Weight Loss History Taking and Differential Diagnoses

History of Presenting Complaint

Overview

With each symptom, always (if relevant) ask about:

• When did it start?
• Did it come on suddenly or gradually?
• Is it continuous or intermittent?
• Has this ever happened before?

Weight loss

Questions to ask are:

• Onset – when did it start?
• Timeline – over how long?
• Severity – how much has been lost?
  • Has anyone noticed they have lost weight?
• Did they intend to lose weight?
• What has their appetite been like?
• What are their normal eating habits?
• Has their physical activity changed recently?
• Have they had any other symptoms?
• Have they had any recent illnesses?
• Has this ever happened before?

Review of systems

• Screen for psychiatric problems:
  • How has their mood been?
  • Screen for eating disorders using SCOFF (2/5 requires further assessment):
    • Sick – has the patient been vomiting?
    • Control – does the patient feel like they have lost control over their eating habits?
    • One stone – have they lost a stone in the last 3 months?
    • Fat – does the patient feel fat?
    • Food – does the patient spend a lot of time thinking about food?
  • Any laxative abuse?
• Screen for gastrointestinal tract disorders:
  • Inflammatory bowel disease:
    • Ask about abdominal pain, diarrhoea +/- blood, mouth ulcers
  • Coeliac disease
    • Ask about abdominal pain, diarrhoea, steatorrhoea
  • Peptic ulcer disease:
    • Ask about pain worsened with eating (gastric ulcer), pain relieved when eating (duodenal ulcer) 
• Screen for thyrotoxicosis:
  • Ask about sweating, bowel changes, menstrual irregularities, tremor, eye problems
• Screen for diabetes mellitus:
  • Ask about polyuria, polydipsia, recurrent urinary tract infections
• Screen for Addison’s disease:
  • Ask about fatigue, hyperpigmentation, feeling faint
• Screen for cancer and ask about red flags:
  • Ask about fatigue, unexplained weight loss, night sweats, family history
  • Lung cancer – any cough, shortness of breath, or haemoptysis?
  • GI tract cancer – any dysphagia, any changes in bowel habits, or any blood in the stools/melaena?
  • Haematological malignancy – palpable lymph nodes
• Screen for systemic inflammatory conditions such as rheumatological disease:
  • Any joint pain, muscle pain, or any skin rashes? 
• Screen for chronic infection (such as tuberculosis):
  • Any haemoptysis?
  • Any shortness of breath?
  • Any fevers?
  • Any night sweats?
  • Any foreign travel?

Past Medical History

• Do they have any other medical conditions?
• Have they ever had any previous surgery?
• Do they take any regular medications?
• Do they take any over-the-counter medications, herbal remedies, or supplements?

Family History

• Is there any family history of anything similar?

Allergy History

• Are they allergic to anything?
• What happens during the allergic reaction?

Social History

• Do they smoke?
  • If so, how much and how long?
• Do they drink alcohol?
  • If so, how much and how long?
• Do they use any illicit drugs?
  • If so, how much and how long?
• Who’s at home?
  • What support do they have?
• What is their occupation?
• How has this impacted their activities of daily living?
• Has there been any recent foreign travel?

Physical Examinations

Some physical examinations to consider may involve:

• A cardiovascular exam for cardiac disorders
• An abdominal exam for gastrointestinal disorders
• A mental status exam for psychiatric disorders
• A reticuloendothelial exam for lymphadenopathy
• A musculoskeletal exam for joint problems

Investigations

Overview

When suggesting investigations in an OSCE, the BOXES (Blood tests, orifice tests, x-rays, ECGs, special tests) mnemonic is useful for deciding the order of investigations:

• Blood tests:
  • Full blood count (FBC):
    • To assess for anaemia
  • Haematinics (B12, folate, and iron studies):
    • To identify an underlying cause of anaemia if present
  • Liver function tests (LFTs) and albumin:
    • To identify liver disease
  • Thyroid function tests (TFTs):
    • To identify thyroid disorders
  • Urea and electrolytes (U&Es) and urinalysis:
    • To identify metabolic abnormalities and renal disorders
  • C-reactive protein (CRP)/erythrocyte sedimentation rate (ESR):
    • Non-specific markers of inflammation
  • Lactate dehydrogenase:
    • Non-specific marker that may be elevated in malignancy
• Orifice tests:
  • Stool occult blood tests:
    • If colorectal cancer is suspected

Differential Diagnoses

Hyperthyroidism

• A history may reveal:
  • Palpitations, heat intolerance, palpitations, sweating, anxiety, tremor, hair loss, diarrhoea, oligomenorrhoea
• A physical exam may reveal:
  • Tachycardia, fine tremor, proptosis, pretibial myxoedema, arrhythmia
• Investigations may reveal:
  • TFTs: low serum TSH, elevated T3 and T4

Peptic ulcer disease

• A history may reveal:
  • A history of NSAID use or H. pylori infection
  • Gastric ulcers – pain is worse when eating
  • Duodenal ulcers – pain is improved when eating
• Investigations may reveal:
  • Positive H. pylori urea breath test

