Diagnosis of Eating disorders

• Gastrointestinal and malabsorption disorders (e.g., celiac disease, Crohn's disease, cystic fibrosis, PUD)
  –Diarrhea is often present

• Depression
  –Weight loss is one diagnostic criterion
  –Most common cause of weight loss in outpatient populations

• Adrenal insufficiency
  –Anorexia, nausea, and fatigue are common
• Anorexia nervosa
  –May present with low albumin, parotid enlargement, lesions on knuckles and diminished tooth enamel from induced vomiting, and menstrual irregularities
• Failure to thrive (infants)
  –Parental neglect, emotional deprivation
  –Improper mixing of formula
  –Significant heart (shunts) or lung disease
  –Inborn errors of metabolism
• Intestinal parasites

Workup and Diagnosis

• Comprehensive history and physical examination, including assessment of diet and caloric intake
• In patients with adequate caloric intake, endocrine and malabsorptive disorders are more likely
• Initial tests may include CBC, serum chemistries, glucose (to rule out diabetes), thyroid function tests, ESR, and albumin and/or prealbumin
• HIV testing if risk factors are present
• Chest X-ray in smokers
• Age-appropriate cancer screening (e.g., mammography, fecal occult blood testing, flexible sigmoidoscopy or colonoscopy)
• Morning (AM) cortisol and ACTH stimulation test if suspect adrenal insufficiency
• Consider upper GI endoscopy, colonoscopy, and GI consult

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Source: In a Page: Signs and Symptoms, 2004

Weight Gain: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Primary obesity due to overeating and a sedentary lifestyle
• Medication side effects (e.g., oral contraceptives, corticosteroids, antidepressants, benzodiazepines, hypoglycemics, and anticonvulsants)
• Overeating secondary to nicotine withdrawal, depression, binge phase of bulimia nervosa
• Pregnancy
• Pre-eclampsia/eclampsia
• Premenstrual syndrome
• Nephrotic syndrome
  –Renal loss of protein results in decreased intravascular oncotic pressure, leading to water “leakage” to extravascular compartments (e.g., edema, ascites)
  –Due to primary renal disease or secondary causes (e.g., diabetes mellitus)

• Acute or chronic liver disease
  –Decreased hepatic protein production results in decreased intravascular oncotic pressure, leading to water “leakage” to extravascular compartments (e.g., edema, ascites)
• Congestive heart failure
• Hypothyroidism
• Diabetes mellitus
• Polycystic ovarian syndrome
  –Associated with hirsutism, menstrual irregularities, insulin resistance, obesity
• Cushing's syndrome
  –Excess cortisol levels due to ACTH-secreting adrenal adenoma, adrenal hyperplasia, ACTH-secreting ectopic tumor, or ACTH-secreting pituitary adenoma (Cushing's disease)
• Less common etiologies (“zebras”) include hypothalamic lesions (e.g., tumor, infection), hyperphagia due to hyperthyroidism, acromegaly (growth hormone excess, usually due to a pituitary tumor), or growth hormone deficiency

Workup and Diagnosis

• Complete history and physical examination
  –Baseline weight, rapidity of weight gain, food diary, medication list, tobacco and/or alcohol use, menstrual history, review of systems, and screen for depression
  –Note body habitus (e.g., Cushing's often presents with moon facies, buffalo hump, and thin extremities)
  –Note body hair distribution (scarce in hypothyroidism; hirsutism in PCOS and Cushing's syndrome)
  –Note skin appearance (abdominal striae and easy bruising in Cushing's; acanthosis nigricans in diabetes)
  –Check for peripheral edema and ascites (CHF, nephrotic syndrome, liver disease, pre-eclampsia)
• Initial labs include CBC (leukocytosis in Cushing's, thrombocytopenia in pre-eclampsia), fasting glucose (elevated in diabetes and Cushing's), BUN/creatinine (rule out renal failure), urinalysis (excessive proteinuria and lipiduria in nephrotic syndrome; proteinuria in pre-eclampsia and diabetes), TSH (hypothyroidism), lipid profile (hypercholesterolemia in nephrotic syndrome, Cushing's, diabetes), albumin (decreased in nephrotic syndrome and liver disease), and urine β-hCG
• Further studies may include 24-hour urine (if urinalysis reveals >3 g proteinuria), LFTs (elevated in liver disease and pre-eclampsia), dexamethasone suppression test (rule out Cushing's), chest X-ray and/or echocardiogram (rule out CHF if pulmonary edema suspected on exam), abdominal ultrasound and/or CT scan (rule out liver or renal disease), and/or pelvic ultrasound (rule out polycystic ovaries)

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Source: In a Page: Signs and Symptoms, 2004

Anorexia: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Psychosocial/psychiatric
  –Unrealistic parental expectations of what child should eat leads to pressure and causes food refusal
  –Anorexia nervosa: Common among adolescents, particularly females
  –Depression

