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Probability diagnosis

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Stress and anxiety (e.g. redundancy, divorce)

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Depressive illness

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Non-coping elderly/dementia

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Eating disorders: anorexia nervosa/bulimia nervosa

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Serious disorders not to be missed

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Chronic heart failure

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Malignant disease, including especially:

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  • stomach

  • pancreas

  • lung

  • myeloma

  • caecum

  • lymphoma

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Infection:

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  • HIV infections (AIDS, AIRC)

  • tuberculosis

  • hidden abscess

  • infective endocarditis

  • brucellosis

  • others e.g. overseas acquired infection

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Pitfalls (often missed)

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Drug dependence (esp. alcohol)

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Malabsorption states:

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  • ?intestinal parasites/infestations

  • coeliac disease

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Other GIT problems (e.g. inflammatory bowel disease)

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Chronic kidney and hepatic failures

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Connective tissue disorders (e.g. SLE, RA)

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Dementia

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Rarities:

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  • malnutrition

  • Addison disease

  • hypopituitarism

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Masquerades checklist

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Depression

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Diabetes

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Drugs: adverse effects/substance abuse (see list)

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Anaemia

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Thyroid disorder (hyperthyroidism, Addison disease)

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UTI

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Is the patient trying to tell me something?

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A possibility. Consider stress, anxiety and depression. Anorexia nervosa and bulimia are special considerations.

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Key history

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Document the weight loss carefully and evaluate the patient’s recordings. Determine food intake and obtain the help of an independent witness such as a spouse or parent (if possible). Food intake may be reduced with psychogenic disorders and cancer but increased with endocrine disorders such as diabetes and hyperthyroidism, and with steatorrhoea.

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Document drug history.

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Key examination

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Consider:

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  • vital parameters (e.g. BMI, pulse, BP, temperature, urine analysis (dipstick))

  • thyroid and signs of hyperthyroidism

  • abdominal examination (e.g. organomegaly, masses)

  • rectal examination

  • look for acid dental erosion on surface upper teeth (bulimia).

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Key investigations

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Consider:

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  • FBE

  • ESR/CRP

  • thyroid function tests

  • U&E

  • HIV

  • blood sugar

  • faecal occult blood

  • CXR

  • endoscopy upper GIT

  • specific imaging (e.g. CT scan abdomen).

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Diagnostic tips

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Any loss of more than 5% of body weight is significant.

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  • The most common cause in adults of recent weight loss is stress and anxiety.

  • Two conditions commonly associated with weight loss are anaemia and fever; they must be excluded.

  • Ask patients what they believe is the cause of their weight loss.

  • An anxiety state and hyperthyroidism can be difficult to differentiate clinically.

  • Drug use causing weight loss includes opioids, amphetamines, alcohol, laxatives, digoxin, cytotoxics, NSAIDs, theophylline.

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