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C. Tobacco, alcohol, and drug histories are very important and frequently
lead to other concerns.
E. Social factors include stress, isolation, and the cost and effort required to
eat.
History taking (1)
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Is there fever?
Suggest an infectious disease, such as tuberculosis, AIDS,
brucellosis, and typhoid fever
Collagen diseases and neoplasms should not be forgotten
Is there anorexia?
Anorexia may be related to a febrile process, but if there is
no fever one should consider the possibility of Addison's
disease, anorexia nervosa, Simmonds' disease, drug abuse,
poisoning such as arsenic poisoning, scurvy, malabsorption
syndrome, uremia, and liver failure, neoplasm.
History taking (2)
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Is there lymphadenopathy?
Generalized lymphadenopathy should suggest leukemia, sarcoidosis,
and lymphoma, as well as infectious disease processes.
Is there an abdominal mass?
An abdominal mass may be an enlarged spleen, a pancreatic
carcinoma, an enlarged liver, or renal mass. These masses would suggest
disease of those organs.
Mass also may be a carcinoma of the stomach or intestine.
Is there hyperpigmentation?
Hyperpigmentation would suggest Addison's disease.
History taking (3)
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Maldigestion/malabsorption Myelofibrosis
Inflammatory bowel disease Myotonic dystrophy
Pernicious anemia Parkinson's disease
Malignancy, especially Pink disease (mercury poisoning in
Biliary children)
Breast Psychiatric disease
Gastrointestinal Anorexia nervosa
Glucagonoma Anxiety disorders
Hepatic Bulimia
Leukemia Conversion disorders
Lymphoma Depression
Myeloma Manipulative behaviors
Pancreatic Psychosis/paranoia
Pulmonary Schizophrenia
Somatostatinoma Substance abuse
Differential Diagnosis (4)
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Diabetes :
At the onset, weight loss is primarily caused by osmotic diuresis with
polyuria/nocturia.
Later glycosuria produces caloric loss, combined with the increased catabolic state of
insulin deficiency and glucagon excess.
In a patient with new diabetes and prominent weight loss, consider underlying
pancreatic cancer.
Depression
It is recognized by sadness, anhedonia, anorexia, and sleep disturbance.
Inadequate intake
Common causes include painful oral lesions (phenytoin gum hypertrophy, vitamin
deficiency glossitis, heavy metal intoxication, candidiasis, poor dentition)
Solitary living in the elderly, early dementia, food fads, abnormal taste (hepatitis,
zinc deficiency, drugs)
Abdominal pain associated with eating (intestinal ischemia).
Protein-calorie malnutrition, the skin is dry and baggy. There is weakness, tremor,
polyuria, edema, and ascites.
Clinical finding(2)
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Drugs
Weight loss is associated with cholestyramine, digoxin, diuretics, oral
hypoglycemics, cytotoxics, amphetamines, and sibutramine.
Hyperthyroidism
Despite an increased appetite, weight loss occurs. Tachycardia, fine tremor,
silky skin, and eye signs (exophthalmos or lid lag)
Apathetic hyperthyroidism can occur in elderly patients producing
listlessness and tachycardia or atrial fibrillation.
Occult cancer
Pancreatic cancer is the prototype, with aversion to food, and weight loss
(20 to 40 lbs.) that precedes visceral pain or jaundice, and is not
proportional to size of the tumor.
Gastric and pancreatic cancer, moderate in prostate, colon, and lung
cancer, and mild in breast cancer.
Pathophysiology
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Clinical finding(3)
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Chronic infection
• Fever is the key sign. Common occult causes include bacterial
endocarditis, osteomyelitis, tuberculosis, and HIV.
Adrenal insufficiency
• Fatigue, hypotension, and hyperpigmentation—especially when
seen in the palmar creases or buccal mucosa—are important
findings.
Emphysemia
• Cachexia occurs in “pink puffers.” The patient will have a smoking
history, a barrel chest with reduced breath sounds, and will be
dyspneic on exertion
Management
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