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Local bacterial infection
inflammatory cells
Dipiro, Pharmacotherapy: A Pathophysiologic Approach
(a)peripheral neuropathy
Kept NBM
(b) angiopathy and ischemia
Wound inspection:
clean
minimal slough
no surrounding erythema
Alert well
H S1S2
L clear
A soft
12 May A&E
SBMY 41 y.o Male Malay
CC: Swelling of left plantar.
A/w pain. Has to limp to walk.
PE: T 35.8 HR 109 RR 20 BP 112/72
Alert well
H S1S2
L Clear
A soft
Left plantar of foot boggy warm abscess, tender
HPI: L foot sole swelling and pain since 30 Apr 14
History of barefoot walk in Mecca.
Started on sole of left foot and progressed.
Seen by KTPH and treated with analgesics with no improvement.
No fever, SOB, palpitations, chest pain.
No URTI or UTI symptoms
Rx from 2010
Aspirin 100mg OM
Dipyridamole 150mg TDS
Famotidine 40mg OM
Metformin 500mg BD
Simvastatin 10mg ON
Atacand 16mg OM
PMH: Obstructive sleep apnea syndrome s/p ENT surgery and weight loss
TIA
DM HTN HLD, non-compliance to treatment
Famotidine 20mg OM
SH: Smoker: 20 cigarettes/day x 20 yrs
Non-drinker
Radiology:
Medications: Nil current medications
Rx from 2010 - Aspirin 100mg OM
Dipyridamole 150mg TDS
Famotidine 40mg OM
Metformin 500mg BD
Simvastatin 10mg ON
Atacand 16mg OM ( GP Rx from 2012)
HTN
Objective: elevated BP (BP chart)
restart his medications
Goals: Reduce risk of CVD
AHA, Treatment of Hypertension in the Prevention and Management of Ischemic Heart Disease 2007
BP < 140/90 JNC8
BP <130/80 JNC7
Post-op: Losartan 25mg BD
Non-pharmacological: Weight reduction
Adopt DASH eating plan
Physical exercise
Quit smoking
Discharge medications and appointment
References
1. ADA, Standards of Medical Care in Diabetes, 2014
2.ADA, Management of Hyperglycemia in Type 2 Diabetes, 2012
3.Stone NJ, et al 2013 ACC/AHA Blood Cholesterol Guideline
4.Dipiro, Pharmacotherapy -A Pathophysiologic Approach
5.Lexi-Comp online, Lexi-Drugs Multinational, Acute Postoperative Pain; accessed May 20, 2014
6. UpToDate
7. AHA, Use of Nonsteroidal Antiinflammatory Drugs, 2007.
Goal: Reduce ASCVD risk
ATPIII LDL <1.8 to 2.6 (DM, CKD, Clinical ASCVD)
TG <1.7
HDL >1.6
TC <5.2
Post-op (D4): Simvastatin 20mg ON
LFTs should be performed before starting statin therapy, and "as clinically indicated thereafter"
Diagnosis
Left plantar diabetic foot abscess
Uncontrolled DM HTN HLD, non compliance to medication
High Intensity Therapy
Hx of ASCVD (TIA)
Non-pharmacological
Weight reduction BMI 29.1
Diet modification
Physical exercise
Quit smoking
ACE/ARB: 1st line agent in patients with DM & CKD
Class I ACC/AHA recommendation
Check renal function, K+
Lab:
(CrCl 171ml/min) (Plt 311)
(+) useful for DM with proteinuria
Urine protein/Creatinine ratio 0.2 (normal <0.2 nephrotic range >3.0)
Monitor: renal function, K+, dry cough & angioedema
(less likely vs ACE inhibitors)
– Follow up fasting lipids panel in 4-12 weeks after initiation or dose adjustment
– If therapeutic, follow up 3-12 months thereafter
– If not therapeutic, follow up in 4-12 weeks again for adherence and tolerability as needed
2013 ACC/AHA Blood Cholesterol Guideline
Prevent target organ damage
(stroke, MI, CHF, proteinuira, retinopathy)