A

CASE STUDY

ON

Diabetic Foot Ulcer Infection

Submitted to:

Raymund Christopher R. Dela Peña, MAN, RN

Clinical Instructor

Submitted by:

Jorelly Myles Fieldad

BSN Level III Section A

Student
 TABLE OF CONTENTS

I. INTRODUCTION ...........................................................................................................

II. PATIENT’S PROFILE ...................................................................................................

III. HISTORY OF PRESENT AND PAST ILLNESS .........................................................

IV. PEARSON ASSESSMENT ..........................................................................................

V. DIAGNOSIS………………………...............................................................................

a) IDEAL………………………………………………………………………………

b) ACTUAL…………………………………………………………………………

VI. ANATOMY AND PHYSIOLOGY OF ORGAN

INVOLVED………………………...

VII.PARHOPHYSIOLOGY................................................................................................

a) MEDICAL AND SURGICAL

b) NURSING CARE PLAN

c) PROMOTIVE AND PREVENTIVE

VIII. DISCHARGE PLAN .............................................................................................

IX. UPDATES

X. BIBLIOGRAPHY

XI. CONSENT FORM

I. INTRODUCTION

Diabetic ulcers are a major health issue worldwide, causing significant

economic burdens and affecting both the patient and the society. Predisposing

factors in diabetic patients, known as the pathogenic triad, comprise trauma,

ischemia, and neuropathy. Regardless of the cause, correct diagnosis and prompt

treatment are essential in the management of leg ulcers.

Wound healing is a complex process. It depends on multiple factors that

play a major role in healing. The concentration of biochemical transmitters and

the cellular composition of wound surfaces are the most important factors. A

defect in one of these factors can lead to the development of skin ulcers, i.e.,

wounds that do not heal by the usual process. Undoubtedly, skin ulcers are caused

by the alteration of physiological and functional integrates of the wounds.

Objectives:

The purpose of this study is to integrate knowledge from known studies

including nursing research and theory regarding diabetic foot ulcers, to plan,

provide and evaluate holistic care provided to client selected during this clinical

rotation.

The study aims to:

 Identify interventions to prevent or reduce risks of infection.

 Provide information about foot care.

 Provide information about the disease.

  Identify interventions to prevent/reduce risk of infection.

 Demonstrate techniques, lifestyle changes to prevent development of

infection.

II. PATIENT’S PROFILE

NAME: Eugenio Reyes

AGE: 51 years old

ADDRESS: Tamurong, Sta. Catalina, Ilocos Sur

BIRTHDATE: January 24, 1970

BIRTHPLACE: Tamurong, Sta. Catalina, Ilocos Sur

CIVIL STATUS: Married

RELIGION: Roman Catholic

EDUCATIONAL ATTAINMENT: High School Graduate

OCCUPATION: Security Guard at a Local Mall

CITIZENSHIP: Filipino

SEX: Male

CHIEF COMPLAINT: Increasing pain sensation from the left leg

ADMITING PHYSICIAN: Dr. M. Daz

DIAGNOSIS: Diabetic Foot Ulcer Infection

III. NURSING HISTORY OF PRESENT AND PAST ILLNESS

a) History of Present Illness

 Mr. Eugenio Reyes is a 51-year-old male who presented in the

outpatient department (OPD) with a history of a one-year history of non-

healing diabetic ulcer on distal left leg posteriorly around 5 cm from the

heel and measured about 3 cm in diameter. The pain intensifies every time

the patient takes a step using his left foot. Over the counter tablet

Mefenamic Acid (an anti-inflammatory drugs used to treat mild to

moderate pain) betadine (is an antiseptic used for skin disinfection) and

cotton balls was taken before presenting at OPD, which did not alleviate

the pain. The pain was exacerbated by lifting the left leg and relieved by

taking aspirin medication as prescribed by the doctor. Severity was rated

eight on a scale of 1 to 10, with 1 being no pain and 10 being the most

pain possible. Visible signs of active local infection were noted, and it

was the main reason for the clinic visit. Lower limb was dry and scaly

(xerosis). Positive signs of trophic changes, brittle nails, and loss of hair

were also observed. The vascular exam was fair. Capillary refilling was

less than 2 seconds, and palpable distal pulses (dorsalis pedis and posterior

tibial) were noted.

b) History of Past Illness

Patient was diagnosed with poorly controlled Type 2 Diabetes Mellitus,

dyslipidemia, hypertension, asthma, appendectomy in 2015, previous

debridement of left big toe. Drug history of Salbutamol with no known

drug allergies and had flu vaccine last month. Patient has a family history
 of Type 2 Diabetes (Father) and Hypertension (mother). The patient is ex-

smoker, reported alcohol consumption occasionally, and denied

recreational drug use.

