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Common generalised histories

Weight loss

Exploring symptom

  • How much
  • Over how long
  • Associated symptoms

Relevant system reviews

  • Gastrointestinal
    • Weight: appetite change
    • Work down body: dysphagia, nausea/vomiting, indigestion/heartburn, abdominal pain, bowel habit change, tenesmus, blood/mucus in stool
  • Full systems review
    • Consider full systems review if diagnosis unclear

Differential diagnoses and clues

Malignancy

  • Symptoms of tumour, e.g. breast lump, haemoptysis (lung), prostatic symptoms, change in bowel habit (bowel), haematuria (TCC), jaundice (head of pancreas), post-menopausal bleed (uterine) etc.

Gastrointestinal

  • Elderly
  • Blood/melaena PR
  • Change in bowel habit
  • Diarrhoea with blood/mucus 
  • Abdominal pain
  • Diarrhoea, steatorrhoea
  • Anaemia symptoms, e.g. SOB, tiredness 
  • Abdominal discomfort

Endocrinological

  • Diarrhoea
  • Heat intolerance
  • Irritability/restlessness
  • Tremor
  • Oligomenorrhoea / amenorrhoea
  • Polyuria
  • Polydipsia

Psychological

  • BMI <17.5 in anorexia
  • Binge eating in bulimia
  • Effort to lose weight (gym, vomiting, laxatives)
  • Menstrual cycle disturbance
  • Core: low mood, anhedonia
  • Biological: poor sleep, lack of energy
  • Future: hopelessness, suicidal thoughts
  • Organic stress

Others

  • Diet changes/malnutrition
  • Substance misuse
  • End organ failure
  • Chronic inflammatory diseases
  • Chronic infection (e.g. TB)
  • HIV

Tiredness

Exploring symptom

  • Timeframe
    • Duration
    • Onset (sudden or gradual)
    • Progression
    • Timing (intermittent or continuous)
  • Tiredness
    • What they mean by tiredness
    • Sleep pattern/quality
    • How it affects patient
  • Associated symptoms
    • Anaemia symptoms: breathlessness on exertion
    • Hypothyroidism symptoms: constipation, weight gain, cold intolerance etc.
    • Depression symptoms: mood
    • Diabetes symptoms: polydipsia, polyuria

Full systems review

  • Consider full systems review if diagnosis unclear

Differential diagnoses and clues

Haematological

  • Breathlessness on exertion
  • Weakness
  • May get palpitations, worsening angina, worsening claudication

Endocrinological

  • Constipation
  • Cold intolerance
  • Weight gain
  • Polydipsia/thirst
  • Polyuria
  • Weight loss
  • Visual disturbance
  • Non-specific symptoms
  • Postural hypotension

Psychological

  • Core: low mood, anhedonia
  • Biological: poor sleep, lack of energy
  • Future: hopelessness, suicidal thoughts

Respiratory

  • Loud snoring
  • Night time breathing interrupted by apnoeas / gasping / snorting
  • Excessive daytime sleepiness 
  • Obesity is a risk factor

Others

  • Stress
  • Post-viral fatigue
  • Organ failure
  • Drugs (e.g. recreational, Ξ²-blockers, diuretics)
  • Malignancy
  • Chronic inflammatory diseases (e.g. connective tissue diseases)
  • Chronic infection (e.g. TB)

Here are a few questions for you

A patient presents with weight loss and chronic diarrhoea. Which conditions would you include in your differential diagnosis? Please structure your answer.

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You see a patient who complains of tiredness and extreme fatigue. A workup excludes other causes and you think they may have chronic fatigue syndrome. Which features may suggest this diagnosis?

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Try some related OSCE stations

  1. Tiredness history
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