Weight Loss
Age: years old
Gender:
HISTORY:
Presents with a - history of weight loss
Lost , (from to )
Changes in diet or eating habits
Changes in physical activity
Associated symptoms: *Try using right-click for negatives*
, up to °, over
, , ,
, , , clots
, strong foul smell
, episodes , ,
,
Contributing factors:
no history of: , , , , , , ,
no use of: , , , ,
no family history of:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Breasts: , ,
Abdomen: , , , , bowel sounds , ,
Anorectal: DRE , prostate , , , anus
Pelvic: external genitalia , vagina , cervix , uterus , adnexa ,
Genital: penis , testes and epididymis ,
Extremities: , , cap refill sec, pulses , ,
Mental status: , , speech , mood , thought , , judgment
ASSESSMENT:
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: , , , , , , , , ,
- 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
- Return if weight loss continues or if new symptoms develop
HISTORY: Associated symptoms: EXAM: ASSESSMENT: PLAN: