The patient, a 69 years old female, was admitted to our hospital on Feb 29^th 2008, with the chief complaint of “dyspnea for 2 months, fever and cough for 1 month”.

2 months ago, the patient developed shortness of breath after physical load, and it could be released by rest. At the same time, she got poor appetite, without fever, cough, expectoration, hymoptysis, chest pain or night sweat. She went to the local hospital and chest X-ray showed: “right pleural effusion”. She was prescribed some traditional Chinese medicine for about 10 days. However, her symptoms got worse. 1 month ago, she began to had cough and white sputum. She was admitted to the local hospital, and was given some antibiotics. She underwent thorax centesis for several times, but she did not feel better. Then she went to another local hospital and was given closed thoracic drainage. The white blood cell in the fluid was 260×10⁶/L, monocyte 80%. No TB and tumor cell were found in the pleural fluid. 10 days later, she began to have fever and the temperature was 38-39.5℃. Although she was given some antibiotics, she still had fever and dyspnea. She was admitted to our hospital for further diagnosis and treatment. Since the illness, she did not get hemoptysis, palpitation, night sweat and arthralgia. She had good spirit and sleep, bad appetite, normal urine and stool. Her weight decreased 2.5kg during the 2 months period.

Past history: she denied the history of hypertension, DM, tuberculosis or hepatitis. She had not contact history with special poison or drugs. She did not smoke or drink.

PE: T38.3℃, P120/min, R19/min, BP 100/60mmHg. She was well developed, conscious and cooperative, but fleshless. There was no jaundice, eruptions or hemorrhagic spots in her skin. The superficial lymphnodes were not paipable. There was a drainage tube in the 8^th intercostals on middle axillary line on her chest wall. The vocal fremitus of right lower lung was weak. The percussion of right lower lung was dullness. The breathing sound of right lower lung was weak. Fine moist rales could be heard in the left lower lung. No dry rales. There was no cardiomegaly. HR 120bpm, regular, A2>P2, systole stage II/6 murmur could be heard in apical region of heart. The abdomen was flat and soft. There was no tenderness and rebound tenderness in the abdomen. The liver and spleen could not be palpable. The shifting dullness was negative. There was no athocele and athodiskinesia in joints. There was no edema in her lower extremities.

Laboratory examination: (2008-2-2, local hospital) pleural effusion: yellowish, WBC 260×10⁶/L, monocyte 80%. (2008-2-29) blood WBC 11400/mm3, N 86.6%, HGB120g/l. pleural effusions: yellowish, specific gravity 1.020, WBC11900×10⁶/L, monocyte 20%, ADA 77u/L, Glu 0.0mmol/L, LDH 7055u/L.

Questions:

1. What is the diagnosis for this case?

2. What other disease would you distinguish with?

3. How would you investigate and manage this patient?

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