Clerking weight loss

History

Due to the high percentage of underlying serious aetiologies, clerking weight loss should be thorough. Particular attention should be paid to symptoms and signs of cancer, gastrointestinal conditions, and psychiatric conditions. The following approach should be used:

Greet patient and establish rapport.

Obtain the biodata with attention to age. Younger age points more to psychiatric or gastrointestinal conditions, or cancers which have a younger age of onset (e.g., leukaemia, lymphoma). Older age points to cardiovascular conditions, cancers and neurological conditions such as dementia and Parkinson’s disease.

Explore the symptom along the following lines:

  • Degree of weight loss: By and large, a higher degree of weight loss is expected from cancers, gastrointestinal illnesses, and severe infections (e.g., HIV). However, many conditions can cause severe weight loss when in the advanced stages. 

 

Associated symptoms: Weakness, fever, chills, night sweats, muscle wasting, dysphagia, abdominal pain, jaundice, post-prandial pain, heartburn, frequent loose stools, bloody stools, black/tarry stools, oily/floating stool, rectal bleeding, haematuria, lower urinary tract symptoms, lower pelvic pain, headache, seizures, fatigue, palpitations, anxiousness, and heat intolerance, polyuria and polydipsia, cough, haemoptysis.

More specific direct questions may then be asked as follows based on the possible list of differentials generated after having characterised the weight loss:

  • Stomach cancer: 

Helicobacter pylori infection, prior gastric ulcer or atrophic gastritis, epigastric/abdominal pain, nausea, haematemesis, melaena, dysphagia

  • Colorectal cancer:

rectal bleeding, abdominal pain, change in stool calibre; more likely to be advanced if presenting with unintentional weight loss

  • Oesophageal cancer:

smoking, alcohol use (squamous cell carcinoma), Barrett’s oesophagus, progressive dysphagia, painful swallowing, fatigue, pain, nausea

  • Pancreatic cancer:

unintentional weight loss very common, nausea, anorexia, abdominal bloating, upper abdominal pain/discomfort

  • Hepatoma:

cirrhosis, hepatitis B or C infection, right upper quadrant pain

  • Small cell lung cancer:

cough, haemoptysis, dyspnoea, chest pain; bone pain, headache, seizures (metastases); altered mental status, abdominal pain, muscle weakness (paraneoplastic syndromes)

  • Non-small cell lung cancer:

cough, haemoptysis, dyspnoea, chest pain; bone pain, headache, seizures (metastases)

  • Non-Hodgkin’s lymphoma:

night sweats, fatigue/malaise, enlarged lymph nodes

  • Hodgkin’s lymphoma:

usually young adults but has second peak in sixth decade, night sweats, chest pain (if mediastinal mass present), generalised pruritus

  • Chronic leukaemia:

unintentional weight loss more common compared with acute leukaemia, night sweats

  • Multiple myeloma:

fatigue, bone pain, infections

  • Oropharyngeal cancer: 

smoking/chewing tobacco, alcohol use, oral pain, sore throat, dysphagia

  • Laryngeal cancer:

smoking/chewing tobacco, alcohol use, dysphagia, painful swallowing, sore throat, hoarseness

  • Ovarian cancer:

pelvic pain/pressure, abdominal bloating, increased abdominal girth (bulky disease or ascites), constipation, nausea, gastrointestinal or vaginal bleeding (less common); weight loss more common in advanced disease or metastases

  • Prostate cancer:

obstructive urinary symptoms, bone pain, pelvic pain; weight loss more common in advanced disease or metastases

  • Breast cancer:

breast lump, bone pain; weight loss more common in advanced disease or metastases

  • Coeliac disease:

diarrhoea, bloating, abdominal pain/discomfort, fatigue

  • Exocrine pancreatic insufficiency:

previous pancreatitis, cystic fibrosis, diarrhoea, oily/floating/foul-smelling stools; unintentional weight loss usually only occurs in severe cases

  • Crohn’s disease:

can occur in younger patients (15-40 years) and peaks again in sixth decade, abdominal pain, diarrhoea (may be bloody), bloating, fatigue

  • Ulcerative colitis: 

can occur in younger patients (20-40 years) and peaks again in sixth decade, abdominal pain, diarrhoea (usually bloody), rectal bleeding, fatigue, arthritis

