65/M Farmer/Ration shop owner

65/M 
FARMER BY OCCUPATION
 

Pt WAS APPARENTLY NORMAL 16 YEARS AGO,
WHILE WORKING IN THE FIELDS, A THORN PRICKED HIS LEFT LEG AND FORMED A NON HEALING ULCER, WENT TO A PRIVATE HOSPITAL AND WAS FOUND TO BE DIABETIC, STARTED ON OHA (UNSURE OF THE MEDICATION), AND CONTINUED TO USE MEDICATION

IN LATE 2019, ANOTHER INJURY OCCURRED TO THE LEFT FOOT, FORMED ANOTHER ULCER, RESULTING IN GRADUAL BLACKENING OF THE TOES. DIAGNOSED AS DIABETIC FOOT. AMPUTATION OF THE FIRST TWO GOES OF LEFT FOOT DONE.
PATIENT HAS BEEN USING A CANE FOR SUPPORT TO WALK SINCE THEN.

IN DECEMBER 2020, H/O SOB GRADE 2 SINCE 4 MONTHS WHICH PROGRESSED TO GRADE 3 2 MONTHS AGO AND DIAGNOSED AS ADHF AND CAG WAS DONE. ON REGULAR MEDICATION

(SEPTEMBER, 2021)FIVE MONTHS AGO HE HAD C/O SWELLING OF ARMS AND LEGS (UPTO THIGHS) ,FACIAL PUFFINESS,NAUSEA VOMITING,CONSTIPATION AND ABDOMINAL DISCOMFORT FOR WHICH HE WENT TO A HOSPITAL IN KHAMMAM WHERE INVESTIGATIONS WERE DONE HE WAS ADVICED ADMISSION BUT HE DENIED AND WENT TO NIMS,HYD ON 04-09-2021.
DIAGNOSED AS HYPERTENSIVE, STARTED ON MEDICATION HE PRESENTED WITH FLUID OVERLOAD,UREMIC SYMPTOMS AND HEMODIALYSIS WAS INITIATED THROUGH RIGHT FEMORAL ACCESS. 20 SESSIONS OF HEMODIALYSIS WAS DONE BETWEEN SEPTEMBER-OCTOBER

THEN PT CAME TO KIMS NKP FOR FURTHER TREATMENT AS IT IS CLOSER TO THEIR RESIDENCE
20 SESSIONS OF HEMODIALYSIS WERE DONE SINCE NOVEMBER, 
31/1/22- last session

 PAST HISTORY:
 K/C/O DM 2 SINCE 16 YEARS AND IS ON INSULIN. (On insulin since 2019, two times a day, 8units and 10 units) 
K/C/O CAD SINCE 2019 IN 2020 DECEMBER, ADMISSION IN CARDIOLOGY FOR ADHF,S/P CAG ADVISED CABG,BUT WAS NOT DONE
K/C/O HTN SINCE 5 MONTHS AND IS ON MEDICATION
Patient stopped farming 3 years ago due to difficulty, has been manning his ration shop as a cashier since then. His wife continues to farm.
2/2/22
Hb- 10.0%
Creatinine- 4.4mg/dl
Serum iron- 72 mcg/dl
RBS- 238mg/dl

Pt is c/c/c
Temp- afebrile
Bp- 140/90 mmhg
PR- 68bpm
RR- 13cpm
CVS- S1 S2 heard
Rs- BAE+
CNS NFND
P/a- soft non tender

FLUID AND SALT RESTRICTION
T. LASIX 40MG PO/BD
T. NICARDIA 10MG PO/BD
T. OROFER XT PO/BD
T. NODOSIS 500MG PO/OD
T. SHELCAL CT PO/OD
T. CAP BIO D3 PO/OD
INJ. ERYTHROPOIETIN 4000IU IV/SC WEEKLY ONCE
INJ. HAI SC/BD (10U--X--8U)

Diagnosis CHRONIC RENAL FAILURE WITH GLOBAL HYPOKINESIA WITH HTN,DM-2.CAD WITH HERPES ZOSTER S/P LEFT CRITICAL LOWER LIMB ISCHEMIA 


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