HTN,DM,LIMB WEAKNESS

1. CASE PRESENTATION ON DIABETES
MELLITUS,HYPERTENSION WITH
B/L LOWER AND UPPER LIMB
WEAKNESS
PRESENTED BY:-
CHANDANA C
2nd PHARM D
SREE SIDDAGANGA
COLLEGE OF PHARMACY

2. HYPERTENSION:-
DEFINITION:-Hypertension is defined as a condition
where blood pressure is elevated to an extent that
clinical benefit is obtained from blood pressure
lowering.
COMORBIDITY:-
DIABETES MELLITUS(TYPE II):-It is a long term
metabolic disorder that is characterised by high blood
sugar, insulin resistance , and relative lack of insulin.
WITH PROGRESSIVE WEAKNESS B/L LOWER LIMB AND
UPPER LIMB

3. ETIOLOGY:-
1.PRIMARY HYPERTENSION(90-95%):-Also called as essential
hypertension. Cause is unknown in the majority of patients.
2.SECONDARY HYPERTENSION(5-10%):-
• Renal vascular disease
• Endocrine disorders
• Drugs
• Pregnancy, Phechromocytoma
• Obstructive sleep obnia
• Thyroid and parathyroid disorders
• Acromegaly
• Coarctation of the aorta
• Alcohol
• Renal paranchymal diseases

4. RISK FACTORS:-
1.NON-MODIFIABLE RISK FACTORS:-Age , Genetic factor ,
Gender, Race.
2.MODIFIABLE RISK FACTORS:- Overweight , Obesity ,
Alcohol , Smoking , Salt intake , Certain chronic disease ,
Dislipidemia , Vitamin-D deficiency , Diabetes and sleep
obnia.
COMPLICATION:-
• Coronary artery disease
• Congestive cardiac failure
• Chronic renal failure
• Cerebral vascular accident(stroke)

5. PATHOGENESIS:-
Blood pressure is the mathematical product of cardiac
output and peripheral resistance.
1.Increased cardiac output:-
• Increased cardiac preload
• Venous constriction
2.Increased peripheral resistance:-
• Functional vascular constriction
• Structural vascular hypertropy

6. DIAGNOSIS:-
Blood pressure should be measured using a well
maintained sphygmanometer of validated accuracy.
Other diagnostic test includes:-
• ECG
• Chest X-ray
• Ambulatory blood pressure monitor

7. DIABETES MELLITUS
• Diabetes mellitus is a group of metabolic
disorder , characterised by hyperglycemia ,
associated with abnormalities in carbohydrate
, fat and protein metabolism and resulting in
chronic complications including microvascular
, macrovascular and neuropathic.
CLASSIFICATION:-
 Type 1:
• Immune mediated
• Idiopathic

8.  Type 2:
• May range from predominantly insulin resistant ,
predominantly insulin deficient
• Other specific types
• Genetic defect of beta cell function
• Genetic defect in insulin action
• Diseases of the endocrine pancreas
• Drug or chemical induce
• Infections
• Uncommon forms of immune mediated diabetes

9. EPIDEMIOLOGY:-
• Type 1 DM usually develops in childhood or early
adulthood , all the some latent forms do occur type 1
DM accounts for up to 10% of all cases of DM and
results from autoimmune destruction of pancreatic
beta cells . This process is likely initiated by the
exposure of a genetically susceptible individual to an
environmental agent.
• Preclinical beta cell autoimmunity preceeds the
diagnosis of type 1 DM up to 9 to 13 years .
Autoimmunity may remit in some perhaps less
susceptible persons or can progress to beta cell failure
in others .

10. ETIOLOGY:-
• The exact cause of type 1 diabetes is unknown
usually , the body’s own immune system which
normally fights harmful bacteria and viruses
mistakenly destroys the insulin producing cells in
the pancreas other possible causes include
• Genetics
• Exposure to viruses and other environmental
factors

11. RISK FACTORS:-
• Family history is important in some cases of type
1 diabetes . If any of the family member with
type 1 diabetes , the risk of developing increases
• Race may be risk factor for type 1 diabetes it is
more common in white individuals than in people
of other races

12. PATHOGENISIS:-
• Type 1 diabetes mellitus is characterised by
absolute deficiency of insulin most often this is the
result of an immune mediated destruction of
pancreatic beta cells but rare unknown or idiopathic
processes may contribute.
• The auto immune process is meadiated by
macrophages and T - lymphocytes with circulating
and auto antibodies to various beta cells antigens .
The most commonly detected antibody associated
with type 1 DM is islet cell antibody.

