A 74 year old man was admitted with weight loss, nausea and vomiting, Rt hip pain.

Back ground history showed

1. Recent multiple chest infections
2. Under investigation for weight loss (18 kig in last 3 months)
3. COPD on Inhalers for many years
4. MI 1999
5. planned for total hip replacement by ortho.

Social history:

1. Retired factory worker (denied asbesto exposure)
2. lives alone
3. mobilizes with stick, limited by osteoarthritic hip pain
4. Ex smokers (stopped 16 years ago, 25 pack years)
5. Nil alcohol drink

On examination, he lookeed comfortable, but frail and very thin. abdomen.

CVS, Resp, abdo and neurological exams were nil significant.

No leg oedema.

Recent OGD and Colonoscopy showed NAD

FBC and U&E normal

CA 199 and CA 125 borderline high

T4 (15.5)normal and TSH (0.18) slightly low.

Sputum AFB pending.

We requested for CT (abd and thorax)

Update: 10/12/2009:

• Today endocrinologist suggested that low TSH is not uncommon among patient with chronic disease. Advised to do Free T3. If normal, endocrine input no longer required. T3 came back as Normal.
• Today CT done, awaiting formal report.

Update: 11/12/2009

CT Thorax and Abdo report came back with 2 significant issues.

1. Pleural thickening of both upper lobes, forming to a mass.
2. A significant dilation of lower part of oesophagus extending to oesophato gastric junction.

It is interesting that  there is a dilatation of oesophagus on CT scan after an experience gastroenteroligist's OGD finding was NAD. Any way, we requested Barium meal to confirm that finding. For pleural thicking, the respiratory physicain will come and have a look. (He denied asbesto history in the past)

Update: 2/1/2010 (Retrospective entry)

Chest physician reviewed him. But he was frail and an episode of chest infection. agreed to do thoracoscopy and biopsy when well enough.

Ba Swallow confirmed a large oesophageal dilatation with fluid level. He was booked for endoscopy.

Unfortunately, he had new right basal pneumonia. He deteriorted quickly and died.

Conclusion:

We did not find the definite cause of weight loss in this patient. But, clearly, his immidiate cause of death was aspiration pneumonia secondary to narrowing of the lower end of oesophagus.