  • Mesenteric ischaemia:

cardiovascular risk factors, post-prandial pain (mild-to-severe), nausea/vomiting, diarrhoea, haematochezia/melaena; weight loss may be severe

  • Depression:

comorbid medical/psychiatric conditions (may coexist with other conditions in differential for unintentional weight loss), anhedonia, depressed mood, functional impairment, appetite changes, sleep disturbance, libido changes, low energy, poor concentration, excessive guilt, suicidal ideation; weight change (loss or gain) can be variable

  • Bipolar disorder: 

episodes of mania (elevated mood, increased energy, perceived decreased need for sleep, impulsivity) with periods of depression; weight loss may be significant

  • Generalised anxiety disorder:

excessive worry for at least 6 months, anxiety, muscle tension, functional impairment, irritability, restlessness, poor concentration, fatigue, sleep disturbance; weight loss is not part of diagnostic criteria

  • Anorexia nervosa:

comorbid psychiatric disorders, fear of gaining weight, food restriction, distorted body image, amenorrhoea, suicidal ideation, bingeing/purging, history may be denied by patient

  • Substance abuse:

substance use/abuse (e.g., opioids, cocaine, amfetamine, cannabis, inhalant, hallucinogen, benzodiazepine, alcohol), comorbid psychiatric disorders, inadequate nutrition; weight loss when abuse is severe

  • Parkinson’s disease:

bradykinesia, cognitive impairment, dementia

  • Dementia:

progressive cognitive dysfunction, memory loss, taste changes; weight loss generally associated with advanced disease

  • Hyperthyroidism:

palpitations, tremor, fatigue, weakness (may be subtle), heat intolerance, hair thinning/loss, anxiousness; older patients have fewer classic symptoms

  • Tuberculosis (pulmonary):

exposure to infection, endemic location, immunosuppression, cough, night sweats, malaise, haemoptysis, dyspnoea; weight loss is more common with reactivation

  • Adverse drug effects:

started new medication; common drugs include anticonvulsants (e.g., topiramate, zonisamide), antidepressants (e.g., selective serotonin-reuptake inhibitors, bupropion), stimulants (e.g., dexamfetamine), diabetes medications (e.g., metformin; exenatide, liraglutide, and other glucagon-like peptide-1 receptor agonists), antibiotics and other medications that cause diarrhoea, cholinesterase inhibitors (e.g., donepezil), diuretics, laxatives, thyroid hormone (from misuse); withdrawal of drugs that support/maintain weight loss (e.g., pancreatic enzymes, mirtazapine); no other significant history

  • Cholangiocarcinoma:

primary sclerosing cholangitis, fever, right upper quadrant pain, pruritus; usually presents late

  • Acute leukaemia:

unintentional weight loss less common compared with chronic leukaemia/lymphoma, fatigue, infections, bone pain, bleeding

  • Zollinger-Ellison syndrome: 

GORD, peptic ulcer disease, diarrhoea, abdominal pain, fatigue, weight loss uncommon; may be part of multiple endocrine neoplasia syndrome (type 1) or associated with hyperparathyroidism or pituitary tumours

  • VIPoma:

young-to-middle age, profuse watery diarrhoea (non-bloody), nausea, fatigue

  • Carcinoid syndrome:

diarrhoea, wheezing, GI bleeding, weight loss due to diarrhoea is uncommon

  • Peptic ulcer disease:

non-steroidal anti-inflammatory drug (NSAID) use, Helicobacter pylori infection, epigastric pain (especially after meals, classically with a delay of a few hours), dark stools (if bleeding)

  • Chronic hepatitis:

risk of exposure (hepatitis B or C), fatigue, malaise, right upper quadrant pain, pruritus

  • Oesophageal webs, rings, and diverticula:

usually asymptomatic; dysphagia, decreased oral intake (severe cases)

  • Small intestinal bacterial overgrowth:

prior gastrointestinal surgery/short bowel syndrome, systemic sclerosis (scleroderma), diarrhoea, abdominal pain, bloating; unintentional weight loss in severe cases

  • Gastroparesis:

diabetes mellitus, post-prandial epigastric pain or nausea/vomiting; unintentional weight loss in severe cases

