50 year old male patient presented with history of cough and short of breath since two months.No history of fever or loss of weight. Know diabetic and chronic alcoholic. Breath sounds are absent on left side of chest wall. This is his chest x-ray. Please let me know the diagnosis and treatment plan. thanks

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Left lung shows loss of volume with left diaphragm is raised.. Trachea is also shifted mildly to the same side.. There is a dense opacity in the left Paratracheal region with a non homogeneous lesion occupying most of the left lung.. With no fever associated the diagnosis in order of priority will be.. (1)Old healed tubercular lesion with secondary obstructive airway disease confirmation needs spirometry pre and post bronchodialator (2) scar carcinoma in a old healed tubercular lesion.. Esp due to presence of dense Paratracheal opacity (3) reactivation of old tubercular infection.. Needs sending sputum for AFB smear and bactec culture and gene Xpert plus on two different days.. Once the diagnosis is established treatment plan can be done..
Cect thorax may be needed to confirm or exclude scar carcinoma
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trachea is diverted to left, with generalized opacity of left lung, my two primary differentials will be fibrosis and tuberculosis, line of management will be 2 sputum samples for afb as per protocol, plus look for constitutional symptoms of tb and a pulmonary function test for lung capacity and others , if still diagnosis is not confirmed can only go hrct thorax if logistics allow, with that mx of diabetes and supportive therapy like domicilary oxygen etc
trachea deviated to left lt diaphragm is also elevated multiple cystic changes in lt upper and mid zone suggestive of lt fibrocavitatory lung disease with compansitatory emphysema on rt side do sp afb bactec culture and gene expert and pyogenic culture treat accordingly
nebulise with bronchidilator
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Sputum AFB first. If negative, advise sputum CB-NAAT under RNTCP. Most likely PTB , may not have typical symptoms when diabetic. look for new onset pleural effusion to explain for your finding. If still inconclusive, consider CECT thorax. May require FOB later.
Chest X-ray quality could have been better. Left lung showing heterogeneous opacity with trachea shifted to left. DM being immunocompromised state the lesions are not typically localised to right apex. Rt lung fields hyper inflated suggesting copd/
fibrocavitary disease of left upper and mid zone in chest xray.... if constitiutional symptoms are absent...go for ESR, MT, SPUTUM EXAMINATION (if produces sputum)...look for AFB, NTM, Look for eosinophilia....
Looks like kochs do sputum afb and esr inconclusive then go for gene expert for tb / ct thorax otherwise start with akt and see the response if responding then continue and treatment of Dm and other conditions
differential diagnosis.. PTB..staphylococcal pneumonia...fungal pneumonia..
Do sputum AFB... Most likely tuberculosis.. Start AKT
Pulmonary koch's with fibrosisl left,advised AKT.
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