• Infectious
  –Gastroenteritis: Salmonella, Shigella, E. coli, Norwalk agent
  –HIV
  –Hepatitis A, B, C
  –Pyelonephritis
  –Mycobacterium tuberculosis

• GI disorders
  –Gastroesophageal reflux disease
  –Constipation
  –Appendicitis
  –Celiac disease
  –Pancreatitis
  –Crohn disease
  –Achalasia
  –Esophageal foreign body
  –Liver failure
• Metabolic/endocrine disorders
  –Hypothyroidism
  –Hypercalcemia
  –Panhypopituitarism
  –Addison disease
  –Diabetes insipidus
  –Lead poisoning
• Nutritional disorders
  –Zinc deficiency
  –B12 deficiency
  –Iron deficiency
  –Dietary chloride deficiency
  –Hypervitaminosis A
• Cardiopulmonary disease
  –Congestive heart failure
  –Cystic fibrosis
• Drug toxicity
  –Illicit drugs
  –Antihistamines
  –Methylphenidate
  –Ephedrine
  –Digitalis
• Rheumatic disorders
  –Systemic lupus erythematosus
  –Juvenile rheumatoid arthritis
• Pregnancy

Workup and Diagnosis

• History
  –Nausea, vomiting, weight loss, diarrhea, hematochezia, melena, abdominal pain, pica
  –Fever, sick contacts, recent travel, headache, rashes, diaphoresis, dysuria, cough, rashes, joint complaints, insomnia, activity level
  –Medications: Prescription and over-the-counter
  –Dietary history: Quantity and types of food
  –Social history: Changes in home environment, abuse, drug use, alcohol use, tobacco use, changes in grades in school, changes in activities/interests

• Physical exam
  –Height and weight, pulse, blood pressure
  –Scleral icteris, jaundice, abdominal pain/distension, hepatosplenomegaly
  –Dentition, mucous membranes, murmurs, lung sounds, joint tenderness, skin turgor, rashes, neurology exam including funduscopy

• Labs/studies
  –Electrolytes and CBC with differential
  –Consider LFTs, amylase and lipase, thyroid tests
  –Stool for blood, stool culture, urinalysis with culture
  –Vitamin levels, lead level, HIV test, hepatitis panels
  –Pregnancy testing
• Consider upper endoscopy/colonoscopy
• Consider chest X-ray
• Consider upper GI with small bowel follow through

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Polyphagia: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Exogenous obesity
• Bulimia
• Depression
• Anxiety
• Diabetes mellitus
• Hypoglycemia
• Diabetes insipidus in infants
  –On breast milk or formula diet, excessive drinking is misinterpreted as excessive eating
• Hyperthyroidism or Graves disease
  –Increased metabolic rate, increased appetite, and increased oral intake as well as increased stool output
• Medications
  –Corticosteroids
  –Cyproheptadine
  –Tricyclic antidepressants
  –Valproic acid
  –Tetrahydrocannabinol
  –Neuroleptics
  • Hypothalamic lesions (hypothalamic –Tumors (e.g., craniopharyngioma)
    –Inflammation/autoimmune
    –Central nervous system infection
    –Head trauma
• Genetic syndromes
  –Prader-Willi syndrome
  –Laurence-Moon-Bardet-Biedl syndrome
  –Kleine-Levin syndrome
• Cystic fibrosis
  –Malabsorption results in chronic malnutrition, especially of fat

Workup and Diagnosis

• History
  –Nutritional history/diet recall for 24–72 hour
  –Onset (age, life events) of change in eating behaviors
  –Symptoms of depression, anxiety, eating disorders, or other psychiatric illness
  –Symptoms of diabetes: Polyuria, polydipsia, wt loss
  –Symptoms of hyperthyroidism or Graves disease: Palpitations, proximal muscle weakness, heat intolerance, ocular symptoms, difficulty concentrating, tremulousness
  –Past medical history, medications
  –Symptoms of brain tumor or infection/injury to CNS: Headaches, visual changes, fever, trauma, mental status changes
  –A history of poor feeding and hypotonia at birth, developmental delay, hypogonadism, and hyperphagia with subsequent obesity suggests Prader-Willi syndrome

• Physical exam: Height and weight, visual fields, optic disks, visual acuity (brain tumor), proptosis, goiter, lid lag (Graves), syndromic features
• Labs/studies: Blood glucose; TSH, T4, T3, thyroid stimulating immunoglobulin; genetic testing for Prader-Willi or Laurence-Moon-Bardet-Biedl syndrome; simultaneous serum and urine osmolalities may indicate DI; often requires formal water deprivation test
• MRI of the brain and pituitary

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Weight Loss: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Infectious
  –The most common cause overall and can be divided into acute and chronic
  –Gastroenteritis most common infection
  –May be viral, bacterial, fungal, or parasitic
  –Estimated 21–37 million episodes a year in children under 5
  –Others include strep, osteomyelitis, EBV, TB

