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Presented by:Vineetha Menon
VI pharm DJSSCP
RISK FACTORS:•Diet and obesity, increasing age, female gender, and genetics.•Reduced sleep- effect on metabolism•Medical conditions and drugs
DIAGNOSIS:•Fasting plasma glucose •OGTT
SYMPTOMS:•Numbness and tingling of extremities•Diarrhea•Erectile dysfunction•Urinary incontinence•Facial, mouth and eyelid drooping•Vision changes•Difficulty swallowing•Speech impairment
SYMPTOMS:Anxiety, confusion, reduced alertness, headache, blurred vision, weakness and numbness of limbs, nausea, vomiting
DIAGNOSISPersistently high blood pressure- 3 separate readings at 1 month interval
RISK FACTORS:•Obesity•Genetics•Diabetes•High cholestrol•Low birth weight•Smoking
IP NO : 1310280 UNIT : VKH general medicine
AGE : 38 yrs SEX : Female
WEIGHT: 52 kg DOA : 27/8/13
DOD : 31/8/13
Patient details
C/O: Giddiness and generalized weakness 1week Burning and Tingling sensation of lower limbs Blurring of Vision
H/O: Burning micturition
Reason for admission
SHx : NS
PMHx : K/C/O Type II DM x 3yrs (on T. triglycomet) and
HTN x 1yr (T. Amlodipine 2.5mg)
Allergies : NKA
Type II DM with Hypertension
? Peripheral neuropathy
? UTI
Provisional diagnosis
Day 1
c/o: Burning sensation in lower limbs
BP : 140/100 mmHg PR : 80 bpm
ADV : Hb, TC, DC, RBS, HbA1C, Urine routine, Lipid Profile, AST, ALT, SCr, ECG, Ophtho Opinion CST
8 pm CBG : 196 mg/dl
Medication Dose Route Frequency D1 D2 D3 D4 D5
Glibenclamide+ metformin+ pioglitazone
5mg+ 500mg+1
5mg
PO 1-0-1 +
Pantoprazole 40 mg IV 1-0-0 + (tab)+
+ + +
Amlodipine 2.5 mg PO 1-0-1 +
Losartan 50 mg PO 1-0-1 + + + +
H. mixtard 30/70 SC 20-0-10 + 22-0-12
+ +
Pregabalin+ Mecobalamin
75mg+750µg
PO 1-0-1 + + + +
Ciprofloxacin 100 ml IV 1-0-1 + + + +
Metformin 500 mg PO 1-0-1 + +
Medications:
Day 2
BP : 130/98 mmHg PULSE : 84 bpm
C/o: Tingling and numbness of lower limbs Adv: Fundoscopy, Diet Counselling and Urine culture
STOP: T. Triglycomet
START: Inj. H.Mixtard (30/70) S/C 20-0-10
C. Pregabalin+ Mecobalamin (75mg+750mcg) PO 1-0-1
Inj. Ciprofloxacin 100 ml IV 1-0-1
6 am CBG : 273 mg/dl1 pm CBG : 176 mg/dl8 pm CBG : 210 mg/dl
Day 2 cont…..
Hematology:
Hb 12 mg/dl
TLC 5400 cells/cu.mm
DLC: N 60%
L 35%
M 01%
E 04%
B 00%
PLT 1.8 cells/cu.mm
ESR 30 mm/hr
Biochemistry:
HbA1c 8
Urea 20 mg/dl
Se. Cr 1.2 mg/dl
AST 23 U/l
ALT 19 U/l
Day 2 cont…..
Cholesterol 232 mg/dl
HDL 39 mg/dl
LDL 78 mg/dl
VLDL 15 mg/dl
TG 80 mg/dl
Sodium 138 mmol/l
Potassium 4.0 mmol/l
Chloride 105 mmol/l
Albumin +
Sugar ++
Pus cells 6-8
Epithelial cells 2-3
Presence of occasional casts
ECG WNL
Medication Dose Route Frequency D1 D2 D3 D4 D5
Glibenclamide+ metformin+ pioglitazone
5mg+ 500mg+1
5mg
PO 1-0-1 +
Pantoprazole 40 mg IV 1-0-0 + (tab)+
+ + +
Amlodipine 2.5 mg PO 1-0-1 +
Losartan 50 mg PO 1-0-1 + + + +
H. mixtard 30/70 SC 20-0-10 + 22-0-12
+ +
Pregabalin+ Mecobalamin
75mg+750µg
PO 1-0-1 + + + +
Ciprofloxacin 100 ml IV 1-0-1 + + + +
Metformin 500 mg PO 1-0-1 + +
Medications:
O/e : Burning sensation decreased.
