MR RS a 46yr old retired hobby farmer who developed an infected wound following a mid-foot amputation. It presented as a fungating ulcer with clear signs of infection and inflammation to the mid-foot area. He was sent to theatre for further debridement of wound.
Medications on admission Amlodipine 10mg in the morning
Atenolol 50mg daily
Metformin 500mg twice a day
NovoRapid 25 units mane, 20 units noon, 25 units nocte
Prazosin 1mg twice a day
Ramipril 10mg daily
Simvastatin 40mg at night
BP 156/74 Creatinine 144 μmol/L (60 – 110 μmol/L)
eGFR 40 mL/min/1.73 m2
Nil tobacco, Alcohol occasionally
Mr RS developed hyperglycaemia post-surgical procedure.
He was commenced one insulin glargine (Lantus) 34 units mane and 20 units nocte whilst in hospital. Other medications and adjustments made during admission were as follows.
Cephalexin 500mg orally QID
Sitagliptin and Metformin (Janumet) 50/500mg BD
Metformin 500mg BD
NovoRapid 14 units TDS (before meals)
Ibuprofen 400mg three times a day and Oxycodone 5mg to 10mg every 3 hours when needed for severe pain.
Questions:
1. Describe the microvascular and macrovascular issues in diabetes and how these may have impacted Mr RS .( 200 words )
2. Discuss diabetes management in relation to his surgical procedure ..( 200 words )
3. Discuss insulin glargine, listing any potential benefits this therapy may offer and the specific aspects of the formulation in relation to its action. Include appropriate counselling points regarding the administration of this agent ..( 250 words )
4. Discuss the new oral medication for this patient and any concerns that you would have with its use specifically in this patient taking into account the information presented ?( 200 words )
5. What considerations need to be made regarding this patient’s pain relief ?( 200 words )