13. DIAGNOSIS:-
Type 1 diabetes is usually diagnosed through a series of tests
• Fasting blood sugar > 126 on two separate tests
• Random blood sugar >200 along with symptoxal of diabetes
• Hemoglobin ALC >6.5 on two separate tests (glycosylated hb)
COMPLICATIONS:-
• Increased heart attack risk
• Eye problems , including blindness
• Infection on the skin
• Kidney damage
• High blood pressure
• High cholesterol

14. PATIENT DEMOGRAPHIC DETAILS:-
Patient name :- BGX
Age :- 64 years
Gender :- Male
BMI :- Normal
IP No. :-18110303
Unit :- GNW MALE- 1
Ward :- 184
DOA :- 21-11-2018
DOD :- 24-11-2018

15. CHIEF COMPLAINTS ON ADMISSION:-
C/O Progressive weakness B/L lower limb
H/L weakness B/L upper limb

16. PATIENT HISTORY:-
Past medical history:-K/C/O DM,HTN
Past medication history:-He taken medicines
Social history:-NS
Family history:-NS
Allergies:-NKA
Diet:-Mixed diet

17. GENERAL PHYSICAL EXAMINATION:-
CVS :- NAD
RS :- NAD
CNS :- NAD
BP :- 120/80 mmHg
PR :- 94 b/m
Temperature :- 97.9^F
SPO2 :- 94%

18. PROVISIONAL DIAGNOSIS:-
DIABETES MELLITUS
HYPERTENSION

19. TREATMENT CHART:-
SL.
NO.
GENERIC
NAME
BRAND
NAME
DOSE FREQ
UENC
Y
ROA DAY-1 DAY-2 DAY-3
1. Methyl
prednisolone
Solumedrol 500mg 1-0-1 IV   
2. Sodium
bicarbonate
Sodamint 2-2-2 Oral   
3. Pregabalin Prenig 75mg 0-0-1 Oral   
4. Snigmin-B 1-0-0 Oral   
5. Telmisartan+c
hlorthalidone
Tazloc-CT 40mg 1-0-0 Oral   
6. Glimepiride+
metformin
Vasoglim-
M2
500mg 1-0-0 Oral   
7. Sodium
chloride
3% NS 10ml IV   
8. Tolvaptan Resodim 15mg 1-0-1 PO   

20. PROGRESSION:-
DAY-1:-
C/O Progressive weakness B/L lower limb and upper
limb
CVS:-NAD Fluid balance:-
RS:-NAD Intake:-775ml
Vitals:-Normal Output:-1000ml
GRBS:-
6hr176mg/dl
20hr114mg/dl

21. DAY-2:-
• No other complaints
• Patient is concious,oriented
CVS:-S1S2+
BP:-120/70mmHg Fluid balance:-
PR:-80bpm Intake:-1230ml
Temp.:-Normal Output:-1450ml
SPO2:-95%
GRBS:-
6hr180mg/dl
14hr250mg/dl
20hr300mg/dl
• Adv. Rx as per chart

22. DAY-2 CONTINUED………
PHYSIOTHERAPY:-
PT:-Limb physiotherapy
Physiotherapy is defined as a treatment method
that focuses on the science of movement and helps
people to restore, maintain and maximise their physical
strength,function,motion and overall well-being by
addressing the underlying physical issues.
• General passive meets to both lower limb and upper
limb.

