pleural effusion of 32yr old female

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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 prognosis 

A 32yr old Male resident of Miryalguda came to causality with 

CHIEF COMPLAINTS

Fever since 7 days 

Pain in abdomen since 7 days 

Burning micturition since 3 days

𝐇𝐈𝐒𝐓𝐎𝐑𝐘 𝐎𝐅 𝐏𝐑𝐄𝐒𝐄𝐍𝐓𝐈𝐍𝐆 𝐈𝐋𝐋𝐍𝐄𝐒𝐒 :-

Patient was apparently asymptomatic 7 days back then he developed fever which is sudden in onset,high grade , associated with chills and rigors, releived by taking medication and no aggregating factors.pricking type of pain in the abdomen since 7 days in right hypochondriac,right lumbar, umbilical region, aggrevated during deep inspiration.

H/o burning micturition since 3 days,no urgency , frequency, hesitancy.

No chest pain,sob, palpitations

No nausea, vomiting 

No loose stools 

No increased or decreased output

Umblicus is in position, inverted

Skin over abdomen normal shiny, no scars, no sinuses, no nodules, no puncture marks.

No visible veins.

No engorged veins.

Movements of abdominal wall are normal, no visible gaatric peristalsis 

Palpation: 

Liver examination:

On superficial palpation

no tenderness , raised temperature

On deep palpation

 No tenderness in liver

Non pulsatile

Infraclavicular area. Reduced. N

Mammary area. Reduced. N

Axillary area Reduced. N

Infraxillary area Reduced. N

Suprascapular area. Reduced. N

Interscapular area. Reduced. N

Infrascapular area. Reduced. N

Percussion :

On direct percussion in clavicular area

On right side :

On left side :

Tidal percussion: dullness in the right 5 th intercostal space even after deep inspiration.

Traubes space percussion : dull note

Blood grouping

ECG

Chest x ray 

Random blood sugar

 

Complete urine examination

HIV

HBsAg

dropping of right shoulder :

Provisional diagnosis :

 right side plural effusion with lung collapse.

Tubercular pleuritis 

Treatment :

IV FLUIDS NS 50ML/HR with 1 AMP OPTINEURON

INJ.NEOMOL 1GM IV /SOS IF TEMP >101 F

T.PCM 650 MG PO SOS

INJ.TRAMADOL 1 AMP IN 100ML NS SOS 

T.AZITHROMYCIN 500MG PO/OD

INJ PAN 40 MG IV/OD

TAB.ATT 4tab po/of

H 5mg/kg 340mg

R 10mg/kg 680mg

Z 25mg/kg 1700 mg

E 15mg/kg 1020mg