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Undifferentiated Weight Loss — Written Clinical Reasoning
DCE long-case preparation: structured written reasoning for the diagnostic approach to the patient with involuntary weight loss — the definition of the clinically significant loss, the two first-minute branch points (intentional versus involuntary; appetite preserved versus lost), the seven-category differential, the Tier 1 and the Tier 2 investigations, the Hernandez prediction score for malignancy, the Metalidis evidence supporting the observation after the normal workup, the Fearon cancer cachexia consensus, the nutritional assessment and the management ladder, the refeeding syndrome prevention, and the exam traps.
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Undifferentiated Weight Loss — Written Clinical Reasoning
Prompt 1 — Diagnostic approach and investigation strategy (12 marks)
A 68-year-old man presents with 3 months of involuntary weight loss (8 kg, 10 per cent of his usual body weight), anorexia, early satiety, and night sweats. He is a non-smoker with no significant past medical history. His Tier 1 bloods show a haemoglobin of 102 g per litre (MCV 72 fL), an alkaline phosphatase of 320 U per litre, an LDH of 480 U per litre, an albumin of 32 g per litre, a white cell count of 14.2, normal electrolytes, normal TFTs, normal glucose, and a CRP of 48. His faecal immunochemical test is positive. His CXR and abdominal ultrasound are pending. Discuss the diagnostic approach, the differential diagnosis, the investigations, and the initial management plan. [1]
References6ShowHide
- [1]Gaddey HL, Holder K Unintentional weight loss in older adults Am Fam Physician, 2014.PMID 24784334
- [2]Hernández JL, Riancho JA, Matorras P, González-Macías J Clinical evaluation for cancer in patients with involuntary weight loss without specific symptoms Am J Med, 2003.PMID 12798450
- [3]Hernández JL, Matorras P, Riancho JA, González-Macías J Involuntary weight loss without specific symptoms: a clinical prediction score for malignant neoplasm QJM, 2003.PMID 12925720
- [4]Metalidis C, Knockaert DC, Bobbaers H, Vanderschueren S Involuntary weight loss. Does a negative baseline evaluation provide adequate reassurance? Eur J Intern Med, 2008.PMID 18549937
- [5]Fearon K, Strasser F, Anker SD, et al. Definition and classification of cancer cachexia: an international consensus Lancet Oncol, 2011.PMID 21296615
- [6]Wallace JI, Schwartz RS, LaCroix AZ, Uhlmann RF, Pearlman RA Involuntary weight loss in older outpatients: incidence and clinical significance J Am Geriatr Soc, 1995.PMID 7706619