Anorexia
Anorexia: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Shawn H. Blanchard and Scott A. Fields
Anorexia is defined as the lack or loss of appetite, which can lead to unintentional weight loss. Interestingly, only 50% of people complaining of anorexia actually have documentable weight loss (Chapter 2.13).
Approach.
Two objectives for the patient encounter are (a) to ascertain the cause of this complaint and (b) to understand the effect that the patient’s loss of appetite has had on his or her well-being. Patient age and gender play a role in the evidence-based approach to anorexia as well. If the patient is a young woman, the clinician may suspect anorexia nervosa (5% prevalence in the population), whereas depression is a predominant factor in elderly persons with anorexia (1). Possible causes of anorexia are listed in Table 2.1. The diagnostic pathways are divided into four categories: pathologic, pharmaceutic, psychiatric, and psychosocial.
A. Pathologic. Acute loss of appetite can be as significant as a surgical emergency. Existing chronic disease can substantially reduce the appetite and should not be overlooked. Processes that negatively reward consumption and digestion can also lead to a change in eating behavior. Infectious diseases to consider include human immunodeficiency virus (HIV), tuberculosis, viral hepatitis, parasites, and intestinal protozoa (2). Pathologic or medical causes rarely present without related complaints or constitutional symptoms.
B. Pharmaceutic. Recreational drugs, prescription medications, or the discontinuation of either, are far more likely to be responsible for loss of appetite than are medical causes. Tobacco, alcohol, and amphetamines can cause varying degrees of anorexia. Withdrawal from narcotics, marijuana, and stimulants can cause loss of appetite. Use of prescription anorectic medications and over-the-counter products, including dietary supplements, can lead to anorexia.
C. Psychiatric. Time spent eliciting the history is likely to lead to a diagnosis. This includes time interviewing family members and significant others. Psychiatric diagnoses, including anorexia nervosa, depression, personality disorders, conversion disorder, schizophrenia, and obsessive-compulsive disorder, can affect appetite and, thus, cause loss of weight (3). It is important to remember that depressive illnesses are the most common cause for loss of appetite in the elderly and are often comorbidly associated with chronic progressive disease (4) (Chapter 3.3).
D. Psychosocial. Current social history may identify factors responsible for a change in the desire to eat. Loneliness or loss of a loved one, for example, can cause a patient to lose interest in meal preparation (4). Changes in social situation—a recent move away from a support group; a brief stress reaction; and even a sudden increase in positively perceived events such as preparation for a wedding, a recent graduation, or a job promotion—can affect one’s appetite.
History
A. History of present illness. The patient must provide a careful explanation of the problem: How is it affecting daily life? What does the patient think is responsible for the problem? Is the patient describing early satiety, dysphagia, or social dissatisfaction associated with eating? Do symptoms fluctuate? How are symptoms associated with meals? What has been tried to increase appetite and what does the patient think is responsible for the problem? Is there weight loss, or other associated symptoms?
B. Past medical history. Is there any history of eating disorders, chronic medical conditions, or history of psychiatric diagnosis?
C. Medications. Prescription and nonprescription medications as well as recreational drugs, herbal medications, and dietary supplements need to be listed. Over-the-counter medications are often overlooked by physicians, as well as by patients. Ask if any medications have recently been discontinued and why. Antidepressants, for example, can have anorexia as a withdrawal symptom.
D. Social history. The major focus is on recent life stressors that may play a pertinent role. Stressors can be positively perceived and still be constitutionally disabling. Take a brief life satisfaction survey of the patient. Anniversary dates of lost loved ones or marked changes in lifestyle can also be important.
E. Review of systems. A careful review of systems beginning with weight loss is necessary. An accurate diet history, either retrospective or prospective (with a dietary log), can prove helpful. Include signs and symptoms of depression and a brief psychiatric inventory. Consider a mental status examination. Are there any negative rewards for eating or any pain or difficulty swallowing? The patient may have painful dentition, nausea, vomiting, bloating, diarrhea, constipation, or bleeding associated with food ingestion. Finally, ask about recent head injury, or general neurologic changes suggestive of postconcussion syndrome, a central lesion, or cerebral vascular accident (5).