  • Post-surgical complications: 

prior gastrointestinal surgery/short bowel syndrome, diarrhoea, abdominal pain, nausea

  • Stomatitis:

malnutrition, dentures, prior radiotherapy or chemotherapy, oral trauma, oral pain, xerostomia

  • Bulimia nervosa:

recurrent episodes of binge eating and compensatory behaviour (e.g., purging, fasting, exercise), depression, low self-esteem, concern about body image/weight, menstrual irregularities

  • Multiple sclerosis: 

focal neurological deficits lasting >24 hours in different regions, vision loss, numbness, pain, weakness, dizziness, fatigue, depression

  • Amyotrophic lateral sclerosis:

progressive upper and lower motor neuron deficits, limb weakness, dementia (uncommon), dyspnoea

  • Cardiac cachexia syndrome:

symptoms of advanced heart failure (e.g., dyspnoea on exertion, fatigue, orthopnoea and paroxysmal nocturnal dyspnoea, peripheral oedema)

  • Post-stroke complications:

prior stroke, depression, cognitive impairment, dysphagia, arm/hand weakness

  • Pulmonary cachexia syndrome:

symptoms of advanced COPD or interstitial lung disease (e.g., cough, dyspnoea)

  • Cystic fibrosis:

cough, dyspnoea, diarrhoea, oily/floating stool, failure to gain weight (children), chronic pulmonary/sinus infections

  • Microscopic polyangiitis:

overlap with granulomatosis with polyangiitis (Wegener’s granulomatosis) and lung disease, haematuria, arthritis

  • Renal cachexia syndrome:

symptoms of advanced renal failure (e.g., fatigue, oedema)

  • Diabetes mellitus:

polyuria, polydipsia, infections, history of poor glycaemic control may be chronic symptoms of type1; nausea, vomiting, anorexia (diabetic ketoacidosis); type 1 more frequently presents with or is complicated by weight loss than type 2, and ketosis compounds weight loss

  • Adrenal insufficiency:

metastases, tuberculosis, autoimmune endocrinopathies (primary adrenal insufficiency); glucocorticoid exposure (tertiary adrenal insufficiency); fatigue, decreased appetite, weakness, diarrhoea, abdominal pain

  • Hypopituitarism:

infiltrative disease (e.g., sarcoidosis, haemochromatosis), hypotension, fatigue; headache, vision loss (pituitary adenoma)

  • Pheaochromocytoma: 

may be part of multiple endocrine neoplasia syndrome (type 2); symptoms can be episodic; headache, sweats, palpitations, tremor, weakness

  • Rheumatoid arthritis:

symmetric polyarthritis, joint pain/swelling

  • Systemic lupus erythematosus:

rash, fatigue, arthralgia/arthritis, Raynaud phenomenon, chest pain, dyspnoea

  • Granulomatosis with polyangiitis (Wegener’s):

cough, dyspnoea, haemoptysis, sinusitis, earache, fatigue, arthralgia/arthritis, myalgia, numbness, muscle weakness, abdominal pain, diarrhoea, nausea/vomiting; presentation variable depending on systems affected

  • Polyarteritis nodosa:

history of hepatitis B or C, myalgia/arthralgia, paraesthesia, abdominal pain, purpura, livedo reticularis, skin ulcers, muscle tenderness

  • Systemic sclerosis (scleroderma): 

positive family history, hand swelling, Raynaud’s phenomenon, skin thickening/tightness, loss of hand function, dysphagia, heartburn, abdominal bloating, melaena, myalgia/arthralgia, fatigue

  • Sarcoidosis:

cough, dyspnoea, fatigue, arthralgia, photophobia, vision changes; symptoms are highly variable and depend on organ involved

  • Mixed connective tissue disease (overlap syndromes):

digital pallor/pain, Raynaud’s phenomenon, arthralgia/arthritis, myalgia, swollen hands, dyspnoea, cough, heartburn

  • Adult-onset Still disease:

daily-spiking fevers, rash, abdominal pain, nausea, arthralgia/arthritis

  • HIV infection:

injection drug use, unprotected sex, needle stick injury, transfusions of blood or blood products before adequate testing was introduced or currently in areas without adequate testing, night sweats, diarrhoea, oral ulcers, altered mental status, opportunistic infections; weight loss more common with advanced disease

