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Venous ulcer
- 1. Case presentation on Venous Ulcer with Heart Failure with Type 2 DM With AKI By : Abhimanyu Parashar Pharm D Intern 1
- 2. I.P No. 262406 UNIT Surgery 1 AGE 56 years SEX Male WEIGHT NAS 2
- 3. 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 3
- 4. 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 4
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- 7. 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 7
- 8. PROVISIONAL DIAGNOSIS Chronic Venous Ulcer, Type 2 DM, Hypertension and IHD 8
- 9. DAY 1 BP: 160/90 mm Hg PULSE: 86 BPM Plan – Debridement ADV: 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 9
- 10. LAB REPORTS : Electrolytes Hematology Hb 12.9 g% Sodium 134 mmol/L TC 12400 cells/cumm Potassium 5.3 mmol/L DC N- 73%; L-26%; E-1% Chloride 102 mmol/L PLT 4.05 L/cumm ESR 40 mm/hr PT 17 sec RBS 180 mg/dl INR 1.30 Urea 42 mg/dl S.Cr 1.7 mg/dl GFR 41.9 ml/min CXR-PA View Biochemistry Cardiomegaly 10
- 11. DAY 2 BP: 170/100 mmHg PULSE : 84 BPM FCBG: 157 mg/dl C/O Pain in Left Lower Limb, Difficulty in passing urine O/E: Febrile ADV: physician Opinion, Fundoscopy, USG KUB, Diet Counseling, CST HIV Negative HBS Ag Negative 11
- 12. 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 12
- 13. DAY 3 BP: 190/110 mmHg PULSE : 86 BPM FCBG: 108 mg/dl O/E Febrile, C/O pain in lower limb CVS, RS: NAD ADV: CST, ECHO 13
- 14. DAY 4 BP: 160/90 mmHg PULSE : 84 BPM FCBG: 115 mg/dl CVS/RS: NAD ADV: CST C/S/B Ophthalmologist : Imp- Grade II Hypertensive retinopathy changes in both eyes ADV: Fundoscopy every 6 months 14
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- 16. • HTR Grade III & IV are only considered as end organ damage • Grade I & II will be asymptomatic 16
- 17. 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 17
- 18. DAY 5 BP: 150/90 mmHg PULSE : 82 BPM FCBG: 129 mg/dl USG-KUB: • Mild Prostatomegaly • Small Renal calculi. ADV: Urologists opinion, CST 18
- 19. DAY 6 BP: 130/70 mm Hg PULSE : 74 BPM FCBG: 122 mg/dl O/E No fresh complains Afebrile CVS, RS: NAD ADV: Physiotherapy Physician 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 19
- 20. Drug Dose R Freeq Tab. Carvedilol 3.125 mg PO 1-0-1 Tab. Ramipril 1.25 mg PO 1-0-1 2 mg PO 1-0-0 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. glimpiride Tab. Aspirin + Clopidogrel + Atorvastain 20
- 21. DAY 7 BP: 162/98 mm Hg PULSE: 84 BPM O/E: Pt Febrile RBS: 180 mg/dl FBS: 129 mg/dl ADV: Physician opinion, Plastic surgeon Physician opinion: CVS: S1s2 +, No murmurs RS: B/L NVBS + ADV: CST 21
- 22. Drug Dose R Freeq Tab. Carvedilol 3.125 mg PO 1-0-1 Tab. Cardace 1.25 mg PO 1-0-1 2 mg PO 1-0-0 75/75/10 mg PO 0-1-0 Tab. Cilnidipine 10 mg PO 1-0-0 Tab. Tramadol 100 mg PO 1-0-1 48+90+100 mg PO 1-1-1 650 mg PO 1-0-1 Tab. glimpiride Tab. Aspirin + Clopidogrel + Atorvastain Enzoheal (Trypsin+ Bromelin + Rutaside) Tab. Paracetamol 22
- 23. DAY 8 BP: 150/80 mm Hg PULSE: 86 BPM FCBG: 145 mg/dl • C/S/B Plastic SurgeonO/E Afebrile Contraction band 15 cm over the ankle joint B/L Lower limb varicositis + ADV: Release of contraction - fasico cutaneous flap But 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 23
- 24. 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. 24
- 25. • 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) 25
