Weight Loss (Case 41)

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Chapter 49
Weight Loss (Case 41)

Pamela R. Schroeder MD, PhD

Case: A 34-year-old woman with a history of HIV infection presents complaining of an unintentional weight loss of 20 pounds in 3 months despite an increased appetite. She also has been experiencing diaphoresis, heat intolerance, palpitations, fatigue, hair loss, and a gritty feeling in her eyes. Before 3 months ago her weight had been stable. She denies difficulty swallowing or breathing, mood changes, voice changes, or difficulty concentrating. She has noted that her menses are lighter than usual, but they are regular, occurring every 28 days without skipping months. She is compliant with her antiretroviral medications. She has a 15 pack-year history of smoking cigarettes, but denies alcohol or illicit drug use. She does not get any regular exercise.

Differential Diagnosis

Cancer

Infection (e.g., HIV, tuberculosis)

Gastrointestinal causes (e.g., malabsorption, hepatitis)

Endocrine (e.g., uncontrolled diabetes, thyrotoxicosis)

Psychiatric (e.g. depression, anorexia, bulimia)

Chronic illness

Intense exercise

Cardiac (e.g., advanced heart failure)

Pulmonary (e.g., chronic obstructive pulmonary disease [COPD])

Substance abuse (e.g., opiates, cocaine, amphetamine, cannabinoids)

Heavy cigarette smoking

Medications (e.g., antidepressants, antiepileptics, exenatide, metformin, pramlintide, topiramate, digoxin, nonsteroidal anti-inflammatory drugs [NSAIDs])

 

Speaking Intelligently

Upon initially encountering a patient who reports weight loss, I first quantify the amount of weight lost over a specified time frame and determine whether this was intentional or unintentional weight loss. Clinically significant weight loss is defined as over 10 pounds or greater than 5% of body weight in 6 to 12 months. I like to know what kind of appetite the patient has. Causes of unintentional weight loss with an increased appetite usually involve either an underlying medical cause or a significant increase in rigorous exercise, leading to calorie loss despite increased appetite. Examples in this category include malabsorption, uncontrolled diabetes mellitus, and hyperthyroidism. I also like to find out if there is any history of cancer, if patients are up to date on their general medical screenings (e.g., Papanicolaou test, or PAP smear; mammogram; colonoscopy), and if there are gastrointestinal symptoms, fever, psychiatric symptoms, substance abuse or heavy smoking, rigorous exercise, medications, and chronic illnesses. As there is a broad differential diagnosis, the key is to narrow down the possible causes with a thorough history and physical exam.

PATIENT CARE

Clinical Thinking

• If the weight loss is intentional—as, for example in an obese patient (BMI > 30) who is now exercising and modifying the diet—then this patient should be encouraged and the weight loss is not concerning.

• If the patient is overly concerned about the weight loss and exhibits a distorted self-image, excessive exercise, decreased food consumption, laxative abuse, or induced vomiting, one should be concerned about psychiatric conditions such as anorexia nervosa or bulimia.

• Always ask about occupation; for example, a ballet dancer or gymnast may be more likely to exhibit these behaviors.

• A complete medication history, including OTC medications and herbal supplements, is essential, as a number of drugs can cause weight loss.

• I then want to know if appetite is increased or decreased. Since the majority of causes of weight loss are associated with decreased appetite, if the patient’s appetite is increased, this can help narrow down the potential underlying pathologies.

History

• Quantify the amount of weight loss and the onset with time frame (over what period of time the weight was lost; how rapidly the weight was lost).

• Determine if symptoms are intentional or unintentional.

• Determine if appetite is increased or decreased.

• Ask about any known chronic medical conditions or history of cancer.

• Ask if up to date on general medical screening (e.g., colonoscopy, mammogram).

• Ask about occupation and hobbies (e.g., excessive exercise, wrestler, gymnast, ballet dancer).

• Ask about medications, including OTC (e.g., laxative abuse).

Physical Examination

• Note the patient’s appearance, including cachexia, and clues to mood and affect (e.g., disheveled appearance, flat affect).

• For exam of the head, ears, eyes, nose, and throat, pay attention to any signs suggestive of an underlying disorder like lipodystrophy in HIV and ophthalmopathy in Graves disease.

• For the neck exam, feel for lymphadenopathy, thyroid size, and nodules.

• In women, examine the breasts for any lumps, discharge, or peau d’orange skin suggestive of breast cancer.

• In the pulmonary exam, look for signs of COPD, like “pink puffers” from emphysema with cachexia, pink skin, and use of accessory muscles of respiration.

• During the cardiovascular exam, pay attention to any signs of chronic heart failure, such as jugular venous distension, crackles, S3 gallop, murmurs, and peripheral edema.

• When performing the abdominal exam, look for jaundice, ascites, hepatomegaly, or any abdominal pain or masses on palpation, as some of these findings can be seen in patients with hepatitis, colon cancer, or inflammatory bowel disease.

• In the genitourinary exam be sure to check the rectum for masses, prostate enlargement, or blood in the stool, which could be suggestive of colon or prostate cancer.

• Be sure to check reflexes for hyperreflexia and note any tremors, both of which could suggest thyrotoxicosis.

• Include a mini mental status exam with the neurologic exam because elderly patients with dementia often present with weight loss.

• Examine the extremities for clubbing, which can be seen in COPD or lung cancer, and edema, which is seen in congestive heart failure (CHF).

• During your examination of the skin, note any ecchymoses, jaundice, rashes, erythema, dryness, and diaphoresis.

Tests for Consideration

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• Use clinical judgment when ordering tests based on degree of clinical suspicion for the disease.

CBC: WBC count is increased in infection.

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Comprehensive chemistry panel: Liver function tests will be abnormal in hepatitis; renal function might be abnormal if taking a medication (e.g., NSAIDs) causing renal failure; electrolytes might be abnormal in multiple chronic illnesses; blood glucose will be elevated in uncontrolled diabetes.

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TSH with reflex free thyroxine (T4): TSH is suppressed in thyrotoxicosis with elevated free T4.