Concluded Case

DM,toe amputation, sensory nueropathy, Depression, cognitive decline.

Gangrene toe and its amputation . Treated and its follow up . Mr X aged about 40 years ,is T2 DM on insulin therapy of Biphasic insulin on multiple doses. Due to poverty ,he fails to take the insulin in an regular basis and therefore he is on intermittently he is on insulin therapy. Due to sensory loss, and he is hard labourer, he gets his toes hurt. One year before he came with gangrene right great toe ,and it was amputated and leg was saved from further spread of infection. He was suffering from both central cognitive impairment due to depression and sensory loss of feet.Both of them are directly related to DM. Due to cognitive impairment ,he is inattentive to the advise while on ,one to one discussion regarding diabetes educational issues and its preventive management's of secondary and tertiary care regarding.The end result is ,he came back with 2 toe gangrene in the same foot,which forced me to amputate the terminal phalanx of the toe. Both the situation , he is lucky enough to save the limb. His depression is due to multifactorial. DM,toe loss,sensory loss and loss of job ,poverty all further push him to depression. Diabetes variability, its glucose peak and valley in serum of the patient , high glycemic index and neuroglycopenias further favoured the cognitive impairment and depression related cognitive impairment both combined together ,worsen the situation of diabetes complications . Now he is put on SSRI to manage the depression is recuperating him from the depressions and he is now attentive to the medical advise. Discuss the case.

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Concluded answer
This is the case of DM T2,poly nueropathy diabetic ,toe gangrene, with occupational hazard of injury to the toe in sensory deficit ,and gangrene development. Diabetes variability, major depression due to nueroglycopenia ,and hyperglycemia induced cerebral cortical dysfunction, with attention deficit of cognitive impairment. Multi prong approach of multi disciplinary specialist service will help him. But due to his poverty ,physician with well equipped knowledge of medicine may tackle him. SSRI added therapy in this patient helped him to learn about diabetes management, of foot care .
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Thanks Dr Elumaiai for the elaborate and detailed history and sympathetic attitude towards,patient. There are many points which require appropriate settlement 1.Considering his poor financial condition- as insulin is costly and require refrigeration- it is better not to use insulin if he is not regular . A combination of Pioglitazone 15 mg + glimepride 2 mg + metformin- ( Glorimet PG2 ) by Oaknet Pharma company- the makers of inj Jectocos is available at Rs 65 per strip of 10 tablets , If use once or twice a day depending upon his glycemic index is a better alternative. 2.As age 40 years is too young to have cognitive impairment due to DM but cerebral paraventricular T2 weighted hyperdensities and arteriolosclerosis is the commonest cause of cognitive impairment. Tab cerevate ( cerebro protein ) or tab Donepezil 5 or 10 mg is effective in improvement of cognitive function in such cases . 3.Considering his depression- you have rightly put him on SSRI . 4.Diabetic foot care advice need to be given besides use of tab cilostazol 50 mg B.D to improve blood supply to the limb due to associated diabetic PVD . 5.As he is poor - motivate him to work more and burn his calories
Thank you doctor.
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This case rquar insulone Propr care toes nfeef T wear diabetic shoe Multivimine Doppler study leg Xy test to see bony iinvolmt gvccult I sensitivity of wound swab Strrt bbroad spet antibiotic
This is the case of DM T2,poly nueropathy diabetic ,toe gangrene, with occupational hazard of injury to the toe in sensory deficit ,and gangrene development. Diabetes variability, major depression due to nueroglycopenia ,and hyperglycemia induced cerebral cortical dysfunction, with attention deficit of cognitive impairment. Multi prong approach of multi disciplinary specialist service will help him. But due to his poverty ,physician with well equipped knowledge of medicine may tackle him. SSRI added therapy in this patient helped him to learn about diabetes management, of foot care .
True it is just like a death but to live Nice efforts done by you sir SSRI will definitely help in his cognitive impairment Simultaneously control of diabetes Yes his poverty and joblessness forcing him to be irregular despite a wise counseling by you All you can do it to take help of pharmacies and social trusts to help him and provide medication
Thank you doctor
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Congratulations! Your case has been selected as Case of the day and you have been awarded 5 points for sharing the case. Keep posting your interesting cases, Happy Curofying!
Diabetic may be smoker raynods disease CT angiogram at muncipal centre opinion of vascular surgeon proper covered shoe if any blockage can be corrected
Diabetic foot lab take care these type of cases especially
Thank you doctor
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Immediate hospitalization under dia- Specialist.