What is this? 86y/o DM pt with this darkened area since 15days initially there was pain now no pain but sensation present pt is suffering frm dementia doesn't remember how it happened Dm under control with actrapid TDS , n Lantus at night .Help me DX n give proper advice fr further management

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Dear Gayathri, this is a case of 86 years old patient with diabetes with diabetic foot ? ? dry gangrene of affected area with neuropathy. Is the diabetes under control? Is she on antiplatelet drugs? Is there any history of trauma? Look for Peripheral pulses to assess vascularity. order the following investigations FPG PPG HBA1C CBP RFT LFT TFT Fasting lipid profile Serum electolytes ECG CUE Micralbuminuria X ray of same foot vascular doppler of the same limb . Culture and sensitivity of pus if any. Treatment is 1 Meticulous control of diabetes with insulin. 2 Wound debridement with slough excision after assessment of vascularity of the limb. 3 Regular dressings 4 Antibiotics against gram positive gram negative and anerobes 5 Tissue lytics like chymotrypsin and trypsin 6 Proper foot wear 7 proper foot care 8 Absolute bed rest 9 Refer the patient to a surgeon for further management.

Thanks mam he is my uncle have already referred him to higher center .just 1wk back he was discharged frm Fortis Hospital. he was treated fr fever all parameters were normal except low sodium ,mildly positive fr typhoid (1:60) RX given on discharge Levofloxicin x7days alog with his usual meds ...with all parameters normal then suddenly he developed this problem ..better to get him admitted again anyways thanks fr the feedback
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Mam if dm is under control it may b RAYNAUD disease hyperactivation of the sympathetic nervous system causing extreme vasoconstriction of the peripheral blood vessels, leading to tissue hypoxia. Chronic, recurrent cases of Raynaud's phenomenon can result in atrophy of the skin, subcutaneous tissues, and muscle. In rare cases it can cause ulceration and ischemic gangrene. It is important to distinguish Raynaud's disease (primary Raynaud's) from phenomenon (secondary Raynaud's). Looking for signs of arthritis or vasculitis as well as a number of laboratory tests may separate them. A careful medical history will often reveal whether the condition is primary or secondary. Once this has been established, an examination is largely to identify or exclude possible secondary causes. Digital artery pressure: pressures are measured in the arteries of the fingers before and after the hands have been cooled. A decrease of at least 15 mmHg is diagnostic (positive). Doppler ultrasound: to assess blood flow. Full blood count: this may reveal a normocytic anaemia suggesting the anaemia of chronic disease or renal failure. Blood test for urea and electrolytes: this may reveal renal impairment. Thyroid function tests: this may reveal hypothyroidism. An autoantibody screen, tests for rheumatoid factor, Erythrocyte sedimentation rate, and C-reactive protein, which may reveal specific causative illnesses or a generalised inflammatory process. Drugs can be helpful for moderate or severe RP. Vasodilators calcium channel blockers such as the dihydropyridines nifedipine, amlodipine or diltiazem, preferably slow release preparations are often first line treatment. They have the common side effects of headache, flushing, and ankle edema; but these are not typically of sufficient severity to require cessation of treatment.The limited evidence available shows that calcium channel blockers are only slightly effective in reducing how often the attacks happen.Patients whose RP is secondary to Erythromelalgia often cannot use vasodilators for therapy as they trigger 'Flares' in EM patients causing the extremities to become burning red due to there being too much blood in the extremity. Patients with severe RP prone to ulceration or large artery thrombotic events may be prescribed aspirin. Sympatholytic agents, such as the alpha-adrenergic blocker prazosin may provide temporary relief. Losartan can, and topical nitrates may, reduce the severity and frequency of attacks, and the phosphodiesterase inhibitors sildenafil and tadalafil may reduce their severity. Angiotensin receptor blockers or ACE inhibitors may aid blood flow to the fingers,and there is some evidence that angiotensin receptor blockers (often losartan) reduce frequency and severity of attacks, and possibly better than nifedipine. The prostaglandin iloprost is used to manage critical ischemia and pulmonary hypertension in RP, and the endothelin receptor antagonist bosentan is used to manage severe pulmonary hypotension and prevent finger ulcers in SSc. Statins have a protective effect on blood vessels, and SSRIs such as fluoxetine may help RP symptoms but the data is weak.

Thank you so much Dr Dinesh fr such a wonderful n detailed feedback .will go fr further investigations
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DD Pressure sore A simple contusion turning into diabetic foot due to uncontrolled DM An ulcer due to peripheral vascular disease... As patient can't remember.. it may be a scald burn... Just give him parenteral antibiotics with good coverage... a combination of trypsin chemotrypsin and rutin bid... do color Doppler... DM control... wait and watch...

Ok agreed Dr
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? PRESSURE SORE.. ? DIABETIC FOOT.. ? VASCULOPATHY..? PVD .. NEED'S.. * HEMOGRAM.. * CT BT PT.. * BSR..HBA1C.. * X-RAY STUDY.. * COLOUR DOPLAR STUDY.. * EXPERTS OPINION..

Hi. Dr Gayathri. A similar case I saw recently in an .88yr old female DM patient. Do not know how long it was present but when I saw her she had pain and cellulitis of that leg with fever. She was hospitalised and given Clindamycin and local dressing.Since she is bedridden, this could be due to some pressure effect on that area?.

Agree with u Dr this pt is hardly walks due to less food intake n dementia meds most of the days he is drowsy
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SINCE PATIENT HAS D M THE PICTURE IS DIGESTIVE OF DIABETIC ULCER WITH IMPENDING GANGRENE WHAT IS THE PRESENT F B S HBAIC ONE HAS TO CONTROLL PATIENTS BLOOS SUGER ALL THESE DEMENTIA DIABETIC DERMOOATHY ULCER ARE COMPLECATIONS OF UNCONTROLLED D M

Gangrene do CT angiogram& ref to vascular surgeon

Dibetic foot cellulities dibetic control purpura vasular diseses do rbs cbc for platlet urin e r tft rft lft for renal function test for microalbuminurea

Thanks for your feedback Dr but sorry that pt died last year
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Dr sepuri terumali.wonderful explanations and advice

Control blood sugar strictly Get done Doppler of involved limb and preferably opposite limb too Asses local pulses Improve microcirculation by pentoxyphylline Avoid vasodilators as it will aggregate post stenotic ischaemia on performing activity Improve circulation locally and get opinion of of cardiologist whether angiographic intervention required or not Improve local circulation by above measures then debride patch otherwise ulcer won't heal

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