48 year male with fever and headache

A 48 year old male who is a artist by occupation, came to casuality with

Chief complaints :

Fever since 4 days

Headache since 2 days 

History of Present Illness :

Patient was apparently asymptomatic 7 years back, then he had fever for which he visited the local doctor and was found to have increased blood sugar levels (diagnosed as DM type 2). He used OHAs for a few days and stopped the medication and started taking plant medication. 5 months back, he had generalized weakness for which he visited the hospital and he was informed that his blood sugar levels were elevated but still did not follow up with the treatment. Presently, he had fever since 4 days high grade associated with chills. He has headache since 2 days, which is present all over the head increased with loud noises not associated with photophobia.

H/o pain in the knuckles.

No h/o neck stiffness.

No h/o vomiting.

Past History:

Not a known case of HTN, CAD, ASTHMA, TB, EPILEPSY, THYROID DISEASE. 

Personal History :

Diet : Mixed

Appetite : Normal

Sleep : Adequate 

Bowel and bladder movements : Regular

Addictions : Chronic alcoholic (stopped since 1 month), smokes tobacco 

Family History :

No significant family history 

General Examination:

Patient is conscious, coherent and cooperative.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema. 

Moderately built and nourished 

Vitals :

At the time of admission :

BP : 130/90 mm Hg

PR : 110 bpm

RR : 20 cpm

Temp : 101°F

SpO2 : 99% on RA

GRBS : 525 mg/dl

Systemic examination:

CVS : S1S2 +

RS : BAE +

P/A : Soft, non tender

CNS : NAD

Investigations :

Treatment :

1. IVF NS @ 100 ML/HR, 5%D @ 75 ML/HR (IF GRBS < 150 MG/DL)

2. INJ. HAI 6U - IV/STAT (INJ. HAI 1 ML IN 39 ML NS @ 4ML/HR)

3. INJ. NEOMOL 1 G IV/SOS(IF TEMP.>101°F)

4. INJ. PANTOP 40 MG IV/OD

5. INJ. ZOFER 4 MG IV/SOS

6. TAB. DOLO 650 MG PO/TID

PROVISIONAL DIAGNOSIS :

Pyrexia under evaluation (uncontrolled sugars)