IV. PEARSON ASSESSMENT

ASSESSMENT CLINICAL DATE: CLINICA CLINICA HOME

04/12/2021 L DATE L DATE VISIT

PSYCHOSOCI  Appearance

AL Mr. Eugenio Reyes,

51 years old, Married,

who is overweight

and high BMI scale.

On presentation he

was disheveled, with

torn shirt, soiled

jeans, and bad body

odor. He has a pale

complexion, appears

weak, and a tattoo on

his right arm. Skin is

warm when touched

and presence of ulcers

in the left leg. He

lays in the clinical bed

throughout the
 interview.

 Behavior

He looks timid and

exhausted. He avoids

eye contact when

speaking to the

interviewer.

 Motor

He remained calm and

still with little to no

movements. He

moves for a while to

change position.

 Speech

There was a minimal

spontaneous speech;

answers were brief. He

speaks softly and

slowly. Speech is easy

to follow even though

there are long pauses

 and stuttering.

 Mood

Reports feeling of

pain and irritation

over the past few

months and finding it

hard to concentrate on

his current

assignment.

 Affect

Looks sad, rarely

smiles, or changes

expression. Voice us

monotonous and there

is little reaction to

attempts of humor.

Affect is appropriate

and in keeping with

his description of

recent event.

 Thought Content
 He believes he

inherited his condition

to both parents and

that he uses a small

sized shoe he wears to

work for 2 years since

he does not have the

means to buy a new

one. He feels irritated

and helpless thinking

he might get fired at

work for his sickness

that sometimes he

thinks of robbing

instead of doing hid

job to help himself get

treated.
ELIMINATION Defecate once two hours

before admission.

500mL urine output

ACTIVITY Well positioned at clinical

AND REST bed, awake and alert, on

stable condition, patient is

well oriented.
SAFETY AND Initial vital signs taken as
SECURITY follows:

Temp: 36.2C

BP: 165/72mmHg

HR: 88

RR 20

SatO2 95% on air

Patient place in a clinical

bed with bed rails raised.

Patient claimed with

moderate pain at distal left

leg due to his pressure

ulcer
OXYGENATIO With o2 supplement

N RR= 20 cpm

NUTRITION Diet is mostly on meat and

fish, seldom vegetables

Occasional alcohol

consumption

No bowel movements,

defecated 2 hours before

admission, had urinate

upon admission.

With Good Appetite

V. Diagnostics

a) Ideal

 IV FLUIDS. Sodium Chloride 0.9% intravenous infusion can be

given in cases of fluid replacement. Ringer's lactate can be used as

a safe alternative intravenous fluid in the perioperative period in

patients with well- controlled diabetes mellitus receiving spinal

anesthesia. Dextrose 5% in water (D5W) is used to treat low blood

sugar (hypoglycemia), insulin shock, or dehydration (fluid loss).

 MEDICATIONS. Metformin 850mg 3 times a day with meals.

Aspirin + Cilazapril can be taken for HPT and reduce CVD.

Salbutamol for asthma.

 DIET. A DASH diet is prescribed. The focus is on fruits,

vegetables, lean meat, low-fat dairy, whole grains, beans, and nuts.

The diet limits sodium, red meat and sugary foods and drinks.

b) Actual

 IV FLUIDS. Sodium Chloride 0.9% intravenous infusion can be

given in cases of fluid replacement. Ringer's lactate can be used as

a safe alternative intravenous fluid in the perioperative period in

patients with well- controlled diabetes mellitus receiving spinal

 anesthesia. Dextrose 5% in water (D5W) is used to treat low blood

sugar (hypoglycemia), insulin shock, or dehydration (fluid loss).

 MEDICATIONS. Metformin 850mg TDS is given after meals.

Gliclazide 80mg BD is taken with meals. Metformin + Gliclazide

is used to treat T2DM. Enteric coated Aspirin 100mg daily +

Cilazapril (Zapril)10mg daily for HTN and reduce CVD risk.

