Chapter 041. Weight Loss (Part 3) Approach to the Patient: Weight Loss Before extensive evaluation is undertaken, it is important to confirm weight loss and to determine the time interval over which it has occurred. Almost half of patients who claim significant weight loss have no actual change when body weight is measured objectively. In the absence of documentation, changes in belt notch position or the fit of clothing may be confirmatory. Not infrequently, patients who have actually sustained significant weight loss are unaware that it has occurred. Routine documentation of weight during office visits is therefore important. The review of systems should focus on signs or symptoms that are associated with disorders that commonly cause weight loss. These include fever, pain, shortness of breath or cough, palpitations, and evidence of neurologic disease. Gastrointestinal disturbances, including difficulty eating, dysphagia, anorexia, nausea, and change in bowel habits, should be sought. Travel history, use of cigarettes and alcohol, and all medications should be reviewed, and patients should be questioned about previous illness or surgery as well as diseases in family members. Risk factors for HIV infection should be assessed. Signs of depression, evidence of dementia, and social factors, including financial issues that might affect food intake, should be considered. Physical examination should begin with weight determination and documentation of vital signs. The skin should be examined for pallor, jaundice, turgor, scars from prior surgery, and stigmata of systemic disease. The search for oral thrush or dental disease, thyroid gland enlargement, adenopathy, and respiratory or cardiac abnormalities and a detailed examination of the abdomen often lead to clues for further evaluation. Rectal examination, including prostate examination, should be performed in men; and all women should have a pelvic examination, even if they have had a hysterectomy. Neurologic examination should include mental status assessment and screening for depression. Laboratory testing should confirm or exclude possible diagnoses elicited from the history and physical examination (Table 41-2). An initial phase of testing should include a complete blood count with differential, serum chemistry tests including glucose, electrolytes, renal and liver tests, calcium, thyroid-stimulating hormone (TSH), urinalysis, and chest x-ray. Patients at risk for HIV infection should have HIV antibody testing. In all cases, recommended cancer screening tests appropriate for the gender and age group, such as mammograms and colonoscopies, should be updated (Chap. 78). If gastrointestinal signs or symptoms are present, upper and/or lower endoscopy and abdominal imaging with either CT or MRI have a relatively high yield, consistent with the high prevalence of gastrointestinal disorders in patients with weight loss. If an etiology of weight loss is not found, careful clinical follow-up, rather than persistent undirected testing, is reasonable. Table 41-2 Screening Tests for Evaluation of Involuntary Weight Loss Initial testing CBC Electrolytes, calcium, glucose Renal and liver function tests Urinalysis TSH Additional testing HIV test Upper and/or lower gastrointesti nal endoscopy Abdominal CT scan or MRI Chest CT scan Chest x-ray Recommended cancer screening Further Readings Alibhai S: An approach to the management of unintentional weight loss in elderly people. CMAJ 172:773, 2005 [PMID: 15767612] Bouras EP, Lange SM: Rational approach to patients with unintentional weight loss. Mayo Clinic Proc 76:923, 2001 [PMID: 11560304] Hernandez JL, Matorras JA: Involuntary weight loss without specific symptoms: A clinical prediction score for malignant neoplasm. Q J Med 96: 649, 2003 [PMID: 12925720] Inui A: Cancer anorexia-cachexia syndrome: Current issues in research and management. Cancer J Clinicians 52:72, 2002 [PMID: 11929007] Nora E, Raman A: Hypermetabolism, cachexia and wasting. Curr Opin Endocrinol Diabetes 12: 326, 2005 Schwartz MW: Brain pathways controlling food intake and body weight. Exp Biol Med 226:978, 2001 [PMID: 11743132] Strasser F, Bruera ED: Update on anorexia and cachexia. Hematol Oncol Clin North Am 16:589, 2002 [PMID: 12170570] Wallace JI: Involuntary weight loss in elderly outpatients: Recognition, etiologies, and treatment. Clin Geriatr Med 13:717, 1997 [PMID: 9354751] . Chapter 041. Weight Loss (Part 3) Approach to the Patient: Weight Loss Before extensive evaluation is undertaken, it is important to confirm weight loss and to determine. consistent with the high prevalence of gastrointestinal disorders in patients with weight loss. If an etiology of weight loss is not found, careful clinical follow-up, rather than persistent undirected. management of unintentional weight loss in elderly people. CMAJ 172:773, 2005 [PMID: 15767612] Bouras EP, Lange SM: Rational approach to patients with unintentional weight loss. Mayo Clinic Proc