  • Tuberculosis (extrapulmonary):

variable depending on system involved; abdominal pain/swelling, change in bowel habits, dysuria, haematuria, frequency, skeletal pain, chest pain, headache, neck stiffness

  • Mycobacterium avium-intracellulare:

underlying lung disease, cough, dyspnoea, fatigue

  • Histoplasmosis:

exposure to spores, endemic region, immunosuppression, cough, dyspnoea, headache, abdominal pain, chest pain; weight loss more common with disseminated disease

  • Amoebiasis:

exposure history (e.g., visit to endemic area), immunosuppression, diarrhoea, dysentery, abdominal pain

  • Giardiasis:

exposure history (contaminated water), non-bloody diarrhoea (severity varies), malaise, bloating; weight loss in severe and/or chronic disease

  • Infective endocarditis:

prior dental work, injection drug use, prosthetic heart valves, cough, haemoptysis, dyspnoea, night sweats, fatigue, myalgia/arthralgia, weakness

  • Whipple’s disease: 

male gender, diarrhoea, abdominal pain, joint pain

  • Inadequate nutrition:

older age, poverty, inadequate resources, taste changes, dental problems, fewer social interactions, reduced or no access to food and different types of food

Physical exam

General Examination

  • Look for other signs of chronic illness like fluffy hairs, muscle wasting, hanging skin folds.
  • Check for fever and note the temperature if abnormal. Fever may be a sign of multiple aetiologies including infectious, malignant, and inflammatory conditions.
  • Observe for jaundice which may indicate a chronic liver disease or hepatic malignancy.
  • Assess for pallor which may indicate malignancy or chronic blood loss.
  • Cyanosis and digital clubbing may be as a result of an underlying cardiorespiratory illness.
  • Dehydration may be from excess fluid loss or poor intake.
  • Lymphadenopathy may indicate malignancy, especially if mass lesions are present and the patient has risk factors for cancer. It may also indicate an infection.
  • Edema is suggestive of a liver, renal, cardiac or gastrointestinal pathology causing dysproteinemia or fluid retention.

Systemic Examination

Gastrointestinal:

  • Poor dentition: many older patients have decreased oral intake because of poor dentition; this may also be a risk factor for infective endocarditis.
  • Mass lesions, hepatomegaly, splenomegaly, or ascites: may indicate malignancy
  • Bruits: may be consistent with mesenteric ischaemia but are neither specific nor diagnostic.

Genitourinary:

  • Mass lesions: rectal, prostate, or pelvic masses may indicate malignancy.

Cardiovascular:

  • Tachycardia: may be a sign of hyperthyroidism; however, it is non-specific and is common to multiple syndromes with volume depletion
  • Blood pressure: many patients will have low blood pressure; however, high blood pressure or orthostasis in combination with paroxysmal headaches and sweats may suggest phaeochromocytoma
  • Cardiac murmur: new regurgitant murmurs may suggest infective endocarditis
  • Signs of decompensated heart failure: lung rales, peripheral oedema, and elevated jugular venous pressure may indicate heart failure or pericarditis.

Pulmonary:

  • Pleural effusion: may indicate malignancy or serositis
  • Hyperinflation: may be suggestive of COPD or cystic fibrosis
  • Rales and consolidation: usually a sign of chronic lung disease.

Dermatological:

  • Dermatitis herpetiformis: consistent with a diagnosis of coeliac disease
  • Mass lesions: may indicate skin cancer; however, it does not typically cause unintentional weight loss unless it is metastatic
  • Janeway lesions or Osler nodes: diagnostic for infective endocarditis
  • Rash: malar or discoid rash may indicate SLE
  • Livedo reticularis: may indicate polyarteritis nodosa
  • Hyperpigmentation: may be seen with primary adrenal insufficiency
  • Skin tightening or thickening: common in systemic sclerosis (scleroderma).

Nervous system:

  • Delirium and altered mental status: may be caused by electrolyte imbalances (e.g., hyponatraemia or hypercalcaemia can be a feature of multiple conditions, including syndrome of inappropriate antidiuretic hormone [SIADH] and cancer), endocrinopathies (e.g., hyperthyroidism), infections, or CNS vasculitis
  • Cognitive impairment: should prompt an evaluation for dementia.