Coeliac disease

• A history may reveal:
  • Chronic diarrhoea, bloating, abdominal pain, fatigue, skin rash, and steatorrhoea 
• A physical exam may reveal:
  • Features of anaemia (e.g. pallor), dermatitis herpetiformis
• Investigations may reveal:
  • Anti-tissue transglutaminase (anti-TTG) may be elevated
  • Endoscopy with duodenal/jejunal biopsy: confirms diagnosis

Type 1 diabetes mellitus

• A history may reveal:
  • Polyuria, polydipsia, features of diabetic ketoacidosis (DKA, abdominal pain, nausea, vomiting, fluctuating consciousness) 
• A physical exam may reveal:
  • Tachycardia, hypotension, dehydration, Kussmaul breathing, acetone breath, fluctuating consciousness
• Investigations may reveal:
  • Blood glucose: elevated
  • Serum ketones: elevated
  • U&Es: in DKA, may show hyponatraemia, hypokalaemia, elevated creatinine
  • Arterial blood gas: metabolic acidosis

Inflammatory bowel disease

• A history may reveal:
  • Chronic diarrhoea that may have blood, abdominal pain, fever, fatigue
  • Crohn’s disease (CD): may have mouth ulcers, skin tags, perianal disease
  • Ulcerative colitis (UC): may have faecal urgency, tenesmus, bloody diarrhoea is more prominent
• A physical exam may reveal:
  • CD: ileocaecal valve, lower right quadrant tenderness, perianal lesions
  • UC: lower left quadrant
• Investigations may reveal:
  • FBC: anaemia
  • Faecal calprotectin: positive
  • Endoscopy with tissue biopsy: confirms diagnosis

Oesophageal cancer

• A history may reveal:
  • Dysphagia, nausea, fatigue, a history of smoking, a history of alcohol consumption, a history of gastro-oesophageal reflux disease (GORD)
• Investigations may reveal:
  • FBC: may show anaemia
  • Oesophagogastroduodenoscopy (OGD): confirms diagnosis

Gastric cancer

• A history may reveal:
  • A history of peptic ulcers or H. pylori infection, abdominal pain, haematemesis, melaena
• A physical exam may reveal:
  • Epigastric tenderness, epigastric mass, hepatomegaly, Sister Mary Joseph nodules or a palpable mass in Virchow’s nodes
• Investigations may reveal:
  • FBC and haematinics: iron-deficiency anaemia
  • CT abdomen: may show mass/metastases
  • Oesophagogastroduodenoscopy (OGD): confirms diagnosis

Pancreatic cancer

• A history may reveal:
  • Painless jaundice (although pain can be present), weight loss, upper abdominal discomfort, bloating
• A physical exam may reveal:
  • Jaundice, palpable gallbladder (Courvoisier’s law), epigastric mass 
• Investigations may reveal:
  • LFTs: may show cholestatic LFTs (ALP raised more compared to ALT)
  • Abdominal ultrasound: may show masses or biliary dilation (‘double duct’ sign)
  • High-resolution CT scan: identifies mass

Colorectal cancer

• A history may reveal:
  • Rectal bleeding, changes in bowel habits and stool calibre, abdominal pain
• A physical exam may reveal:
  • Features of iron deficiency anaemia, abdominal or rectal masses
• Investigations may reveal:
  • FBC and haematinics: may show iron deficiency anaemia
  • Stool occult blood test: positive
  • Colonoscopy: identifies tumour

Lung cancer

• A history may reveal:
  • Cough, haemoptysis, shortness of breath, chest pain, features of paraneoplastic syndromes (e.g. muscle weakness due to Lambert-Eaton myasthenic syndrome in small cell lung cancer)
• A physical exam may reveal:
  • May show wheezing, dullness to percussion
• Investigations may reveal:
  • FBC: may show thrombocytosis
  • U&Es: may show hypercalcaemia (ectopic PTHrP) or hyponatraemia (ectopic ADH)
  • Chest x-ray: may show mass, may show pleural effusion
  • CT chest with contrast: identifies lung cancer
  • Bronchoscopy: allows histological diagnosis 

Lymphoma

• A history may reveal:
  • Rubbery and hard painless lumps, fevers, night sweats, drinking alcohol may elicit pain (although this is very uncommon) 
• A physical exam may reveal:
  • Lymphadenopathy, splenomegaly, hepatomegaly
• Investigations may reveal:
  • FBC: anaemia, leukocytosis, thrombocytopenia
  • LDH: elevated
  • CT abdomen and pelvis: may show lymphadenopathy
  • Lymph node biopsy and flow cytometry: confirm diagnosis

Leukaemia

• A history may reveal:
  • Fever, night sweats, recurrent infection
• A physical exam may reveal:
  • Lymphadenopathy, splenomegaly, hepatomegaly
• Investigations may reveal:
  • FBC: derangements in haemoglobin, white cells, and platelets
  • Peripheral blood smear: derangements in different cell types
  • Flow cytometry: identifies abnormal cell populations
  • Bone marrow biopsy: confirms diagnosis