Simvastatin (Lipex) 40mg daily for dyslipidaemia & reduce CVD

risk. Salbutamol inhaler (Ventolin) 2 puffs Q4H PRN for treatment

of asthma.

 CLINICAL TEST AND PROCEDURES. Medical History and

Physical Exam. The Physician takes notice of presence foot ulcer.

The Physician will also ask for any other medical condition the

patient has.

X-ray. X-ray imaging to assess changes in the alignment of the

bones in the foot, which can contribute to an ulcer. X-rays can also

reveal a loss of bone mass, which may occur because of hormonal

imbalances related to diabetes.

MRI Scans. MRI scans use a magnetic field and radio waves to

create computerized, three-dimensional images of soft tissues

inside the body. The Physician may recommend this test if he or

she needs more information about the extent of damage caused by

 an ulcer. MRI images can also reveal inflammation, which may be

a sign of infection.

Blood test. If there are signs of infection, blood test is

recommended to screen for it.

 DIET. A DASH diet is prescribed. The focus is on fruits,

vegetables, lean meat, low-fat dairy, whole grains, beans, and nuts.

The diet limits sodium, red meat and sugary foods and drinks.

 LIFESTYLE MODIFICATION. Keeping blood glucose levels

optimal. Good nutrition and eating habits. Reducing high blood

pressure. No smoking.

VI. Anatomy and Physiology of Organ Involved

Pancreas.

The pancreas is a long, slender organ, most of which is located posterior to

the bottom half of the stomach. Although it is primarily an exocrine gland,

secreting a variety of digestive enzymes, the pancreas also has endocrine cells. Its

pancreatic islets—clusters of cells formerly known as the islets of Langerhans—

secrete the hormones glucagon, insulin, somatostatin, and pancreatic polypeptide

(PP).
Skin.

The skin is the largest organ of the body, accounting for about 15% of the

total adult body weight. It performs many vital functions, including protection

against external physical, chemical, and biologic assailants, as well as prevention

of excess water loss from the body and a role in thermoregulation. The skin is

continuous, with the mucous membranes lining the body's surface (Kanitakis,

2002).

The skin is composed of three layers: the epidermis, the dermis, and

subcutaneous tissue (Kanitakis, 2002). The outer most level, the epidermis,

consists of a specific constellation of cells known as keratinocytes, which function

to synthesize keratin, a long, threadlike protein with a protective role. The middle

layer, the dermis, is fundamentally made up of the fibrillar structural protein

known as collagen. The dermis lies on the subcutaneous tissue, or panniculus,

which contains small lobes of fat cells known as lipocytes. The thickness of these

layers varies considerably, depending on the geographic location on the anatomy

of the body. The eyelid, for example, has the thinnest layer of the epidermis,

measuring less than 0.1 mm, whereas the palms and soles of the feet have the

thickest epidermal layer, measuring approximately 1.5 mm. The dermis is thickest

on the back, where it is 30-40 times as thick as the overlying epidermis (James,

Berger, & Elston, 2006).

Heart

The heart itself is made up of 4 chambers, 2 atria and 2 ventricles. De-

oxygenated blood returns to the right side of the heart via the venous circulation.

It is pumped into the right ventricle and then to the lungs where carbon dioxide is

released, and oxygen is absorbed. The oxygenated blood then travels back to the

left side of the heart into the left atria, then into the left ventricle from where it is

pumped into the aorta and arterial circulation.

Kidneys

The kidneys are the primary functional organ of the renal system. They are

essential in homeostatic functions such as the regulation of electrolytes,

maintenance of acid–base balance, and the regulation of blood pressure (by

maintaining salt and water balance). They serve the body as a natural filter of the

blood and remove wastes that are excreted through the urine.

They are also responsible for the reabsorption of water, glucose, and

amino acids, and will maintain the balance of these molecules in the body. In

addition, the kidneys produce hormones including calcitriol, erythropoietin, and

the enzyme renin, which are involved in renal and hematological physiological

processes.
VII. Pathophysiology
 Persons with DM are susceptible to peripheral neuropathy with sensory,

autonomic, and motor components. The Maillard reaction is a slow but complex

reaction between reducing sugars and amino groups of biomolecules leading to

the production of a complex structures known as advanced glycation end products

(AGEs). Hyperglycemia, dyslipidemia, insulin resistance, and oxidative stress can

lead to cellular damage, endothelial dysfunction, and various diabetes-associated