• Psychiatric/psychosocial
  –Anorexia nervosa
  –Bulimia
  –Depression
  –Rumination
  –Drugs: Cocaine, amphetamines, laxatives
• Gastrointestinal disorders
  –Gastroesophageal reflux disease
  –Inflammatory bowel disease
  –Hepatitis
  –Pancreatitis
  –Pancreatic insufficiency (e.g., CF, Shwachman syndrome)
  –Celiac disease
  –Sucrase-isomaltase deficiency
  –Fat malabsorption: Abetalipoproteinemia
  –Protein malabsorption: Hartnup disease
  –Superior mesenteric artery syndrome
• Nutritional
  –Dieting; inadequate caloric intake
  –Iron deficiency
  –Zinc deficiency
  –Neglect
• Metabolic/endocrine
  –Diabetes mellitus
  –Diabetes insipidus
  –Addison disease
  –Hyperthyroidism
  –Hypopituitarism
• Malignancy
• HIV
• Acute/chronic renal failure
• Inflammatory
  –Systemic lupus erythematosus
  –Juvenile rheumatoid arthritis
  –Sarcoidosis
• Neurologic
  –Increased ICP: Pseudotumor cerebri, mass
• Cardiopulmonary
  –Cystic fibrosis
  –Congenital heart disease
  –Congestive heart failure

Workup and Diagnosis

• History
  –Bowel function including number and consistency of stools, melena, hematochezia, vomiting, abdominal pain, fever, headache, diaphoresis, sick contacts, travel history, oral intake
  –Diet history: Food consumption, number of meals
  –Medications: Prescription and over-the-counter
  –Social history: Changes in family structure, alcohol, illicit drug use, smoking, changes in grades in school, changes in activities and interests
  –Developmental history: Milestones, multiple points on growth curve

• Physical exam
  –Height/weight, pulse, blood pressure, mucous membranes, scleral icteris, adenopathy, neck mass, thyroid, lung sounds, murmurs, abdominal mass/tenderness, hepatosplenomegaly, skin turgor, joint tenderness, neuro exam including funduscopy, gynecologic exam
• Laboratory/radiology are based on H&P
  –Initial electrolytes, CBC with differential
  –Consider LFT, amylase/lipase, ESR, iron studies
  –Throat culture, stool culture, stool for O&P
  –Stool for blood, urinalysis and culture, fat/reducing substances, thyroid function
  –HIV test, PPD
  –Consider chest X-ray
  –Limited value of CT/MRI unless dictated by H&P

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Diarrhea – Chronic, No Blood or Weight Loss: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Osmotic: Presence of nonabsorbable solute, pH <5, volume <200 mL/day, normal electrolytes, stops with fasting
• Secretory: Mostly due to toxins, pH >6, volume >200 mL/day, no response to fasting, stool Na >70 mEq/L, negative reducing substances
• Toddler's diarrhea: Chronic nonspecific diarrhea, onset 3 months to 3 years of age, average 4–6 stools daily, due to excessive juice intake or low-fat diet
• Excessive intake of nonabsorbable solutes (lactulose, sorbitol, magnesium hydroxide)
• Congenital lactose deficiency: Very rare in infancy, but may occur in extremely premature infants; adult-onset type of hypolactasia may be seen in older children (over age 5), autosomal recessive, 15% white adults, 85% of black adults, 90% of Asian adults
• Secondary lactase deficiency: Follows a viral gastroenteritis, most commonly rotavirus, may persist for months
• Fructose intolerance
• Sucrase-isomaltase deficiency: Autosomal recessive, found in 0.2% of North Americans, symptoms commence on starting sucrose or glucose polymer-containing foods
• Glucose-galactose malabsorption: Rare, autosomal recessive disorder
• Infections
  –Giardiasis (most common infectious cause of chronic diarrhea in toddlers)
  –Cryptosporidium
  –Microsporidium
• Irritable bowel syndrome (IBS)
  –Abnormality of intestinal motility and pain perception with no organic basis
  –Abdominal pain associated with intermittent diarrhea or constipation
• Bacterial overgrowth: Enteric bacteria colonizes the upper small intestine
• Trehelase deficiency (trehelose is the sugar found in mushrooms)
• Zinc deficiency
  –Acrodermatitis enteropathica is typical rash
• Low-fat diet

Workup and Diagnosis

• History
  –Weight loss
  –Daycare setting, ill contacts
  –Diet history: Type and amount of fluids daily (intake of >150 mL/kg/day with normal weight and height suggests toddler's diarrhea)
  –Frequency of stool and consistency
  –Associated symptoms: Abdominal pain, bloating, flatulence, rash, fever, or vomiting
  –Onset of symptoms and relation to ingestion of milk, sucrose, or glucose
  –Worsening with stress (typical for IBS)
  –Exposure to lakes, well water (suggestive of parasite)
  –Travel history
  –Excessive “sugar free” gum chewing (sorbitol)