Multiple myeloma

• A history may reveal:
  • CRAB features (hypercalcaemia, renal dysfunction, anaemia, bone pain) 
• A physical exam may reveal:
  • CRAB features, pathological fractures
• Investigations may reveal:
  • FBC: anaemia, may show thrombocytopenia
  • U&Es: calcium, elevated creatinine +/-urea
  • Serum electrophoresis: monoclonal M proteins present
  • Urine electrophoresis: Bence Jones proteins (monoclonal M proteins present)
  • Skeletal x-ray: may show lytic lesions
  • Bone marrow biopsy: confirms diagnosis

Ovarian cancer

• A history may reveal:
  • Features similar to irritable bowel syndrome (IBS, abdominal distention, constipation, and bloating), abdominal and pelvic pain, nausea, diarrhoea, unexplained weight loss
• IBS is uncommon in people <50 years, suspect ovarian cancer in any woman >50 years with features suggestive of IBS
• A physical exam may reveal:
  • May be unremarkable, may show adnexal mass, ascites
• Investigations may reveal:
  • CA-125: elevated
  • Pelvic ultrasound: shows adnexal mass
  • Laparotomy may be considered to confirm diagnosis

Prostate cancer

• A history may reveal:
  • Lower urinary tract symptoms (LUTs, poor flow, weak stream, hesitancy, dribbling), pelvic pain, bone pain
• A physical exam may reveal:
  • Enlarged prostate that may be asymmetrical or nodular
• Investigations may reveal:
  • Prostate-specific antigen (PSA): elevated
  • Prostate biopsy: confirms diagnosis

Mesenteric ischaemia

• A history may reveal:
  • Cardiovascular disease (including myocardial infarction, angina, or atrial fibrillation), pain when eating (abdominal angina), haematochezia/melaena, fear of eating food due to pain 
• A physical exam may reveal:
  • Abdominal tenderness, abdominal bruits
• Investigations may reveal:
  • CT with contrast/CT angiogram: confirms diagnosis

Anorexia nervosa

• A history may reveal:
  • Fear of gaining weight even if underweight, restrictions in what food is eaten, body dysmorphia (e.g. thinking they are still overweight despite being underweight)
• A physical exam may reveal:
  • Reduced BMI, bradycardia, hypotension, muscle wasting, hair loss, lanugo hairs, parotid hypertrophy
• Investigations may reveal:
  • FBC: may show anaemia
  • U&Es: may be deranged
  • Blood glucose: may show hypoglycaemia

Bulimia nervosa

• A history may reveal:
  • Episodes of binge eating and compensatory behaviours (e.g. purging, fasting, laxative use, or exercise), a lack of control over eating during the episode, 
• A physical exam may reveal:
  • Erosions of the teeth, Russell’s sign (calluses on the dorsum of the hands due to repeatedly inducing vomiting), parotid hypertrophy
• Investigations may reveal:
  • FBC: may show anaemia
  • U&Es: may be deranged
  • Blood glucose: may show hypoglycaemia

Tuberculosis

• A history may reveal:
  • Travel to an endemic area, immunosuppression or HIV, cough, shortness of breath, haemoptysis, night sweats 
• A physical exam may reveal:
  • Fever, lymphadenopathy
• Investigations may reveal:
  • Chest x-ray: may show upper zone fibrosis, bilateral hilar lymphadenopathy, pleural effusion, or cavitation
  • Sputum culture: confirms diagnosis

Gastroparesis

• A history may reveal:
  • A history of type 2 diabetes mellitus, epigastric pain after eating, nausea/vomiting, poor control over blood glucose (swings from high to low)
• Investigations may reveal:
  • Blood glucose: hyperglycaemia or hypoglycaemia

Adrenal insufficiency

• A history may reveal:
  • Lethargy, weakness, nausea/vomiting, anorexia, fever, salt-craving
• A physical exam may reveal:
  • Skin hyperpigmentation (if primary adrenal insufficiency)
• Investigations may reveal:
  • U&Es: may show hyponatraemia and may show hyperkalaemia
  • Morning serum cortisol: low
  • Short synacthen test: positive

Systemic rheumatological disease

• A history may reveal:
  • Joint pain that improves with movement and worsens with rest, joint swelling, skin rashes, photosensitivity, fatigue, Raynaud’s phenomenon, thrombosis
• A physical exam may reveal:
  • Malar rash, synovitis, dactylitis, Raynaud’s phenomenon, other skin rashes
• Investigations may reveal:
  • Rheumatological autoantibodies (e.g. anti-nuclear antibody): may be positive

Abuse

• A history may reveal:
  • Recurrent injuries, unexplained injuries or injuries with an inconsistent story, unstable home environments
  • Injuries and bruising in a non-mobile person
• A physical exam may reveal:
  • Wasting, cachexia, bruises, burn marks, head injuries, injuries across sites that are not in keeping with the story