Optho opinion : Rt eye: Normal Fundus
Lt eye: Fundus- Superficial Hemorrhage, microaneurysm, retinal retinopathy with Grade –III HTN
Adv: INJ. H.Mixtard (30/70) S/C 22 -0- 12
CST
Day 3
BP:120/80 mmHg PULSE: 80 bpm
6 am CBG : 210 mg/dl1 pm CBG : 138 mg/dl8 pm CBG : 179 mg/dl
Urine Culture report : no bacterial growth after 24 hrs of incubation
Medication Dose Route Frequency D1 D2 D3 D4 D5
Glibenclamide+ metformin+ pioglitazone
5mg+ 500mg+1
5mg
PO 1-0-1 +
Pantoprazole 40 mg IV 1-0-0 + (tab)+
+ + +
Amlodipine 2.5 mg PO 1-0-1 +
Losartan 50 mg PO 1-0-1 + + + +
H. mixtard 30/70 SC 20-0-10 + 22-0-12
+ +
Pregabalin+ Mecobalamin
75mg+750µg
PO 1-0-1 + + + +
Ciprofloxacin 100 ml IV 1-0-1 + + + +
Metformin 500 mg PO 1-0-1 + +
Medications:
C/O: Generalized Weakness
Adv : START: T. Metformin 500 mg PO 1-0-1
CST
Day 4
BP: 110/80 mmHg PR: 80 bpm
6 am CBG : 186 mg/dl1 pm CBG : 110 mg/dl8 pm CBG : 132 mg/dl
Medication Dose Route Frequency D1 D2 D3 D4 D5
Glibenclamide+ metformin+ pioglitazone
5mg+ 500mg+1
5mg
PO 1-0-1 +
Pantoprazole 40 mg IV 1-0-0 + (tab)+
+ + +
Amlodipine 2.5 mg PO 1-0-1 +
Losartan 50 mg PO 1-0-1 + + + +
H. Mixtard 30/70 SC 20-0-10 + 22-0-12
+ +
Pregabalin+ Mecobalamin
75mg+750µg
PO 1-0-1 + + + +
Ciprofloxacin 100 ml IV 1-0-1 + + + +
Metformin 500 mg PO 1-0-1 + +
Medications:
C/O: No fresh complaints
Adv : Discharge
Review after 1 week
Day 5
BP: 120/80 mmHg PR: 80 bpm
6 am CBG : 110 mg/dl
Medication Dose Route Frequency D1 D2 D3 D4 D5
Glibenclamide+ metformin+ pioglitazone
5mg+ 500mg+1
5mg
PO 1-0-1 +
Pantoprazole 40 mg IV 1-0-0 + (tab)+
+ + +
Amlodipine 2.5 mg PO 1-0-1 +
Losartan 50 mg PO 1-0-1 + + + +
H. mixtard 30/70 SC 20-0-10 + 22-0-12
+ +
Pregabalin+ Mecobalamin
75mg+750µg
PO 1-0-1 + + + +
Ciprofloxacin 100 ml IV 1-0-1 + + + +
Metformin 500 mg PO 1-0-1 + +
Medications:
Discharge medications
Review after 1 week
Medications Dose Route Frequency
H. mixtard 30/70 SC 22-0-12
Losartan 50 mg PO 1-0-1
Pregabalin+ Mecobalamin
75mg+750mcg
PO 1-0-1
Metformin 500 mg PO 1-0-1
Pantoprazole 40 mg PO 1-0-0
Pharmaceutical Care Plan
Subjective evidences:
Giddiness & Generalized weakness Burning and Tingling sensation of
lower limbs Blurring of Vision
Objective evidences:
Elevated BP Elevated blood sugar levels
(CGB and HbA1c)
Type II DM with Peripheral Neuropathy with Hypertension
Assessment
HYPERTENSION:To relieve signs and symptomsTo control the elevated BP and maintain it in the near normal levelsTo reduce further complicationsTo improve the quality of life by counselling the patient about his disease and managament of HTN.
DIABETES MELLITUS:To relieve signs and symptoms To maintain a near normal blood glucose levelsTo reduce further progression of micro vascular and macro vascular complications To prevent symptoms of hyperglycemia and hypoglycemiaTo improve the quality of life by counselling the patient about his disease and managament of Diabetes.
Goals of treatment
PERIPHERAL NEUROPATHY:To attain relief from pain and to restore functionTo control the underlying disease condition causing itPreventing significant decrease in the patients QOL
BP was under control by day 2 Burning sensation decreased by day 3 Diabetes was under control by day 5
Goals achieved
HYPERTENSION: ACE inhibitors/ABR Thiazide diuretics
TYPE II DIABETES MELLITUS: Insulin Biguanides (statins)
DIABETIC NEUROPATHY: Tricyclic antidepressants Serotonin norepinephrine reuptake inhibitors Antiepileptic drugs Opioid analgesics
Treatment options
Inadequate dose: Pregabalin Untreated indication: Hyperlipidaemia
Problem identified
Monitoring Parameters For
disease
BP ECG CXR Lipid profile Metabolic panel Renal function test Fundoscopy CBG HbA1c
Monitoring parameters for drugs
ADRs
Monitoring Parameters
Patient Counselling
RISK FACTORS:•Diet and obesity, increasing age, female gender, and genetics.•Reduced sleep- effect on metabolism•Medical conditions and drugs
SYMPTOMS:Anxiety, confusion, reduced alertness, headache, blurred vision, weakness and numbness of limbs, nausea, vomiting
RISK FACTORS:•Diet and obesity, increasing age, female gender, and genetics.•Reduced sleep- effect on metabolism•Medical conditions and drugs
SYMPTOMS:•Numbness and tingling of extremities•Diarrhea•Erectile dysfunction•Urinary incontinence•Facial, mouth and eyelid drooping•Vision changes•Difficulty swallowing•Speech impairment
About the medication:
- Medication adherence - How and when to take medications - Missed dose
Restricted •Salt and sugar intake•Red meat•Dairy products
Avoid stress
THANK YOU