Dyspnoea, anorexia and weight loss in a 74 year old man.

A 74 year old male, whilst on holiday, was admitted with a history of increasing dyspnoea on exertion and associated left-sided pleuritic chest pain. He reported that for 2 months he had experienced mild discomfort in the lumbar area, and that 5 weeks previously he had complained of upper abdominal pain and attended an emergency department. Clinical examination and electrocardiogram (ECG) were normal, and a diagnosis of oesophageal reflux was made. The patient was commenced on an antacid, with some initial improvement. He also had a 2 month history of anorexia and weight loss. He had a 20 yr history of hypertension and was an ex-smoker, having smoked 15 cigarettes·day-1 for 20 yrs. On examination, he was pyrexial (38.5°C) and anaemic. Cardiovascular examination was unremarkable, but examination of the chest revealed dullness to percussion at the left base, reduced breath sounds, and decreased vocal resonance. A chest radiograph on admission is presented in figure 1. Investigation revealed a haemoglobin level of 99 g·L-1 with normocytic normochromic indices, leucocyte count 10.0×109 cells·L-1, urea 12.5 mmol·L-1, and creatinine 168 μmol·L-1. An initial differential diagnosis of pneumonia, with possible underlying bronchogenic carcinoma or pulmonary embolism, was made. The patient was heparinized and commenced on a broad spectrum penicillin. Initially, his condition improved, with temperature settling and improvement in his dyspnoea and chest pain. CASE FOR DIAGNOSIS