A Patient with lack of resolution of persistent cough, shortness of breath and now complains of Lack of appetite

The complete case can be found here

What are the possible differential diagnoses?
  • chronic obstructive pulmonary disease (COPD)asthma,
  • pulmonary fibrosis
  • Congestive heart failure
  • pulmonary thromboembolism
  • pneumonia
  • neuromuscular disease
  • left pleural effusion
points in favour and against each diagnosis at this point of time.

pleural effusion
  • heaviness on left side
  • cheast pain
  • shortness of breath
  • decrease breath sounds on left side
congestive heart failure
  • pedal edema
  • dyspnea
  • decreased urine output
  • against: no orthopnea or PND
chronic obstructive pulmonary disease
  • dyspnea
  • beedi smoker
pneumonia
  • dyspnea
  • against: patient is afebrile
pulmonary thromboenbolism
  • dyspnea
  • against: not sudden oncet, no embolic risk factors
renal failure

reference: davidson principles and practice of medicine chapter on respiratory medine

Out of all differential diagnoses, most likely is.
pleural effusion is most likely as heaviness is classic of pleural effusion

More information about history and examination to reach the final diagnosis
diffrential diagnosis for left sided pleural effusion include

Pneumonia (‘parapneumonic effusion’)
  • any history of fever
Tuberculosis
  • socioeconomic status of patient
  • family history of TB
Subdiaphragmatic disorders (subphrenic abscess, pancreatitis etc.)
  • abdominal pain
Malignant disease
  • weightloss - loosening of clothes
  • previous diagnosis of malignancy
  • smoking
nephrotic syndrome - CKD
  • JVP
  • any pleural friction rub
  • brown line on nails
  • signs of perepheral neuropathy
  • easy brusing
  • pruritus
  • preitoneal dialysis catheter
Post-myocardial infarction syndrome
  • history of angina
Asbestos-related benign pleural effusion
  • history of work in asbestos industry

Investigations
Chest xray, CT chest
  • evaluate TB
  • evaluate pleural effusion
  • evaluate pneumonia
  • evaluate COPD
renal function tests
  • confirm CKD
pleural tap
  • find the cause weather it is exudative or transudative effusion
LFT, complete haemogram

Diagnosis
Chest xray shows oblitration of costo diaphragmatic angle and fluid level on left side suggesting pleural effusion.

HRCT shows, endobronchial infection on left side and chronic kidney disease at left kidney

pleural tap analysis

high lumphocyte count and high protien suggests tubercular pleural effusion
        davidson table 15.29

final diagnosis
pulmonary tuberculosis with CKD

Treatment
anti tubercular treatment

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