MSK system: Bone or joint pain may indicate metastatic cancer or a rheumatological condition.

Breast exam: Should be performed in the appropriate age groups, or at any age if symptoms suggest a malignancy.

Specific findings in each likely aetiology may be looked out for as follows:

  • Stomach cancer: 

epigastric tenderness or mass, lymphadenopathy, hepatomegaly, signs of anaemia, abrupt onset of multiple seborrhoeic keratoses (rare)

  • Colorectal cancer:

abdominal distention or tenderness, abdominal or rectal mass

  • Oesophageal cancer:

may be normal

  • Pancreatic cancer:

abdominal tenderness/mass, jaundice

  • Hepatoma:

right upper quadrant mass, abdominal tenderness, jaundice, hepatomegaly, ascites

  • Small cell lung cancer:

lung examination may be normal or show abnormalities (e.g., wheeze, rales, egophony, dullness to percussion); confusion, personality changes (metastases)

  • Non-small cell lung cancer:

lung examination may be normal or show abnormalities (e.g., wheeze, rales, egophony, dullness to percussion); confusion, personality changes (metastases)

  • Non-Hodgkin’s lymphoma:

fever, lymphadenopathy, splenomegaly, hepatomegaly

  • Hodgkin’s lymphoma:

fever, lymphadenopathy (rubbery, firm, non-tender), splenomegaly, hepatomegaly

  • Chronic leukaemia:

fever, lymphadenopathy

  • Multiple myeloma:

pallor, pathological fractures

  • Oropharyngeal cancer: 

neck mass, cervical swelling or lymphadenopathy, tumour may be seen with laryngoscopy

  • Laryngeal cancer:

neck mass, cervical swelling or lymphadenopathy, supraglottic/glottic mass may be seen with laryngoscopy

  • Ovarian cancer:

adnexal mass, ascites

  • Prostate cancer:

enlarged prostate with nodule or asymmetry, bone tenderness

  • Breast cancer:

palpable breast mass, lymphadenopathy, bone tenderness

  • Coeliac disease:

pallor, dermatitis herpetiformis

  • Exocrine pancreatic insufficiency:

abdominal tenderness (chronic pancreatitis)

  • Crohn’s disease:

abdominal tenderness, perianal lesions, blood in stool

  • Ulcerative colitis: 

abdominal tenderness, blood in stool

  • Mesenteric ischaemia:

abdominal tenderness, abdominal bruits may be present; examination may be normal

  • Depression:

psychomotor slowing

  • Bipolar disorder: 

grandiosity, pressured speech, irritability, psychosis, depression (depending on whether manic or depressive episode)

  • Generalised anxiety disorder:

usually normal

  • Anorexia nervosa:

low BMI, bradycardia, hypothermia, hypotension, hair loss, muscle wasting, dental erosion (if co-existing bulimia), signs of cardiomyopathy

  • Substance abuse:

depends on substance

  • Parkinson’s disease:

rigidity, resting tremor, shuffling gait, cogwheeling

  • Dementia:

cognitive impairment

  • Hyperthyroidism:

tachycardia, fine tremor, hyperreflexia, bilateral lid retraction, proptosis

  • Tuberculosis (pulmonary):

fever, rales, pleural effusion, lymphadenopathy

  • Adverse drug effects:

usually normal

  • Cholangiocarcinoma:

right upper quadrant mass, abdominal tenderness, jaundice, hepatomegaly

  • Acute leukaemia:

fever, pallor, hypotension, petechiae, bone tenderness, ecchymosis

  • Zollinger-Ellison syndrome: 

abdominal tenderness, pallor

  • VIPoma:

flushing, poor skin turgor

  • Carcinoid syndrome:

flushing, tumour is not usually palpable

  • Peptic ulcer disease:

epigastric tenderness

  • Chronic hepatitis:

fever; jaundice, oedema, ascites (cirrhosis); examination may be normal

  • Oesophageal webs, rings, and diverticula:

usually normal

  • Small intestinal bacterial overgrowth:

usually normal

  • Gastroparesis:

usually normal

  • Post-surgical complications: 

surgical scars, abdominal tenderness

  • Stomatitis:

erythema or ulceration of oral mucosa

  • Bulimia nervosa:

dental erosion, Russell’s sign (scarring over dorsum of hands from inducing vomiting), arrhythmia, parotid hypertrophy

