intake-2022-03-25.md (805B)
1 # intake 2 3 ## cc: trouble swallowing and weight loss 4 5 28M w few weeks of trouble swallowing (gets stuck "right here," points to mid-sternum), 6 solid/liquids same, 7 gradual over months-weeks, 8 some vomiting w/o specific timing. 9 Sometimes has pain when not eating. 10 20lb weight loss over months. 11 No skin lesions. 12 ?thrush. 13 14 ## PMHx/PSHx 15 16 dx BPD, no other dx or procedures 17 18 19 ## SHx 20 21 - MSM w occasional use of protection, no PrEP 22 - occ MJ use, no other substances 23 - unemployed, lives w mom 24 - no unusual hobbies or travel 25 26 ## PE 27 28 HR 100, SBP 80 -> 100 w 500mL LR, AF 29 cachectic (temporal, hypothenar wasting) 30 +skin tenting 31 diffuse abd tenderness 32 33 ## w/u 34 35 Hgb 10, MCV 88, WBC ~4, ANC 1500 36 BMP wnl 37 Alb 3.4 38 HIV+, VL 15k, rest of STI -ve 39 40 CXR wnl (AP and lateral) 41 42 ## dx 43 44 candidal esophagitis, achalasia, H Pylori PUD