Case History : A 65 year old man presents with generalized weakness ,cough and shortness of breath since 10 days and left sided chest pain.

 A 65 year old man presents with generalized weakness ,cough and shortness of breath since 10 days and left sided chest pain.

The admitting resident physician admits the patient and starts the patient on ventolin nebulization TDs and organizes a Chest X-ray .

The chest X ray is given below:

1. What is the most likely diagnosis?

2. Which specific questions should be asked in the history?

3. Which further investigations need to be performed in this patient?

4. What would be your management plan?

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Answers & Discussion :

1. What is the most likely diagnosis? 

The most likely diagnosis is left sided pleural effusion and right hilar congestion.

2. Which specific questions should be asked in the history?: 

Ask about past history of smoking which predisposes to lung ca. 

Also any weight loss, night sweats and haemoptysis which will be present in Pulmonary TB and Lung carcinoma . 

In addition any palpable lymph nodes in axillary region or other parts of body suggestive of lymphadeopathy. ( Have you noticed any lumps or bumps on your body ?

3. Which further investigations need to be performed in this patient?; 

Pleural tap and pleural fluid Routine examination ( Ultrasound guided) .

Pleural fluid culture and sensitivity. CT scan of chest Sputum for Acid Fast Bacilli ( for TB) 

Sputum Culture and sensitivity 

Quantiferon Gold test for Tuberculosis ESR.

4. What would be your management plan? 

Determine the underlying cause of the pleural effusion and treat accordingly eg if TB : 

Antituberculous treatment. 

In case of cancer , keeping in mind the old age of patient , aggressive treatment for it may not be appropriate but palliative and symptomatic treatment for pain re;ief and keeping the patient comfortable may be the treatment of choice.