• Stool examination
  –Gross examination (blood, mucus, undigested food)
  –Color is not helpful
  –Occult blood test (not detected in IBS)
  –pH: Stool pH <5 indicates osmotic diarrhea from reducing sugars (sucrose and trehelose are nonreducing)
  –Stool cultures, O&P, Clostridium difficile toxin
• More studies only if all of above failed to reveal cause
• Hydrogen breath test
  –Detects carbohydrate malabsorption (lactose, sucrose, fructose, glucose) and bacterial overgrowth
• Stool electrolytes if secretory diarrhea is suspected

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Diarrhea – Chronic, with Weight Loss: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Allergic enteritis: Typically cow's milk or soy in infants
• Inflammatory bowel disease (IBD)
• Cystic fibrosis (CF)
  –Chronic diarrhea may be the only sign
  –90% have pancreatic insufficiency (PI)
• Celiac disease (CD): Gluten sensitivity, increased incidence in selective IgA deficiency, DM, and Down syndrome
• Immune deficiency (e.g., hypogammaglobulinemia)
• Sucrase-isomaltase deficiency: Autosomal recessive, symptoms with starting sucrose or glucose polymer-containing diet
• Microvillus inclusion disease: Most common cause of persistent diarrhea in the neonatal period
• Schwachman-Diamond syndrome
  –Pancreatic insufficiency, neutropenia, short stature, skeletal abnormalities
• Johannson-Blizzard syndrome
  –Pancreatic insufficiency, scalp defects, agenesis of nasal cartilage, deafness, imperforate anus
• Whipple disease:
  –Tropheryma whippelii (actinomycete)
  –Diagnosed mainly in adults
  –Weight loss, diarrhea, and arthropathy
• Tropical sprue: Common in developing countries; folate deficiency and diarrhea
• Neural crest tumors: Pheochromocytoma, VIPoma, Zollinger-Ellison syndrome, carcinoid tumors
• Mastocytoma
• Neuroblastoma
• Abetalipoproteinemia
• Giardiasis, Strongyloides, coccidia
• AIDS
• Acrodermatitis enteropathica: Zinc deficiency, acral perioral and perianal rashes, consider underlying cystic fibrosis
• Mutational defects in ion transport proteins
  –Chloride-losing diarrhea: Rare, ileal chloride transport defect, maternal polyhydramnios
  –Congenital sodium diarrhea
• Tufting enteropathy (epithelial dysplasia)
• Enterokinase deficiency

Workup and Diagnosis

• History and physical exam
  –Diet history and nutritional assessment, onset, frequency, and consistency, history of foreign travel
  –Associated symptoms: Vomiting, irritability, and rashes (dermatitis herpetiformis) with CD; frequent infections in CF and Schwachman-Diamond; digital clubbing in CF, CD, and IBD
  –Hypertension, tachycardia, anxiety, flushing, and sweating with pheochromocytoma; peptic ulcers with Zollinger-Ellison; wheezing, abdominal pain, flushing with carcinoid tumors; pruritus, flushing, and apnea with mastocytoma

• Stool examination: Oily, bulky, and foul-smelling with fat malabsorption; massive watery stools with secretory diarrhea; blood and mucus seen with colitis; stool for ova and parasites or antigen test for Giardia; WBC, eosinophils in allergic disease; occult blood test, stool pH, electrolytes, osmolarity, reducing substances
• PI proven by 72-hour fecal fat, stool elastase, secretin stimulation test, fat-soluble vitamin deficiency (ADEK)
• CBC, ESR, electrolytes, LFT, albumin (low in CD or IBD)
• Sucrose breath test for sucrase-isomaltase deficiency
• Sweat test to rule out CF
• Endoscopic biopsy: CD, IBD, Whipple diagnosis, microvillus inclusion (abetalipoproteinemia)
• Hormonal assay: Gastrin, vasocative intestinal peptide
• Anti-tissue transglutaminase IgA antibodies for CD

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Source: In A Page: Pediatric Signs and Symptoms, 2007

ANOREXIA: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Loss of appetite usually is related to one of four things: a psychiatric disorder, an endocrine disorder, a malignancy, or a chronic disease. If the general physical examination is normal, it is wise to get a psychiatric consult at the onset. Alternatively, one may order a psychometric test such as the MMPI (Minnesota Multiphasic Personality Inventory).

The organic causes of anorexia are usually associated with significant weight loss. The combination with anorexia of other symptoms and signs will help make the diagnosis. Anorexia with jaundice points to hepatitis or liver neoplasm as the cause. Anorexia with nonpitting edema would suggest hypothyroidism. Anorexia with dysphagia would suggest an esophageal neoplasm. Anorexia with tanning of the skin would suggest adrenal insufficiency.

The initial workup of anorexia includes a CBC; sedimentation rate; urinalysis; chemistry panel; stool for occult blood, ovum, and parasites; chest x-ray; and flat plate of the abdomen. If hypothyroidism is suspected, a free thyroxine index (FT4) and thyroid-stimulating hormone–sensitive assay (S-TSH) text is ordered. If liver disease is suspected, a liver profile or hepatitis profile may be ordered. If malabsorption syndrome is suspected, one can order a d-xylose absorption test or quantitative stool fat analysis. If CHF is suspected, a circulation time is a good screening test. If pancreatic carcinoma or other GI malignancy is suspected, a CT scan of the abdomen may be ordered. It is best to consult a gastroenterologist before ordering these expensive tests. He or she can decide if endoscopic procedures or other studies would be more useful before ordering a CT scan.