- 26. Drug Dose R Freeq Tab. Carvedilol 3.125 mg PO 1-0-1 Tab. Ramipril 1.25 mg PO 1-0-1 2 mg PO 1-0-0 75/75/10 mg PO 0-1-0 Tab. Cilnidipine 10 mg PO 1-0-0 Tab. Tramadol 100 mg PO 1-0-1 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 Tab. glimpiride Tab. Aspirin + Clopidogrel + Atorvastain Tab. Enzoheal (Trypsin+ Bromelin + Rutaside) 26
- 27. 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 27
- 28. Drug Dose R Freeq Tab. Carvedilol 3.125 mg PO 1-0-1 Tab. Ramipril 1.25 mg PO 1-0-1 2 mg PO 1-0-0 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 1 gm IV 1-0-1 Tab. glimpiride Tab. Aspirin + Clopidogrel + Atorvastain Inj. Ceftriaxone 28
- 29. DAY 10 • • • • • BP: 140/80 mm Hg Pulse: 76 BPM FCBG: 160 mg/dl O/E: Afebrile CVS/RS: NAD ADV: CST and Physiotherapy 29
- 30. Drug Dose R Freeq Tab. Carvedilol 3.125 mg PO 1-0-1 Tab. Ramipril 1.25 mg PO 1-0-1 2 mg PO 1-0-1 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 Tab. glimpiride Tab. Aspirin + Clopidogrel + Atorvastain 30
- 31. DAY 11 • • • • • BP: 140/80 mm Hg Pulse: 80 BPM FCBG: 142 mg/dl O/E No fresh complains CVS/ RS: NAD ADV: CST 31
- 32. Drug Dose R Freeq Tab. Carvedilol 3.125 mg PO 1-0-1 Tab. Ramipril 1.25 mg PO 1-0-1 2 mg PO 1-0-1 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 Tab. glimpiride Tab. Aspirin + Clopidogrel + Atorvastain 32
- 33. 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 33
- 34. Drug Dose R Freeq Tab. Carvedilol 3.125 mg PO 1-0-1 Tab. Ramipril 1.25 mg PO 1-0-1 2 mg PO 1-0-1 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 Tab. glimpiride Tab. Aspirin + Clopidogrel + Atorvastain 34
- 36. SUBJECTIVE EVIDENCE For Venous Ulcer • 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 For HF • B/L Pitting Edema + • K/C/O IHD For AKI • Difficulty in passing urine • Pitting Edema 36
- 37. OBJECTIVE EVIDENCE For HF • Elevated BP • ECG Changes: T Wave inversion • 2-D ECHO: Mod. LV Systolic Dysfunction LV Diastolic Dysfunction + • EF: 34 % • Chest X- Ray: Cardiomegaly For AKI • Elevated Urea • Elevated S.Cr • Elevated Potassium • Elevated BP • USG-KUB: Prostaomegaly Others • Elevated Blood Glucose • Fundoscopic changes 37
- 38. 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 38
- 39. 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 39
- 40. TREATMENT OPTIONS For HF & HTN • ACE Inhibitors / ARB’s • Beta Blockers • Diuretics • Spironolactone • Digoxin • Anti platelets • Anti Dyslipidemic agents • Non DHP’s For T2DM • SU’s • Biguanides • Alpha Glucosidase Inhibitors • Insulin For BPH • 5 Alfa reductase inhibitors • Alpha 1 antagonists • Surgeries For Varicose Veins & Venous Ulcer • Sclerotherapy • Laser treatment • Radiofreequency treatment • Ligation & Stripping • Catheter Assisted Procedure • Ambulatory Phlebectomy • Endoscopic vein Surgery 40
- 41. GOALS ACHIEVED • Urea & Serum creatinine were brought to near normal • Blood pressure was brought to near normal 41
- 42. PROBLEMS IDENTIFIED Monitoring error: • Lipid profile not done • Cardiac enzymes were not done • Glycosylated Hemoglobin was not done • Serum electrolytes were not repeated Untreated indication: Hyperkalemia, BPH Improper Drug selection: Metformin Drug Class Duplication: Cephalosporin's (Day 8) 42
- 43. 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 43
- 47. About Medications – Name and purpose – Dose and frequency – Medication adherence – Possible adverse effects – Missed dose 47
- 48. 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 48
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