Unintentional Weight Loss

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍month history of ‍intentionalunintentional weight loss

Lost ‍ ‍kglbs, (from ‍ to ‍)

Changes in diet or eating habits ‍

Changes in physical activity ‍



Associated symptoms: *Try using right-click for negatives*

‍fatigue

‍fever, up to ‍°, over ‍ ‍hoursdays

‍night sweats

‍anorexia

‍abdominal pain, ‍diffuse, ‍dull, ‍mild

‍constipation

‍hematochezia, ‍bright reddark red, ‍around stoolsmixed with stools, ‍withwithout clots

‍melenic stools, ‍withwithout strong foul smell

‍vomiting, ‍ episodes ‍per day, ‍, ‍hematemesis

‍polyuria

‍polydipsia

‍dyspnea, ‍at reston exertion

‍palpitations

‍hair loss

‍dry skin

‍cold intolerance

‍body aches

‍depression

‍insomnia

‍cognitive impairment

‍irritability



Contributing factors:

‍smoking

‍recent significant life changes

no history of: ‍hyperthyroidism, ‍diabetes, ‍malignancies, ‍recent surgery, ‍recent illness, ‍depression, ‍malabsorption disorders, ‍eating disorders

no use of: ‍metformin, ‍semaglutide, ‍thyroid medication, ‍new medication, ‍chemotherapy

no family history of: ‍malignant disorders





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

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

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Breasts: ‍normal, ‍mass, ‍axillary adenopathy

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Anorectal: DRE ‍normal, prostate ‍normal, ‍blood, ‍mass, anus ‍

Pelvic: external genitalia ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍cervical motion tenderness

Genital: penis ‍normal, testes and epididymis ‍normal, ‍inguinal hernia

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought ‍organized, ‍suicidal ideation, judgment ‍good





ASSESSMENT:

‍Weight loss due to lifestyle ‍likelysuspectedpossible

DDx: increased physical activity, dietary changes, cancer, hyperthyroidism, diabetes mellitus, chronic infection (e.g. tuberculosis, HIV), celiac disease, inflammatory bowel disease, malabsorption syndromes, chronic pancreatitis, COPD, congestive heart failure, rheumatoid arthritis, lupus, chronic kidney disease, liver disease, depression, anxiety, substance abuse, medication side effect, eating disorders, malnutrition, dental problems, dysphagia, neurological disorders, Addison's disease, dementia, chronic pain syndromes





PLAN:

Investigations:

- 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

Treatments:

- High-calorie diet

- Nutritional supplements

Further care:

- Referral to dietitian

- Referral to gastroenterologist

- Follow-up in ‍ ‍weeksmonths

- Return if weight loss continues or if new symptoms develop