45 year old female

45  female came to opd with chief complaints of fever since  15 days 
which is low grade , intermittent and decreased on medication
associated with dry cough , body pains  and generalized weakness since 10 days 
h/o loose stools 4 to 5 episodes 4 days back which decreased on medication 
no h/o pain abdomen , vomiting ,and burning micturation 
no h/o cold / sob/ headache / rash
and other complaints
 h/o diabetes since 10 years and on OHA
no h / o hypertension , CAD, asthma , Tuberculosis

personal history:
Appetite : lost
bowel and bladder movements regular 
no other addictions
Family history : no relevent family history
 
General examination:
No pallor , Icterus, cyanosis, clubbing and lymphadenopathy

Temperature : 98.6 F
PR: 84 bpm
RR: 18 Cycles per min
Spo2 : 98 % at RA

CVS: 
S 1 and S 2  heard 
Per abdomen : no tenderness present 
Respiratory system: 
BAE + and NVBS +

CNS :  Intact 
Diagnosis: 
Viral pyrexia  under evaluation   

Treatment given :
Day 1
1. IVF - NS ,RL @ 45ml/hr
2. TAB PAN 40 mg PO/OD
3. TAB DOLO 650 mg/PO/TID 
4. TAB LEVOCET 10mg/ PO /h/s
5. TAB GLIMI M2 PO/OD
6. TAB NITROFURANTOIN 100mg/ PO/ BD

Day 2 :
1. Plenty of oral fluids
2. TAB PAN 40 mg PO/OD
3. TAB DOLO 650 mg/PO/TID 
4. TAB LEVOCET 10mg/ PO /h/s
5. TAB GLIMI M2 PO/OD
6. TAB NITROFURANTOIN 100mg/ PO/ BD


Investigations :
ECG:
   USG:
     chest x ray :

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