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Source: Differential Diagnosis in Primary Care, 2007

POLYPHAGIA: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Association with other symptoms is the key to a definitive diagnosis of polyphagia. Thus, polyphagia and obesity suggest an islet cell adenoma. Polyphagia with polyuria, polydipsia, weakness, and weight loss suggest hyperthyroidism or diabetes mellitus.

The laboratory workup should include thyroid function studies, a skull x-ray for pituitary size, glucose tolerance tests, and, possibly, a 48-hour fast with frequent blood sugar determinations. An MRI of the pituitary is the best way to reveal microadenomas.

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Source: Differential Diagnosis in Primary Care, 2007

WEIGHT LOSS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Weight loss rarely occurs as the only symptom. When it seems to be the only symptom, there is almost invariably a psychiatric disorder such as depression or anorexia nervosa to explain it. More often the diagnosis of weight loss can be made by the other associated symptoms. For example, weight loss with a good appetite, polyuria, and polydypsia should point to hyperthyroidism and diabetes mellitus. Weight loss with weakness and polydypsia but no increase of appetite points to diabetes insipidus. Weight loss, weakness, and loss of appetite suggest the possibility of a malignancy, chronic infectious disease, or endocrine disorder. Weight loss with significant local or generalized lymphadenopathy suggests chronic leukemia, lymphoma, sarcoidosis, or a chronic infectious disease process. Weight loss with hyperpigmentation of the skin suggests Addison disease or hemochromatosis. Weight loss with significant pallor of the skin and mucus membranes suggests a diagnosis of anemia, malabsorption syndrome, and malignancy. Weight loss with jaundice suggests alcoholic cirrhosis, chronic hepatitis, primary or metastatic neoplasm of the liver, or biliary cirrhosis. The initial workup of weight loss should include a CBC, sedimentation rate, chemistry panel, thyroid profile, urinalysis, stool for occult blood, chest x-ray, and flat plate of the abdomen. If there is fever, the workup of this symptom can be pursued (see page 207). Other tests may be ordered depending on which disease is suspected. Before ordering a battery of tests, it may be wise to get a psychiatric consult and make sure there is not a “supratentorial” cause for the problem.

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Source: Differential Diagnosis in Primary Care, 2007

Anorexia: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Take the patient’s vital signs and weight. Find out previous minimum and maximum weights. Ask about involuntary weight loss greater than 10 lb (4.5 kg) in the past month. Explore dietary habits such as when and what the patient eats. Ask what foods he likes and dislikes and why. The patient may identify tastes and smells that nauseate him and cause loss of appetite. Ask about dental problems that interfere with chewing, including poor-fitting dentures. Ask if he has difficulty or pain when swallowing or if he vomits or has diarrhea after meals. Ask the patient how frequently and intensely he exercises.

Check for a history of stomach or bowel disorders, which can interfere with the ability to digest, absorb, or metabolize nutrients. Find out about changes in bowel habits. Ask about alcohol use and drug use and dosage.

If the medical history doesn’t reveal an organic basis for anorexia, consider psychological factors. Ask the patient if he knows what’s causing his decreased appetite. Situational factors — such as a death in the family or problems at school or at work — can lead to depression and a subsequent loss of appetite. Be alert for signs of malnutrition, consistent refusal of food, and a 7% to 10% loss of body weight in the preceding month. (See Is your patient malnourished? )

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Weight gain, excessive: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Determine your patient’s previous patterns of weight gain and loss. Does he have a family history of obesity, thyroid disease, or diabetes mellitus? Assess his eating and activity patterns. Has his appetite increased? Does he exercise regularly or at all? Next, ask about associated symptoms. Has he experienced visual disturbances, hoarseness, paresthesia, or increased urination and thirst? Has he become impotent? If the patient is female, has she had menstrual irregularities or experienced weight gain during menstruation?

Form an impression of the patient’s mental status. Is he anxious or depressed? Does he respond slowly? Is his memory poor? What medications is he using?

During your physical examination, measure skin-fold thickness to estimate fat reserves. (See Evaluating nutritional status, pages 644 and 645.) Note fat distribution and the presence of localized or generalized edema and overall nutritional status. Inspect for other abnormalities, such as abnormal body hair distribution or hair loss and dry skin. Take and record the patient’s vital signs.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Low birth weight: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

As soon as possible, evaluate the neonate’s neuromuscular and physical maturity to determine gestational age. (See Ballard Scale for calculating gestational age, pages 382 and 383.) Follow with a routine neonatal examination.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Polyphagia [Hyperphagia]: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Begin your evaluation by asking the patient what he has eaten and drunk within the past 24 hours. (If he easily recalls this information, ask about his intake for the 2 previous days, for a broader view of his dietary habits.) Note the frequency of meals and the amount and types of food eaten. Find out if the patient’s eating habits have changed recently. Has he always had a large appetite? Does his overeating alternate with periods of anorexia? Ask about conditions that may trigger overeating, such as stress, depression, or menstruation. Does the patient actually feel hungry, or does he eat simply because food is available? Does he ever vomit or have a headache after overeating?