complications through several pathways. Excess glucose is converted to sorbitol

by aldose reductase through the polyol metabolic pathway that consumes

nicotinamide adenine dinucleotide phosphate (NADPH). The result is the

depletion of NADPH that in turn affects the normal synthesis of key antioxidants,

such as glutathione. Decreased antioxidant and increased production of reactive

oxygen species play a crucial mediatory role in the pathogenesis and progression

of complications in diabetes. Neuropathy leads to foot deformity or limited joint

mobility, resulting in abnormal foot pressure and subsequent callus formation

over pressure points. Sensory nerves play a role in modulating immune defense

mechanisms, with denervated skin showing reduced leukocyte infiltration. Once

an ulcer develops, susceptibility to infection exists because of a loss of innate

barrier function.

VIII. Management

a) Medical and Surgical

General Chemistry
Sodium: 138mmol/L (135-145)
Potassium: 4.9mmol/L (3.5-5.2)

Chloride: 108mmol/L (95-110)

Creatinine: 94mmol/L (60-105) improving

C-Reactive Protein: 4mmol/L (0-5)

Bicarbonate: 29mmol/L (22-31)

Glucose: 8.6 mmol/L (3.0-11.0)

Urate: 0.42mmol/L (0.14-0.36)

Phosphate: 1.20mmol/L (0.70-1.50)

Calcium: 2.40mmol/L (2.1-2.6)

Albumin: 43mmol/L (38-52)

Hemoglobin A1c
HbA1c:10 3(11-12 mmol/L)

Lipid profile
Total cholesterol: 6.9 (<5.0)

Triglyceride: 3.2 (<2.0)

HDL: 1.17 (>1.0)

LDL: 2.1(<3.4)

Chol/HDL: 3.5 (<4.6)

Renal Function
eGFR: > 72

Microalbuminuria: 21 mg/L (0-30)

 Liver Function
ALT, AST & Bilirubin: in normal ranges
Full Blood Count
Hemoglobin: 128gg/L (130-175)

RBC: 5.43 xE12/L (4.3-6.0)

Hematocrit: 0.48 (0.4-0.52)

Mean Cell Volume 86 fL (80-99)

Mean Cell Hemoglobin: 25.6pg (27-34)

RDW:13.1 (11.5-15.0)

PLATELETS: 400 Xe9/L (150-400)

MPV: 8.9fL (9.0-12.2)

WBC: 5.2 xE9/L (1.9-7.5)

Neutrophils: 2.9 xE9/L (1..9-7.5)

Basophils: 0.05 xE9/L (0 -0.2)

Eosinophils: 0.1 xE9/L (0 -0.5)

Monocytes: 0.5 XE9/L (0.2-1.0)

Lymphocytes: 17 xE9/L(0.2-1.0)

X-Ray
 Treatment and Procedures
 Vital signs taking. Closely monitored because this serves as a baseline

data of the patient and will indicate whether the patient’s condition is

progressing or reclining. It is a routine taking of the patient’s

temperature, pulse rate, respiration rate and blood pressure.

 Glycated hemoglobin (A1C) test. This blood test, which doesn't require

fasting, indicates your average blood sugar level for the past two to three

months. It measures the percentage of blood sugar attached to

hemoglobin, the oxygen-carrying protein in red blood cells.

 Random blood sugar test. A blood sample will be taken at a random

time. Regardless of when you last ate, a blood sugar level of 200

milligrams per deciliter (mg/dL) — 11.1 millimoles per liter (mmol/L)

— or higher suggests diabetes.

 Fasting blood sugar test. A blood sample will be taken after an

overnight fast. A fasting blood sugar level less than 100 mg/dL (5.6

mmol/L) is normal. A fasting blood sugar level from 100 to 125 mg/dL

(5.6 to 6.9 mmol/L) is considered prediabetes. If it is 126 mg/dL (7

mmol/L) or higher on two separate tests, you have diabetes.

 Oral glucose tolerance test. For this test, you fast overnight, and the

fasting blood sugar level is measured. Then you drink a sugary liquid,

and blood sugar levels are tested periodically for the next two hours.
b) Nursing Care Plan
c) Promotion and Preventive

Daily Foot Inspection

It is encouraged that people with diabetes should inspect both feet daily

for blisters, cuts, scratches, and ingrown toenails. It is also important to

check the bottom of each foot with a mirror since blisters often form there.
Doctors also recommend monitoring your feet for signs of infection,

including redness, swelling, and warmth. If you notice these changes, seek

treatment immediately.

