A 52 year old female presents with a 5 month history of weight loss, weakness, shortness of breath and cough with sputum production.

 A 52 year old female presents with a 5 month history of weight loss, weakness, shortness of breath and cough with sputum production.

She has a past history of treated TB at age of 14 years.

Her Temperature is 37.2 C. Oxygen saturation is 92 Percent. BP is 110/79.

Chest auscultation reveals bilateral crepitations, more on right side and right basal dullness.

You perform a Chest X ray which is shown below:

1. What are the findings on Chest X ray?

2. What could be the causes of these findings ?

3.  What further investigations would you like to perform?

4.  What are the management options available?

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1. What are the findings on Chest X ray? 

There is peri hilar shadowing in right lung . Also irregular right basal shadowing is visible.

2. What could be the causes of these findings ? 

There can be numerous possibilities for these findings considering the given history. 

The right basal shadowing could be due to atypical pneumonias like Mycoplasma or Legionella. 

Also given the past history of tretaed TB , we will need to exclude reactivation of Tuberculosis in this patient. As there is a history of weight loss as well, lung carcinoma should also be excluded and pulmonary metastasis from other organs should also be excluded.

3. What further investigations would you like to perform? 

Considering the differentials discussed in Question No 2, we would need to organize investigations to try to find out the underlying cause. A Full blood count would be a good investigation to begin with. 

A low Hb would indicate a chronic process such as Tuberculosis or Cancer. 

A raised white cell count will indicate underlying infection. A raised CRP would be seen in Malignancy or pneumonia. 

A sputum for Culture and sensitivity would help finding out the causative organism causing pneumonia. 

A sputum for AFB will exclude Tuberculosis and will be further supported by Quantiferon Gold Test. 

Tests to exclude Atypical pneumonias include Urinary Legionella testing and Myciplasma serology .

Finally A CT of Chest Abdomen Pelvis should be done to exclude lung Ca/ Malignancy as promary or metastasis from other organs.

4. What are the management options available? 

Management involves : initial resuscitation and stabilizing the patient. making the patient comfortable with proper analgesia. 

Proving oxygen and other measures to improve her breathing. 

Giving emperical antibiotics. Specific management shallbe commenced once results of Cultures and sensitivity and CT scan are available and then depending on final diagnosis , specific treatment should be commenced in case of atypical pneumonias or malignancy .