WEIGHT LOSS (Algorithmic Diagnosis of Symptoms and Signs)
WEIGHT LOSS
Ask the Following Questions:
- Is there fever? The presence of fever would suggest an infectious disease, such as tuberculosis, AIDS, brucellosis, and typhoid fever, but collagen diseases and neoplasms should not be forgotten.
- Is there anorexia? The presence of 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. There may also be a neoplasm.
- Is there lymphadenopathy? The presence of 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. The mass also may be a carcinoma of the stomach or intestine.
- Is there hyperpigmentation? The presence of hyperpigmentation would suggest Addison's disease.
- Is the appetite normal or increased? The presence of a normal or increased appetite in the presence of weight loss should suggest hyperthyroidism and diabetes mellitus. The patient also may be taking thyroid hormone medication in increased quantities.
- Is the thyroid gland enlarged? The presence of an enlarged thyroid would suggest hyperthyroidism. One should also look for a focal thyroid mass which might be a toxic adenoma.
- Is the chest x-ray abnormal? Abnormalities found on x-ray that may induce weight loss are carcinoma of the lung, tuberculosis, congestive heart failure, pulmonary emphysema, and fibrosis.
DIAGNOSTIC WORKUP
Routine diagnostic studies include a CBC, sedimentation rate, urinalysis, chemistry panel, thyroid panel, serum amylase and lipase, febrile agglutinins, tuberculin test, ANA titer, serum protein electrophoresis, serum B
12
and folic acid, chest x-ray, EKG, and a flat plate of the abdomen. An HIV antibody titer needs to be done in selected clinical circumstances.
A stool for fat, trypsin, occult blood, and ovum and parasites should be done. Further tests for steatorrhea are listed on
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. If these tests are within normal limits or are unrevealing, it is best to refer the patient to a gastroenterologist or oncologist for further evaluation. Sometimes, clinical clues suggest the need for an endocrinologist or psychiatrist as well. However, if the primary care physician wishes to proceed further, he may order an upper GI series and esophagogram, a small bowel series, barium enema, and a sigmoidoscopic examination. A CT scan of the abdomen and pelvis may be useful, but it is an expensive procedure.
Twenty-four-hr urine collection for 17-ketosteroids and 17-hydroxysteroids or rapid ACTH stimulation test will diagnose Addison's disease. Quantitative stool fat and
d
-xylose absorption or a simple glucose tolerance test will diagnose some cases of malabsorption syndrome. Endoscopic procedures, including laparoscopy and even an exploratory laparotomy, have their place in the diagnostic workup. However, it is always best to enlist the help of specialists before considering these procedures, even if one is located in an isolated community.
Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.
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