Proper Footwear

Wearing shoes that do not fit well increases the risk of a blister. Shoes

should not be too tight, too small, or too large. Foot size and width may

change over time, so doctors recommend having your foot measured

whenever you buy new shoes.

A well-fitting shoe has half an inch of space between the toes and the tip

of the shoe and provides ample arch support. Podiatrists recommend

wearing clean, dry socks that don’t have tight elastic bands, which may

restrict blood flow to the foot.

Doctors advise people with diabetes to avoid walking barefoot and

wearing sandals, which expose your feet to splinters, concrete, or sand,

which may scrape or irritate the foot. You should also avoid high-heeled

shoes because they put excess stress on the front of the foot. High-heeled

shoes can pinch the skin and cause blisters.

Blood Sugar

If you have diabetes, you must monitor blood sugar levels and ensure that

they are in a healthy range. High blood sugar may lead to foot

complications and difficulty healing. If necessary, our doctors can

prescribe insulin medications, which help the body convert sugar into

energy.

Weight Loss

Being overweight or obese places increased stress on the feet, which can

create friction when wearing shoes and lead to blisters and cuts. Dietitians

and nutritionists at NYU Langone’s Weight Management Program can

help you lose weight. If obesity prevents you from controlling your blood

sugar levels, you and your doctor can discuss the possibility of weight loss

surgery.

Tobacco Cessation

Cigarettes and other tobacco products contain chemicals that slow healing,

which may prevent a full recovery from a foot ulcer. Tobacco products are

also linked to circulatory problems and may significantly increase the risk

of lower extremity arterial disease, which reduces blood flow in the legs

and feet.
IX. Drug Study
X. Discharge Plan

Medicines  Metformin 500mg, PO

2x a day, 1 tablet after meal;

increase every two weeks

8am, 8pm

 Aspirin 650mg, PO

1x every 4-6 hrs as needed

 Simvastatin 20mg, PO

1x a day in the evening

9pm

 Cilazapril 5mg, PO

1x a day in the morning

8am

 Salbutamol Inhaler

1 or 2 puffs if needed; maximum

of 4 times in 24 hours (regardless

of whether you have 1 puff or 2

puffs at a time)
Exercise  Provide clean environment

 Brisk walking
Treatment  Take shower everyday (do not

soak in a tub until incisions are

well healed)

 Gently clean pressure ulcer with

 soap and betadine

 Take prescribed medicines as

indicated. Avoid missing doses.

Health Education  Antiseptic solutions can burn your

skin. Never use them on your feet

without your doctor’s approval.

 Never use a heating pad, hot water

bottle, or electric blanket on your

feet.

 Avoid walking barefoot. Most

people know to avoid hot

pavement or sandy beaches, but

even walking barefoot around the

house can cause sores or injuries

that can get infected.

 Protect your feet from heat and

cold.

 Never attempt to remove corns,

calluses, warts, or other foot

lesions yourself. Do not use

chemical wart removers, razor

blades, corn plasters, or liquid corn

or callus removers. See your

doctor or podiatrist.
  Do not sit with your legs crossed

or stand in one position for long

periods of time.
Outpatient Department  Every 3 months when newly

diagnosed, then every 6 months

once you're stable.

Diet  Low calories diet

 Low fat diet

 Low glycemic diet

 Dash diet
Spiritual/Sexuality  Providing support. The patient and

family needs assistance

explanation and support every

time patient requires treatment.

XI. Updates

Metformin is the first-line treatment for patients with diabetes because it reduces

mortality rates. If metformin is contraindicated or is not tolerated, any one of the

other available antihyperglycemic drugs may be used as monotherapy. These

drugs are equally effective for glucose control, lowering A1c by approximately

1%. Evidence of their benefit for reducing mortality or morbidity or improving

health-related quality of life is lacking. A sulfonylurea, pioglitazone, or exenatide

can be added to maximally dosed metformin if additional glycemic control is

necessary. Sulfonylureas and pioglitazone often cause weight gain. The

combination of metformin plus a sulfonylurea is associated with a greater risk of

 hypoglycemia and mortality than the combination of metformin and a

thiazolidinedione (ie, glitazone). Thiazolidinediones are contraindicated in

patients with severe heart failure or liver disease. Newer drug classes target

incretin, the hormone that stimulates food-dependent insulin secretion. The

incretin mimetic exenatide, a high-cost injectable drug, is like metformin for

reduction of A1c and body mass index. Incretin-enhancing dipeptidyl-peptidase 4

inhibitors (ie, gliptins) are inferior to metformin for lowering A1c and body mass

index; little is known about their effect on all-cause mortality. Fixed combination

products might improve ease of use and adherence; they might also reduce cost

and risk of adverse effects.

