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65yr old male with sweating and diarrhoea

65 yr , male from thopcharla has come to the opd with chief compliants of sweating and motions since 4o ' clock this morning (3-sep- 21) .
History of present illness:
 He was apparently asymptomatic 4 days back ,then he developed fever,which is intermittent associated with chills,he also had edema in both the legs upto knee and went to an hospital where he was diagnosed as hypotension  and infection of lower limb, diabetic. fever decreased on taking medication. edemain right leg had totally decreased & the edema on the left leg is decreased than before but still present which is pitting type, erythema present, a ruptured blister of 3*3cm no surrounding skin discoloration and no engorgement of veins.

 Diarrhoea: yesterday he had loose motions  5-6 times and in the morning he had 4-5 times along with sweating where patient became anxious and this made the patient to come to the hospital
Past History:
known case of bronchial asthma for the past 2yrs and known case of diabetes for the past 4 days 
and not a known case of HTN,TB , epilepsy
tested positive for Widal test on 31st and AST & ALT were rised
Treatment history:
budesonide 2puffs/days since 2yrs
montelucast ??
diclofenac once a month
calcium tablets for 30days (since25/8/21)( getting by his health card, reason??)
Family history  :
 his grand son is a know case of asthma

Personal history :  
diet : mixed
appetite : normal
bladder moments: regular
bowel - had passed loose stools for 4-5 times this morning
sleep - adequate
addictions - alcoholic(3days /week) drinks approx.90ml or more since 30yrs. and also chronic smoker since 30yrs . he stoped talking alcohol for the past 10days.
 General Physical examination : patient is concious coherent but not cooperative. 
he has truncal obesity
 no pallor ,icterus ,cyanosis 
 *clubbing -present*
no generalised lymphadenopathy
edema of left leg, pitting type had a blister on medial aspect of leg.

vitals 
Temperature : Afebrile
BP: 100/60
PR: 88
RR: 21
sPO2 : 98%.
 on examination of eyes - upper and lower eye lids (swollen ??) and (facial puffiness??)


ON 4th/sep
 patient was conscious, coherent but not cooperative
Decubitus: patient was lieing on bed ,irritable and moves his had but his not his legs
on moving his legs and abdomen to one side passively , patient started screaming ,it could be out of pain.

INVESTIGATIONS
                      on3rd                   on 4th
totalcount.   16,500.                 21,000
neutrophils.    84.                       90
lymphocytes   07                        04

RBC                 4.45.          
blood urea.     59mg/dl
serum creatinine  3.2
LFT
total bilirubin: 1.77
direct bilirubin :0.8 (increased)
alkaline phosphate: 503
total protiens 5.9
albumin 2.6
 urine ex.
albumin ++
2D echo
IVC - dilated
dilated - RA/RV
diastolic dysfunction

on 4th 
D-dimer : 5590ng/ml (increase)
prothrombin time : 20sec( increase)
 APTT: 37sec ( increased)
Treatment history:

 
PROVISIONAL DIAGNOSIS:  hypotension ,left leg cellulitis and liver dysfunction with DVT (?)

PATHOPHYSIOLOGY
   

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