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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