28th February 2025

A 61-year-old car salesman presents to A&E with his wife due to a 1-month history of feeling tired all the time

A 61-year-old car salesman presents to A&E with his wife due to a 1-month history of feeling tired all the time, widespread joint pain, and new constipation over the last 4 days and persistent nausea. He has a new dry cough. His wife also mentions her concern that has not been his usual self for the past few days, and his short-term memory has deteriorated. She mentions he has lost weight, and has not been eating as much of late.

His past medical history includes GORD, for which he takes lansoprazole 15 mg once daily, and diverticulosis, diagnosed recently on colonoscopy for rectal bleeding. He takes docusate regularly and usually has a high-fibre diet as recommended by his GP. He drinks 4 pints of lager a week and smokes 5 cigarettes a day and is usually independent with all activities of daily living.

On examination, he appears cachectic. His airway is patent. He has good air entry throughout his chest except in his left midzone, which is dull to percussion. Saturations are 95% on room air. He has dry mucous membranes. Heart sounds are normal, with no murmur. He has a regular radial pulse, approximately 90 bpm. Blood pressure is 145/80 mmHg. His abdomen is soft, but he has some lower abdominal tenderness with dullness on percussion of his lower abdomen. Bowel sounds are present. His GCS is 14 as he cannot recall the date or current location. His calves are soft and non tender and he has no visible rashes. He is afebrile with a temperature of 36.8. Digital rectal exam demonstrates hard stool in the rectum.

The following blood tests are performed:

A chest X-ray shows a central left midzone mass which was not present on an X-ray 3 years previously.

What is the most likely underlying diagnosis in this case?

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