Explore related signs and symptoms. Has the patient recently gained or lost weight? Does he feel tired, nervous, or excitable? Has he experienced heat intolerance, dizziness, palpitations, diarrhea, or increased thirst or urination? Obtain a complete drug history, including the use of laxatives or enemas.

During the physical examination, weigh the patient. Tell him his current weight, and watch for an expression of disbelief or anger. Inspect the skin to detect dryness or poor turgor. Palpate the thyroid for enlargement.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Weight loss, excessive: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Begin with a thorough diet history because weight loss almost always is caused by inadequate caloric intake. If the patient hasn’t been eating properly, try to determine why. Ask him about previous weight and if the recent loss was intentional. Be alert to lifestyle or occupational changes that may be a source of anxiety or depression. For example, has he gotten separated or divorced? Has a family member or friend died recently? Has he recently changed jobs?

Inquire about recent changes in bowel habits, such as diarrhea or bulky, floating stools. Has the patient had nausea, vomiting, or abdominal pain, which may indicate a GI disorder? Has he had excessive thirst, excessive urination, or heat intolerance, which may signal an endocrine disorder? Take a careful drug history, noting especially any use of diet pills and laxatives.

Carefully check the patient’s height and weight, and ask about his previous weight. Take his vital signs and note his general appearance: Is he well nourished? Do his clothes fit? Is muscle wasting evident? Ask about exact weight changes (with approximate dates).

Next, examine the patient’s skin for turgor and abnormal pigmentation, especially around the joints. Does he have pallor or jaundice? Examine his mouth, including the condition of his teeth or dentures. Look for signs of infection or irritation on the roof of the mouth, and note any hyperpigmentation of the buccal mucosa. Also, check the patient’s eyes for exophthalmos and his neck for swelling; evaluate his lungs for adventitious sounds. Inspect his abdomen for signs of wasting, and palpate for masses, tenderness, and an enlarged liver.

Conventional laboratory and radiologic investigations such as complete blood count, serum albumin levels, urinalysis, chest X-ray, and upper GI series usually reveal the cause. Almost all physical causes are clinically evident during the initial evaluation. Cancer, GI disorders, and depression are the most common pathologic causes.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Anorexia nervosa: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

For characteristic findings in patients with this condition, see Diagnosing anorexia nervosa.

Laboratory tests help to identify various disorders and deficiencies and help to rule out endocrine, metabolic, and central nervous system abnormalities; cancer; malabsorption syndrome; and other disorders that cause physical wasting.

Abnormal findings that may accompany a weight loss exceeding 30% of normal body weight include:

❑ low hemoglobin level, platelet count, and white blood cell count

❑ prolonged bleeding time due to thrombocytopenia

❑ decreased erythrocyte sedimentation rate

❑ decreased levels of serum creatinine, blood urea nitrogen, uric acid, cholesterol, total protein, albumin, sodium, potassium, chloride, calcium, and fasting blood glucose (resulting from malnutrition)

❑ elevated levels of alanine aminotransferase and aspartate aminotransferase in severe starvation states

❑ elevated serum amylase levels when pancreatitis isn’t present

❑ in females, decreased levels of serum luteinizing hormone and follicle-
stimulating hormone

❑ decreased triiodothyronine levels resulting from a lower basal metabolic rate

❑ dilute urine caused by the kidneys’ impaired ability to concentrate urine

❑ nonspecific ST interval, prolonged PR interval, and T-wave changes on the electrocardiogram. Ventricular arrhythmias may also be present.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Anorexia: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Take the patient’s vital signs and weight. Find out previous minimum and maximum weights. Ask about involuntary weight loss greater than 10 lb (4.5 kg) in the last month. Explore dietary habits, including what the patient eats and when. Ask what foods he likes and dislikes and why. The patient may identify tastes and smells that nauseate him and cause loss of appetite. Ask about dental problems that interfere with chewing, including poor-fitting dentures. Ask if he has difficulty or pain when swallowing or if he vomits or has diarrhea after meals. Ask the patient how frequently and intensely he exercises.

Check for a history of stomach or bowel disorders, which can interfere with the ability to digest, absorb, or metabolize nutrients. Find out about changes in bowel habits. Ask about alcohol use and drug use and dosage.

If the medical history doesn’t reveal an organic basis for anorexia, consider psychological factors. Ask the patient if he knows what’s causing his decreased appetite. Situational factors—such as a death in the family or problems at school or at work—can lead to depression and subsequent loss of appetite. Be alert for signs of malnutrition, consistent refusal of food, and a 7% to 10% loss of body weight in the preceding month. (See Is your patient malnourished? page 54.)