  • Multiple sclerosis: 

internuclear ophthalmoplegia, limb weakness, sensory deficits

  • Amyotrophic lateral sclerosis:

muscle atrophy, fasciculations, weakness (lower motor neuron involvement); muscle atrophy, weakness, hyperreflexia (upper motor neuron involvement); facial or oropharyngeal weakness (bulbar involvement); decreased air movement, crackles from atelectasis (respiratory involvement)

  • Cardiac cachexia syndrome:

muscle wasting/atrophy, signs of advanced heart failure (e.g., S3 gallop, rales, lower extremity oedema, elevated jugular venous pressure, neck vein distention); distinguish intentional weight loss (i.e., diuretic therapy) from unintentional (i.e., cardiac cachexia)

  • Post-stroke complications:

decreased oropharyngeal function, speech and/or swallowing impairment

  • Pulmonary cachexia syndrome:

muscle wasting/atrophy, signs of advanced COPD or interstitial lung disease (e.g., decreased breath sounds and air movement, increased work of breathing, lung crackles, wheezing, hypoxia, tachypnoea)

  • Cystic fibrosis:

lung hyperinflation, rales (if infection), wheezing

  • Microscopic polyangiitis:

fever, joint tenderness or synovitis

  • Renal cachexia syndrome:

muscle wasting/atrophy, symptoms of uraemia (e.g., confusion, bleeding, pericardial rub)

  • Diabetes mellitus:

acetone breath, Kussmaul respiration, abdominal tenderness (diabetic ketoacidosis); dry mucous membranes, hypotension, tachycardia, tachypnoea, decreased level of consciousness (diabetic ketoacidosis or hyperosmolar hyperglycaemic state)

  • Adrenal insufficiency:

orthostasis, hyperpigmentation (primary adrenal insufficiency), shock (adrenal crisis)

  • Hypopituitarism:

coarse voice, thickened skin, bradycardia, delayed deep tendon reflexes (hypothyroidism); decreased muscle mass, testicular atrophy (hypogonadism); increased fat mass, decreased muscle mass (growth hormone deficiency); no hyperpigmentation; loss of body hair

  • Pheaochromocytoma: 

tachycardia, diaphoresis, hypertension, orthostasis

  • Rheumatoid arthritis:

joint subluxation/destruction (advanced disease)

  • Systemic lupus erythematosus:

fever, malar rash, joint tenderness, haematuria, pleural effusion, pericardial rub, confusion (lupus cerebritis), thrombosis

  • Granulomatosis with polyangiitis (Wegener’s):

fever, haematuria, skin lesions (e.g., purpura), joint tenderness/swelling, may have signs of consolidation (single lung nodules may have otherwise normal lung exam)

  • Polyarteritis nodosa:

fever, high diastolic BP, mononeuritis multiplex

  • Systemic sclerosis (scleroderma): 

digital pits/ulcers, sclerodactyly, joint tenderness, telangiectasias, crackles

  • Sarcoidosis:

wheezing, rhonchi, lymphadenopathy

  • Mixed connective tissue disease (overlap syndromes):

sclerodactyly, nail fold vascular changes, lymphadenopathy, haematuria

  • Adult-onset Still disease:

salmon-colored rash (especially during febrile periods), lymphadenopathy, joint tenderness/swelling

  • HIV infection:

fever, skin rashes, oral thrush, muscle wasting (advanced disease), Kaposi’s sarcoma

  • Tuberculosis (extrapulmonary):

fever, lymphadenopathy

  • Mycobacterium avium-intracellulare:

fever, lymphadenopathy, rales, or consolidation

  • Histoplasmosis:

fever, scattered crackles, bronchial breathing, distant breath sounds

  • Amoebiasis:

fever, abdominal tenderness

  • Giardiasis:

may have abdominal tenderness

  • Infective endocarditis:

fever, cardiac murmur, Osler nodes, Janeway lesions

  • Whipple’s disease: 

fever, may be normal

  • Inadequate nutrition:

signs of starvation