60 year old female with fever , uncontrolled sugars

This is an online E log book to discuss our patient\"s de -identified health data shared after taking his/her/guardian\"s signed informed consent. Here we discuss our individual patient\"s problems through series of inputs from available global online community of experts with an aim to solve those patient\"s clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs in the log. 
Chief complaints:
 Patient came to the casuality with the chief complaints of fever since 10 days.

History of present illness:

Patient developed fever since 10 days which is low grade not associated with chills and generalized body pains.
No H/o of burning micturition, vomitings,loose stools, SOB.
she also complained pain in the abdomen since 15 days on and off.
Patient was taken to local hospital but referred to our hospital due to high sugars.
10 years ago she was diagnosed with DM 2  and used medication for 1 year .
In view of uncontrolled sugars started on insulin .
2 months ago ,she has blebs over toes ,and dressings was done by RMP.

Past history:
k/c/o of DM since 10 years 
Foot ulcer 2months ago

Personal history:
Diet - mixed
Appetite - normal
Sleep- adequate
Bowel and bladder movements- regular
Addictions:
Tobacco chewer since 20 years
She takes toddy since 20 years( occasionally)

Family history:- 
No significant family history

General examination:-
Patient is conscious coherent cooperative, moderately built and moderately nourished.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy.
Vitals:-

Temp -98.7 F
PR:- 88bpm
RR:- 20cpm
BP:- 120/90mm of hg
Grbs:- 395mg/dl

Systemic examination:- 

Cvs:-
 S1 S2 heard, no murmurs
Rs:- 
BAE - present,  Nvbs
Per abdomen:-
Tenderness present 
Bowels sound heard
CNS:- normal

Provisional diagnosis:

 AKI on CKD(?Diabetic nephropathy), with metabolic acidosis secondary to ?dry gangrene of left 3nd and 4th toe, right 2nd toe ,with uncontrolled sugars,DM 2 
?Diabetic enteropathy

Investigations:
ECG
2D ECHO

Lower limb arterial Doppler
USG Report
Treatment:
 
1) IV fluids
2) inj optineuron
3)inj monocef
4) inj insulin subcutaneous
5)Tab dolo
6) inj tramadol
7) inj pantop
Vitals monitoring


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