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Weight gain, excessive: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Determine your patient’s previous patterns of weight gain and loss. Does he have a family history of obesity, thyroid disease, or diabetes mellitus? Assess his eating and activity patterns. Has his appetite increased? Does he exercise regularly or at all? Next, ask about associated symptoms. Has he experienced visual disturbances, hoarseness, paresthesia, or increased urination and thirst? Has he become impotent? If the patient is female, has she had menstrual irregularities or experienced weight gain during menstruation?

Form an impression of the patient’s mental status. Is he anxious or depressed? Does he respond slowly? Is his memory poor? What medications is he using?

During your physical examination, measure skin-fold thickness to estimate fat reserves. (See Evaluating nutritional status.) Note fat distribution, the presence of localized or generalized edema, and overall nutritional status. Examine the patient for other abnormalities, such as abnormal body hair distribution or hair loss and dry skin. Take and record the patient’s vital signs.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Low birth weight: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

As soon as possible, evaluate the neonate’s neuromuscular and physical maturity to determine gestational age. (See Ballard Scale for calculating gestational age, pages 488 and 489.) Follow with a routine neonatal examination.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Polyphagia [Hyperphagia]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Begin your evaluation by asking the patient what he has eaten and drunk within the last 24 hours. (If he easily recalls this information, ask about his intake for the 2 previous days, for a broader view of his dietary habits.) Note the frequency of meals and the amount and types of food eaten. Find out if the patient’s eating habits have changed recently. Has he always had a large appetite? Does his overeating alternate with periods of anorexia? Ask about conditions thatmay trigger overeating, suchas stress, depression, or menstruation. Does the patient actually feel hungry, or does he eat simply because food is available? Does he ever vomit or have a headache after overeating?

Explore related signs and symptoms. Has the patient recently gained or lost weight? Does he feel tired, nervous, or excitable? Has he experienced heat intolerance, dizziness, palpitations, diarrhea, or increased thirst or urination? Obtain a complete drug history, including the use of laxatives or enemas.

During the physical examination, weigh the patient. Tell him his current weight, and watch for any expression of disbelief or anger. Inspect the skin to detect dryness or poor turgor. Palpate the thyroid for enlargement.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Weight loss, excessive: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Begin with a thorough diet history because weight loss is almost always caused by inadequate caloric intake. If the patient hasn’t been eating properly, try to determine why. Ask about his previous weight and whether the recent loss was intentional. Be alert for lifestyle or occupational changes that may be causing anxiety or depression. For example, has he gotten separated or divorced? Has he recently changed jobs?

Inquire about recent changes in bowel habits, such as diarrhea or bulky, floating stools. Has the patient had nausea, vomiting, or abdominal pain, which may indicate a GI disorder? Has he had excessive thirst, excessive urination, or heat intolerance, which may signal an endocrine disorder? Take a careful drug history, noting especially the use of diet pills or laxatives.

Carefully check the patient’s height and weight, and ask about exact weight changes with approximate dates. Take his vital signs and note his general appearance: Is he well nourished? Do his clothes fit? Is muscle wasting evident?

Next, examine the patient’s skin for turgor and abnormal pigmentation, especially around the joints. Does he have pallor or jaundice? Examine his mouth, including the condition of his teeth or dentures. Look for signs of infection or irritation on the roof of the mouth, and note any hyperpigmentation of the buccal mucosa. Also, check the patient’s eyes for exophthalmos and his neck for swelling; auscultate his lungs for adventitious sounds. Inspect his abdomen for signs of wasting, and palpate for masses, tenderness, and an enlarged liver.

Conventional laboratory and radiologic tests, such as complete blood count, serum albumin levels, urinalysis, chest
X-rays, and upper GI series, usually reveal the cause. Almost all physical causes are clinically evident during the initial evaluation. Cancer, GI disorders, and depression are the most common pathologic causes.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Anorexia: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

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.

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Weight Loss: History: Initial data
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Is the loss intentional? Consider dieting, diuretics, and eating disorders.

B. What is the patient’s average daily or weekly intake? Consider frequency of meals, appetite changes, and difficulty with food preparation.

C. Tobacco, alcohol, and drug histories are very important and frequently lead to other concerns.

 D. Chronic conditions? Medical, surgical, psychiatric, and family histories are always pertinent.

 E. Social factors include stress, isolation, and the cost and effort required to eat.

Basic physical examination

A. Relevant physical findings will be present in 66% of cases (1,2,5).

B. Quantify loss by serial weight measurements.

C. Check the vital signs: temperature, blood pressure, and respiratory and heart rates. Consider determining oxygen saturation.