XII. Bibliography

Books

Collaborative Group of Primary Prevention Project (PPP). (2001). Low-dose

aspirin and Vitamin E in people at cardiovascular risk: a randomized trial in

general practice. Lancet, 357(9250), 89-95.

Gutierrez, E. (2008). Pharmacotherapeutics clinical reasoning in primary care.

(2nd Ed.). Saunders: Canada.

Lehne, R. (2007). Study guide: pharmacology for nursing care. (6th Ed.).

Saunders Elsevier: USA

McKenne, L., & Lim, A. (2012). Karch’s pharmacology for nursing and

midwifery. Broadway, N.S.W.: Lippincott Williams & Wilkins

Munger, M. (2010). Polypharmacy and combination therapy in the management

of hypertension in elderly patients with Co-morbid diabetes mellitus. Drug Aging,

27(11):871–883.

New Zealand Guideline Group (NZGG). (2003). The assessment and

management of cardiovascular risk. (3rd Ed.). Wellington: NZGG.

New Zealand Guideline Group (NZGG). (2013). New Zealand primary care

handbook. (3rd Ed.). Wellington: NZGG.

Internet Sources

Drug Bank. (2005). Aspirin. Retrieved on 16th September 2013. From

http://www.drugbank.ca/drugs/DB00945

Drug Bank. (2005). Metformin. Retrieved on 16th September, 2013. From

http://www.drugbank.ca/drugs/DB00331

Drug Bank. (2005). Salbutamol. Retrieved on 16th September, 2013. From

http://www.drugbank.ca/drugs/DB01001

Drug Bank. (2007). Cilazapril. Retrieved on 16th September, 2013. From

http://www.drugbank.ca/drugs/DB01340

Huri, H., & wee, H. (2013). Drug-related problems in patients with type 2

diabetes and hypertension. BMC Endocrine Disorders, 13 (2), Retrieved from

http://www.medscape.com/viewarticle/779871

MedSafe. (2002). New zealand date sheet: Gliclazide. Retrieved on 17th

September, 2014. From

http://www.medsafe.govt.nz/profs/datasheet/a/Apogliclazidetab.pdf
MedSafe. (2009). Cilazapril-AFT. Retrieved from

http://www.medsafe.govt.nz/profs/datasheet/c/Cilazapril-AFTtab.pdf

MedSafe. (2011). New Zealand date sheet: Metformin. Retrieved from

http://www.medsafe.govt.nz/profs/datasheet/m/metformintab.pdf

MedSafe. (2012). SimStatin. Retrieved from

http://www.medsafe.govt.nz/profs/datasheet/s/SimStatintab.pdf

MedSafe. (2013). New Zealand date sheet: Lipex. Retrieved on 29th November,

2013. From http://www.medsafe.govt.nz/profs/datasheet/l/Lipextab.pdf

Ministry of Health (2003). Evidence-based best practice guideline: management

of type 2 diabetes. Retrieved on 17th, September, 2014. From

www.nzgg.org.nz/resources/102/Diabetes_full_text.pdf

Ministry of Health. (2011). Guidance on the Management of Type 2 Diabetes.

Retrieved from

http://www.nzgg.org.nz/library_resources/16_guidance_on_the_management_of_

type_2_diabetes_(2011)

Pharmaceutical Care Network Europe Foundation. (2006). PCNE classification

for drug-related problems V5.01. Retrieved from

http://www.pcne.org/sig/drp/documents/PCNE%20classification%20V5.01.pdf

U.S. Preventive Services Task Force (USPSTF). (2009). Aspirin for the

prevention of cardiovascular disease: U.S> Preventive Services Task Force

Recommendation Statement. Annals of International Medicine, 150(6), 396-404.

Wikipedia (2014). Aspirin. Retrieved on 24th September, 2014. From

http://en.wikipedia.org/wiki/Aspirin#Mechanism_of_action