23. DAY-3:-
• Patient is concious, oriented.
• No fresh complaints.
BP:-120/80mmHg GRBS:-
PR:-90bpm 6hr280mg/dl
Temp.:-Normal 15hr337mg/dl
SPO2:-95%
Others:-well
• Adv. Rx as per chart

24. PHARMACEUTICAL CARE PLAN :-
SUBJECTIVE EVIDENCE OBJECTIVE EVIDENCE NORMAL VALUES
• K/C/O Diabetes mellitus • Sodium :-123mmol/L 135-148mmol/L
• K/C/O Hypertension • Serum creatinine:-
0.6mg/dl
0.7-1.40mg/dl
• PCV:-38.8% 42-52%
• Neutrophill:-73% 40-70%
• Lymphocytes:-19.6% 20-40%
• CSF Protein Analysis:-
53mg/dl
15-45mg/dl

25. FINAL DIAGNOSIS:-
DIABETES MELLITUS, HYPERTENSION
WITH LOWER LIMB AND UPPER
LIMB WEAKNESS

26. THERAPEUTIC GOALS:-
• To reduce signs and symptoms
• To achieve the target BP
• To reduce HTN related morbidity and
mortality
• To improve the QOL by making PT
understand about this disease
• Prevent further complication

27. TREATMENT OPTION:-
• Angiotensin II receptor blockers with the combination
of diuretic for the treatment of hypertension.
eg:-Telmisartan+chlorthalidone(Tazloc-CT)
Valsartan+hydrochlorothiazide(Diovan HCT)
• Sulphonylurea with the combination of biguanide to
treat the diabetes mellitus. They act by increasing
insulin release from the beta cells in the pancrease.
eg:-Glemepiride+metformin(Vasoglim-M2)
Glipizide+metformin
Chlorpropamide and glyburide+metformin

28. • Corticosteroid used to supress the immune system
and decrease inflammation
eg:- Prednisone, Methyl prednisolone
• Antacid for relieve heartburn, acid indigestion, by
neutralizing excess stomach acid.
eg:-Sodium bicarbonate, calcium carbonate,
magnesium carbonate, magnesium hydroxide
• Anticonvulsant neuropathic pain agent with diabetic
neuropathy
eg:-Pregabalin+methylcobalamin,gabapentin,
carbamazepine
• Multivitamin and multimineral medication to treat
or prevent vitamin deficiency due to certain illness
eg:-Snigmin-B,nutrilite,emergen-C

29. • Normal saline (sodium chloride) infusion is a
sterile solution used to treat low sodium levels
and fluid loss.
• Aquaretic drug that functions as a selective,
competitive vasopressin receptor 2 antagonist
use to treat hyponatremia associated with
congestive cardiac failure. eg:-Tolvaptan

30. PROBLEMS IDENTIFIED:-
• Methylprednisolone oral will decreases the level or
effect of tolvaptan oral by altering drug metabolism.
• Telmisartan oral and tolvaptan oral both increase
potassium levels in the blood and chlorthalidone oral
decreases potassium levels in the blood.
• Methylprednisolone oral , chlorthalidone oral
mechanism:-additive drug effects. There may be an
increased chance of low blood potassium.
• Chlorthalidone oral decreases effects of glimepiride oral
by opposing drug effects.
• Chlorthalidone oral decreases effects of metformin oral
by opposing drug effects.
• Methyl prednisolone oral decreases effects of metformin
oral by opposing drug effects.

31. PHARMACIST INTERVENSION:-
• The combination of valsartan-hydrochlorothiazide is
used instead of telmisartan-chlorthalidone.
• The combination of glipizide-metformin is used
instead of glimepiride-metformin.
• Stop the drug tolvaptan ,instead that use
conivaptan.

32. MONITORING PARAMETERS:-
• Vitals (BP,HR,PR,Temperature)
• Electrolytes test
• Renal function test(Serum creatinine)
• Haematology
• CSF analysis
• GRBS(General Random Blood Sugar)

33. PATIENT COUNCELLING:-
 About disease:-
• Educate the patient about the causes, risk
factors and other aspects about the disease.
• Prevent further complication.
 About medication:-
• Take prescribed medications as required by
the doctor.
• Do not miss or double the dose.
• Advice about drug interaction,drug dosage.

34.  About life style modification:-
• Regular exercise(at least 30 minutes a day)
• Regular check up
 About diet:-
• Eat healthy diet, including the DASH diet (eat more
fruits, vegetables, and low fat diary products, less
saturated and total fat).

35. THANK YOU