Physical examination
A. General appearance. Any level of anxiety behavior consistent with a personality disorder should be noted. Signs of systemic disease should be evaluated with vital signs, orthostatic blood pressure assessment, and temperature. Accurate weight documentation is critical in the evaluation for loss of appetite complaints. Serial measurements over time are required.
B. Head, eyes, ears, nose, and throat (HEENT). Dentition and neck examination, including observation of swallowing and thyroid examination, are important.
C. Cardiovascular and respiratory systems. Examine for cardiac arrhythmia and heart failure, including jugular venous distention, rales, peripheral edema, and hepatic congestion. Lungs should be examined for chronic obstructive pulmonary disease.
D. Gastrointestinal. Pain or rigidity of an acute abdomen, absent or hyperactive bowel sounds, ascites, and hepatomegaly should be evaluated. Rectal examination and stool guaiac testing should be done.
E. Skin. Look for the possible presence of skin tracks, cyanosis, or lanugo (fine, white, downy hairs sometimes seen in patients with anorexia nervosa). Jaundice or hyperpigmentation should be noted. Changes in hair pattern may be a clue to peripheral vascular disease.
F. Neurologic examination. Cranial nerve examination, including olfactory sensation and taste, should be performed. Deficits in these basic sensations can affect appetite significantly. Motor weakness, focal or asymmetric proprioception, and gait disturbance may show evidence of cerebral pathology. Most chronic neurologic disease and acute cerebral vascular events will include loss of appetite. Mental status needs to be assessed, if indicated. Organic brain syndrome, dementia, delirium, and psychosis can all play a role in loss of appetite.
Testing
A. History and physical examination should guide clinical laboratory testing. A general evaluation should include a complete blood count and a metabolic panel to assess electrolyte balance and hepatorenal function. Other specific laboratory studies to consider include HIV serology, viral hepatitis panel, calcium, thyroid-stimulating hormone, and albumin levels. Also, low levels of prealbumin can indicate malnutrition or impaired protein metabolism. Suspicion may direct the physician toward a urine drug screen, in addition to a urine dipstick test to screen for glucose, protein, and pH.
B. Special studies may include a chest radiograph, esophagoduodenoscopy (EGD), abdominal ultrasound, abdominal angiogram, or computed tomography (CT) scan. A tuberculosis skin test may be useful.
C. Psychological testing can include a formal depression scale, psychiatric consultation, or pharmaceutical trial with an (orexigenic) antidepressant, such as tricyclics.
Diagnostic assessment
Loss of appetite as a chief complaint rarely stands alone as the only problem when an effective history and physical examination are performed. The acuity of onset and the physical well-being of the patient may direct the urgency of the evaluation. The spectrum of additional constitutional symptoms in a complete review of systems will assist the examiner. The plan of action should be predicated by the assessment. Focus is then on treating the underlying condition: consider a trial of orexigenic therapy and nutritional supplementation to alleviate both the cause and the symptom of loss of appetite.
References
1. Morton KI, Sox HC, Krupp JR. Involuntary weight loss: diagnostic and prognostic significance. Ann Intern Med 1981;95(5):568–567.
2. Summerbell CD, Perrett JP, Gazzard BG. Causes of weight loss in human immunodeficiency virus infection. Int J STD AIDS 1993;4:234–236.
3. Garfinkel PE, Garner DM, Kaplan AS, Rodin G, Kennedy S. Differential diagnosis of emotional disorders that cause weight loss. CMAJ 1983;129(9):939–945.
4. Morley JE. Anorexia in older persons: epidemiology and optimal treatment. Drugs Aging 1996;8(2):134–135.
5. Evans RW. The post concussion syndrome and the sequelae of mild head injury. Neurol Clin 1992;10(4):815–847.
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Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
» Next page: Anorexia nervosa (Handbook of Diseases)
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