aspirin + Clopidogrel + Atorvastain 75/75/10 mg PO 0-1-0
Tab. Cilnidipine 10 mg PO 1-0-0
Tab. Tramadol 100 mg PO 1-0-1
Tab. Enzoheal 48+90+100 mg PO 1-1-1
Tab. Paracetamol 650 mg PO 1-0-1
Tab. Cefditoren Pivoxitil 200 mg PO 1-0-1
Inj. tramadol 50 mg IV 1-0-1
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DAY 11
• BP: 140/80 mm Hg Pulse: 80 BPM• FCBG: 142 mg/dl• O/E No fresh complains• CVS/ RS: NAD• ADV: CST
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Drug Dose R Freeq
Tab. Carvedilol 3.125 mg PO 1-0-1
Tab. Ramipril 1.25 mg PO 1-0-1
Tab. glimpiride 2 mg PO 1-0-1
Tab. Aspirin + Clopidogrel + Atorvastain 75/75/10 mg PO 0-1-0
Tab. Cilnidipine 10 mg PO 1-0-0
Tab. Tramadol 100 mg PO 1-0-1
Tab. Enzoheal 48+90+100 mg PO 1-1-1
Tab. Paracetamol 650 mg PO 1-0-1
Tab. Cefditoren Pivoxitil 200 mg PO 1-0-1
Inj. tramadol 50 mg IV 0-1-0
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DAY 12 & 13
• BP: 140/80 mm Hg & 130/80 mm Hg • Pulse: 86 BPM & 84 BPM• FCBG: 135 mg/dl & 126 mg/dl• O/E Afebrile, C/O Pain• No fresh complains• CVS/ RS: NAD• ADV: CST, Uroflowmetry
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Drug Dose R Freeq
Tab. Carvedilol 3.125 mg PO 1-0-1
Tab. Ramipril 1.25 mg PO 1-0-1
Tab. glimpiride 2 mg PO 1-0-1
Tab. Aspirin + Clopidogrel + Atorvastain 75/75/10 mg PO 0-1-0
Tab. Cilnidipine 10 mg PO 1-0-0
Tab. Tramadol 100 mg PO 1-0-1
Tab. Enzoheal 48+90+100 mg PO 1-1-1
Tab. Paracetamol 650 mg PO 1-0-1
Tab. Cefditoren Pivoxitil 200 mg PO 1-0-1
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PHARMACEUTICAL CARE PLAN (SOAP)
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SUBJECTIVE EVIDENCEFor Venous Ulcer For HF For AKI
• Pain in Left lower leg since 15 days• Ulcer on the Left Leg associated with swelling of the surrounded tissue • K/C/O Varicose veins & operated 3 times
• B/L Pitting Edema +• K/C/O IHD
• Difficulty in passing urine
• Pitting Edema
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OBJECTIVE EVIDENCE
For HF For AKI Others
• Elevated BP• ECG Changes: T Wave inversion• 2-D ECHO: Mod. LV Systolic DysfunctionLV Diastolic Dysfunction +• EF: 34 %• Chest X- Ray: Cardiomegaly
• Elevated Urea• Elevated S.Cr• Elevated Potassium• Elevated BP• USG-KUB: Prostaomegaly
• Elevated Blood Glucose • Fundoscopic changes
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FINAL DIAGNOSIS
On the basis of subjective & objective parameters the final diagnosis was made as Congestive Heart Failure with Hypertensive
retinopathy with T2DM with Benign Prostatic Hyperplasia Induced Acute Kidney Injury
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GOALS OF TREATMENT
Pre- Surgery:• To relieve signs & symptoms.• To Control the patient’s BP, Blood Glucose levels.• To Stabilize Patient before commencing surgery.• To Prevent further insult to the Myocardium & Kidneys• To Prevent Further complications associated with HTN, DM.
Post- Surgery:• To ambulate the patient as soon as possible to prevent Secondary
Complications of the surgery (DVT)• To Improve Health Related Quality of life of the Patient
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TREATMENT OPTIONSFor HF & HTN For T2DM For BPH For Varicose Veins &
Venous Ulcer• ACE Inhibitors / ARB’s• Beta Blockers• Diuretics• Spironolactone• Digoxin• Anti platelets• Anti Dyslipidemic agents• Non DHP’s
• SU’s• Biguanides• Alpha Glucosidase Inhibitors• Insulin
• 5 Alfa reductase inhibitors• Alpha 1 antagonists• Surgeries
• Sclerotherapy• Laser treatment• Radiofreequency treatment• Ligation & Stripping• Catheter Assisted Procedure• Ambulatory Phlebectomy• Endoscopic vein Surgery
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GOALS ACHIEVED
• Urea & Serum creatinine were brought to near normal
• Blood pressure was brought to near normal
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PROBLEMS IDENTIFIED
Monitoring error:• Lipid profile not done• Cardiac enzymes were not done • Glycosylated Hemoglobin was not done• Serum electrolytes were not repeatedUntreated indication: Hyperkalemia, BPHImproper Drug selection: MetforminDrug Class Duplication: Cephalosporin's (Day 8)
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MONITORING PARAMETERS Disease Specific
ECG 2-D ECHO Chest X-RAY Fundoscopy Blood Pressure Lipid Profile Blood Glucose HbA1c RFT Serum Electrolytes Cardiac Enzymes USG- KUB ABG
Drug Specific Blood Pressure Lipid Profile Blood Glucose HbA1c Serum Electrolytes Platelet Count LFT
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PATIENT COUNSELLING
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Symptoms of DM
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Symptoms of BPH
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About Medications
– Name and purpose
– Dose and frequency
– Medication adherence
– Possible adverse effects
– Missed dose
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Life Style Modifications
For Varicose veins & Venous Ulcers
• Exercise (Cycling)• Check on weight & diet• Watch what to wear• Legs Elevation• Avoid Sitting & Standing for
too Long• Avoid sitting cross legged
For Hypertension• Cut the Salt• Get Your Grains• Load Your Plate With
Vegetables• Don't Forget Fruit• Have Some Yogurt• Go for Lean Meats and Fish• Add Nuts and Legumes• Cut Back on Fats and Oils• Watch the Sweets• Get Enough Potassium
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