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Unexplained Weight Loss

Unintentional weight loss is a non-specific symptom but may be indicative of a serious underlying pathology. Developing an approach to unintentional weight loss is important for students as they learn to recognize and treat comorbid illness.

Required Skills/Procedures:

1. Perform situation-appropriate (problem-focused or complete) history and physical examinations
2. Interpret clinical information to formulate a prioritized differential diagnosis
3. Guide the creation of a patient-specific management plan

Appropriate Setting: Inpatient and Outpatient

Expected level of Responsibility: Direct supervision with real patients

Learning Topics during encounters with a patient with UNEXPLAINED WEIGHT LOSS can include:

Medical Knowledge Learning Topics related to UNEXPLAINED WEIGHT LOSS

1. Signs and symptoms of clinically significant weight loss (5% of body weight over six to 12 months)

2. Clinical features that help to differentiate etiologies

3. Rapid unintentional weight loss is associated with significant morbidity and mortality

Diagnostic Evaluation Learning Topics related to UNEXPLAINED WEIGHT LOSS

1. Age-appropriate medical history that includes:

  • conditions that prevent food consumption
  • persistent vomiting
  • malabsorption
  • medication use especially polypharmacy in the elderly
  • endocrine disorders
  • malignancies
  • chronic illnesses such as CHF, COPD, RA
  • acute or chronic infection
  • drug abuse, heavy smoking
  • malnutrition, social isolation
  • psychological stresses or diseases

2. Physical exam to establish the diagnosis and severity of weight loss including:

  • calculation of degree of weight loss
  • assessment for signs of wasting; malnutrition; poor dentition or poorly fitting dentures; thyromegaly; abdominal masses, enlarged lymph nodes; pelvic masses in women; diabetic neuropathy; psychogenic symptoms, e.g., loss of tooth enamel, knuckle ulcerations and calluses

3. Differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology of primary and secondary weight loss

4. Utility and interpretation of diagnostic tests to discern causes of weight loss which may include CBC, chemistries, TFTs, liver tests, calcium, magnesium, phosphate, albumin, HIV test, autoimmune disease tests, CXR, abdominal imaging, EGD and/or colonoscopy

Management Plan Learning Topics related to UNEXPLAINED WEIGHT LOSS

1. Treatment of the underlying disorder

2. Caloric supplementation to achieve intake of 30-40 kcal/kg/day

3. Indications for consultation with a dietician

4. Routine nutritional supplements

5. Pharmacotherapy such as appetite stimulants

6. Temporary naso-jejunal tube, or permanent cutaneous gastric or jejunal tube

7. Cost-effectiveness of the management plan

8. Follow-up planning

Potential Differential Diagnosis Topics Include:

  • Conditions that prevent food consumption: access to food, dysphagia, painful mouth, new orthodontic appliances or loss of teeth
  • Loss of appetite (medication, depression)
  • Persistent vomiting: pyloric stenosis, hiatal hernia
  • Malabsorption: celiac disease, chronic pancreatitis, Crohn’s disease, gastrointestinal infection, gastrointestinal fistulas, carcinoid, intestinal hypermotility, hepatobiliary disease, food intolerance
  • Medication: NSAIDs, SSRIs, antiepileptics, polypharmacy in the elderly
  • Endocrine: diabetes mellitus, hyperthyroidism, Addison’s disease
  • Malignancy: lymphoma, leukemia, carcinoma, sarcoma
  • Systemic disease: heart failure, chronic respiratory disease, chronic renal failure, liver failure, rheumatoid arthritis, systemic lupus erythematosus, ischemic colitis
  • Acute or chronic infection
  • Drug abuse, heavy smoking
  • Psychological: stressful life events, depression, anorexia nervosa, psychoses