74/M with uncontrolled sugars with headache

A 74 year old male came to OPD with
c/o of general body pains since 5 years
c/o of deviation of mouth to Right side since 4 years
 c/o of headche since 15 days.
HOPI:
Pt was apparently asymptomatic 15 days back then she developed headache which is lasting for entire day.photophobia present,phonophobia present,not associated with nausea vomiting,giddiness.
he had a chief complaints of deviation of mouth to Right side since 4 years.It is associated with drooling of saliva/liquids.
he has a chief complaints of general body pains since 5 years.
Past history:
k/c/o DM Type 2 since 10-15 years now using HAI 6U TID.NPH 6U BD
K/c/o HTN since 10 years using TAB.AMLO 5MG OD
k/c/o CVA since 4 years using TAB.ECOSPRIN-AV 75/10 PO/HS
Not a k/c/o Tb,epilepsy,cva,cad,thyroid
Personal History -
Married
Occupation- Farmer
Diet: mixed
Appetite: normal
Bowel and bladder : Normal
Addictions:occasional alcoholic(stopped 5 years back)
Smoker(stopped 5 years back)

Family History -
No similar complaints in the family. 

General Examination -
Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.
She is conscious, coherent andcooperative.
Built & nourishment-Moderate
No pallor 
No cyanosis
No icterus
No clubbing
No edema
No lymphadenopathy.



Systemic examination:
CVS : 
S1 S2 present
No murmurs

RESPIRATORY SYSTEM;
B/l symmetrical chest
Trachea - Central
B/l air entry present
NVBS heard

ABDOMEN:
Shape of abdomen: scaphoid.
Soft, non tender, no organomegaly present.
No rigidity or guarding.

CNS :
Patient is conscious
Speech-normal 
Signs of meningial irritation
Neck stiffness- negative
Kernings sign-negative
Cranial nerves-intact
Motor system:
Power:
          UL              LL
R     5/5.             5/5
L     4/5.             4/5
 
Tone:
            R.                  L
UL.      Normal.      Normal
LL.       Normal       normal
Sensory system: normal
Reflexes:
           Knee. Ankle. Biceps. Triceps supinator
Right        -.     -.        2+              -            -
Left.        -.       -.         2+             2+          -
Plantar flexion seen.
No cerebellar signs 

PROVISIONAL DIAGNOSIS:
Uncontrolled sugars with type 2 DM with HTN with CVA
TREATMENT:
.IV FLUIDS NS@75ML/HR
2.INJ.PIPTAZ 2.25GM IV/TID
3.INJ.HUMAN ACTRAPID INSULIN S/C TID  BEFORE MEALS 
4.INJ.ZOFER 4 MG /IV/BD
5.TAB.CINOD 10MG PO/BD
6.INJ.PAN 40MG/IV/OD
7.TAB.ECOSPRIN-AV 75/10 PO/HS 
8.TAB.NAPROXEN 250MG PO/BD
9.STRICT I/O CHARTING
10.BP,PR,TEMP MONITORIMG 4TH HOURLY
11.GRBS 7 POINT PROFILE

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