A 40 year old female with left sided pleural effusion( multiloculated) with right upper lobe fibrosis( sec to TB??)

  This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan



A 41 year old  female with

C/o fever since 10- 15 days 

C/o loss of appetite since 10- 15 days

C/o generalised weakness since 10-15 days

Cough with expectoration since 10-15 days

HOPI: The patient was apparently asymptomatic 15 days back then she developed fever low grade a/w loss of appetite and genralised waekness.Cough with expectoration.

No H/o weight loss

No H/o night sweats, evening rise of temperature.

Past history 

Not a k/c/o DM HTN TB CAD CVA Epilepsy Asthma 

Personal history 

Diet: Mixed 

Appetite: Decreased since 15 days 

B&B: Regular

Addictions: No addictions 

O/E

General examination 

Patient is C/C

BP: 120/80 mm hg

PR: 90 bpm

RR: 19 cpm

Temp: 97 F

GRBS: 121 mg/dl

SpO2: 98 % @ RA

Systemic examination 

CVS-S1S2 +, No Murmurs 

RS- BAE+ , left ISA Crepts +

P/A: Soft , NT

CNS: No FND

INVESTIGATIONS 































TREATMENT 

Tab PCM 650 mg PO/SOS

Tab.PAN 40 mg PO/OD

Tab. ZINCOVIT PO/BD

Tab. LIMCEE PO/BD

Syp GRILLINCTUS 10 ml PO/TID

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