Weight Loss

HISTORY:

‍IntentionalUnintentional weight loss for ‍ ‍hoursdays

Lost ‍ ‍kglbs, from ‍ to ‍

Changes in diet or eating habits: ‍no ‍

Changes in physical activity: ‍no ‍

‍fatigue

‍fever, up to ‍°, over ‍ ‍hoursdays

‍night sweats

‍loss of appetite

‍abdominal pain

‍constipation

‍hematochezia

‍melenic stools

‍vomiting

‍polyuria

‍polydipsia

‍dyspnea, ‍at reston exertion

‍palpitations

‍hair loss

‍dry skin

‍cold intolerance

‍body aches

‍depression

‍insomnia

‍cognitive impairment

‍irritability



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Breasts: -R: ‍normal, -L: ‍normal

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Pelvic: vulva ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍no cervical motion tenderness

Genital: ‍normal, testicles ‍normal, penis ‍normal

Extremities: ‍edema, ‍warm, cap refill ‍< 3 sec> 3 sec, pulses ‍normal, ‍

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought process ‍organized, ‍no suicidal ideation, judgment ‍good



ASSESSMENT:

‍Weight loss due to lifestyle ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍lytes, ‍creatinine, ‍glucose, ‍LFTs, ‍albumin, ‍TSH, ‍cortisol, ‍HIV, ‍PSA

- Upper GI endoscopy

- Colonoscopy

- Mammogram

- CT scan of thorax, abdomen, and pelvis

- PET scan

- High-calorie diet

- Nutritional supplements

- Referral to dietitian

- Referral to gastroenterologist

- Follow-up in ‍ ‍weeksmonths

- Return if weight loss continues or if new symptoms develop