Phys Vivas · general-medicine
Undifferentiated Weight Loss — Viva Defence
Structured DCE viva for the diagnostic approach to the patient with involuntary weight loss: the long-case defence covering the 68-year-old man with the weight loss, the anorexia, the early satiety, the night sweats, and the iron deficiency anaemia with the positive FIT (the GI malignancy scenario), the Hernandez prediction score, the Tier 2 malignancy workup, and the cancer cachexia management; the branching scenario into the 58-year-old woman with the weight loss, the heat intolerance, and the atrial fibrillation (the hyperthyroidism with the preserved appetite), and the 72-year-old man with the weight loss, the postural hypotension, and the hyperpigmentation (the Addison disease); and the short-case discussion of the examination of the cachectic patient.
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Undifferentiated Weight Loss — Viva Defence
The long case — opening statement (SASPOP)
"Mr R is a 68-year-old retired carpenter presenting with a 3-month history of involuntary weight loss of 8 kg (10 per cent of his usual body weight), anorexia, early satiety after small meals, and drenching night sweats. His Tier 1 bloods revealed a microcytic anaemia (haemoglobin 102, MCV 72), an elevated alkaline phosphatase of 320, an elevated LDH of 480, an albumin of 32, and a white cell count of 14.2. His faecal immunochemical test is positive." [1]
The problem list: [1]
- The significant involuntary weight loss with the multiple red flags for the malignancy — the 10 per cent in 3 months (well above the 5 per cent in 6 months threshold), the anorexia, the early satiety, the night sweats.
- The iron deficiency anaemia — the microcytic anaemia with the low MCV, the likely iron deficiency from the chronic GI blood loss.
- The elevated ALP, the elevated LDH, the low albumin, and the elevated white cell count — three of the five Hernandez malignancy prediction score variables, significantly increasing the probability of the malignancy.
- The positive faecal immunochemical test — confirming the GI bleeding or the mucosal abnormality.
- The nutritional risk — the significant weight loss and the reduced intake warrant the nutritional assessment and the support. [1]
References5ShowHide
- [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