D. Perform a physical examination, with emphasis on areas suggested by clues from the history.

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Involuntary Weight Loss: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Diabetes

❑ Depression

❑ Inadequate intake

❑ Drugs

❑ Hyperthyroidism

❑ Occult cancer

❑ Low cardiac output

❑ Anorexia nervosa

❑ Malabsorption

❑ Chronic infection

❑ Adrenal insufficiency

❑ Emphysema

Diagnostic Approach

Cachexia is accelerated loss of lean body mass in the context of a chronic inflammatory response, caused by a combination of decreased intake (with decreased appetite) and increased metabolic rate. The cause of the weight loss will usually be evident, based on concurrent symptoms. If not, first document that weight loss has occurred by using prior records of measured weights or the discovery of loose-fitting clothes (tightening belt notches) or dentures. If the cause is not found on the first pass, document the weight and re-examine several weeks later.

Weight loss in patients with congestive heart failure, cirrhosis, and
uremia may be masked by fluid retention, but temporalis and limb wasting will be prominent. Weight loss in malignancy of more than 5% of body mass prior to treatment portends a poor prognosis.

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Source: Field Guide to Bedside Diagnosis, 2007

Anorexia nervosa: Diagnosis
(Handbook of Diseases)

For characteristic findings in patients with this condition, see Diagnosing anorexia nervosa.

In addition, laboratory tests help to identify various disorders and deficiencies and help to rule out endocrine, metabolic, and central nervous system abnormalities; cancer; malabsorption syndrome; and other disorders that cause physical wasting.

Abnormal findings that may accompany a weight loss of more than 30% of normal body weight include:

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Source: Handbook of Diseases, 2003

Anorexia: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Find out previous minimum and maximum weights. Ask about involuntary weight loss greater than 10 lb (4.5 kg) in the last month. Explore dietary habits, such as when and what the patient eats. Ask what foods he likes and dislikes and why. The patient may identify tastes and smells that nauseate him and cause loss of appetite. Ask about dental problems that interfere with chewing, including poor-fitting dentures. Ask if he has difficulty or pain when swallowing or if he vomits or has diarrhea after meals. Ask the patient how frequently and intensely he exercises.

Check for a history of stomach or bowel disorders, which can interfere with the ability to digest, absorb, or metabolize nutrients. Find out about changes in bowel habits. Ask about alcohol use and drug use and dosage.

If the medical history doesn’t reveal an organic basis for anorexia, consider psychological factors. Ask the patient if he knows what’s causing his decreased appetite. Situational factors — such as a death in the family or problems at school or at work — can lead to depression and subsequent loss of appetite. Be alert for signs of malnutrition, consistent refusal of food, and a 7% to 10% loss of body weight in the preceding month.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Polyphagia: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Begin your evaluation by asking the patient what he has eaten and drunk within the last 24 hours. (If he easily recalls this information, ask about his intake for the 2 previous days, for a broader view of his dietary habits.) Note the frequency of meals and the amount and types of food eaten. Find out if the patient’s eating habits have changed recently. Has he always had a large appetite? Does his overeating alternate with periods of anorexia? Ask about conditions thatmay trigger overeating, suchas stress, depression, or menstruation. Does the patient actually feel hungry, or does he eat simply because food is available? Does he ever vomit or have a headache after overeating?

Explore related signs and symptoms. Has the patient recently gained or lost weight? Does he feel tired, nervous, or excitable? Has he experienced heat intolerance, dizziness, palpitations, diarrhea, or increased thirst or urination? Obtain a complete drug history, including the use of laxatives or enemas.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Weight gain, excessive: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Determine your patient’s previous patterns of weight gain and loss. Does he have a family history of obesity, thyroid disease, or diabetes mellitus? Assess his eating and activity patterns. Has his appetite increased? Does he exercise regularly or at all? Next, ask about associated symptoms. Has he experienced vision disturbances, hoarseness, paresthesia, or increased urination and thirst? Has he become impotent? If the patient is female, has she had menstrual irregularities or experienced weight gain during menstruation?

Form an impression of the patient’s mental status. Is he anxious or depressed? Does he respond slowly? Is his memory poor? What medications is he using?

CULTURAL CUE:Body weight is influenced by gender and race. For example, Black men tend to weigh less than White men and Black women tend to weigh more than White women of the same age. Socioeconomic status also affects weight gain. Individuals of lower socioeconomic status tend to have more pronounced obesity than those of middle-class or upper middle-class status.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Weight loss, excessive: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Begin with a thorough diet history because weight loss almost always is caused by inadequate caloric intake. If the patient hasn’t been eating properly, try to determine why. Ask him about previous weight and if the recent loss was intentional. Be alert to lifestyle or occupational changes that may be a source of anxiety or depression. For example, has he gotten separated or divorced? Has he recently changed jobs?

Inquire about recent changes in bowel habits, such as diarrhea or bulky, floating stools. Has the patient had nausea, vomiting, or abdominal pain, which may indicate a GI disorder? Has he had excessive thirst, excessive urination, or heat intolerance, which may signal an endocrine disorder? Take a careful drug history, noting especially use of diet pills and laxatives.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Growth Deficiency: Weight and Height: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Normal Variations

Constitutional Delay of Growth and Maturation