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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:

Any malignancySymptoms 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:

Colon cancer – Elderly
– Blood/melaena PR
– Change in bowel habit
Inflammatory bowel disease– Diarrhoea with blood/mucus 
– Abdominal pain
Coeliac disease– Diarrhoea, steatorrhoea
– Anaemia symptoms, e.g. SOB, tiredness 
– Abdominal discomfort

Endocrinological:

Thyrotoxicosis  – Diarrhoea
– Heat intolerance
– Irritability/restlessness
– Tremor
– Oligomenorrhoea / amenorrhoea

Psychological:

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

Others:

Other differentialsDiet changes/malnutrition, Substance misuse, End organ failure, Diabetes mellitus type 1, Chronic inflammatory diseases, Chronic infection (e.g. TB), HIV/AIDS

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:

Anaemia– Breathlessness on exertion
– Weakness
– May get palpitations, worsening angina, worsening claudication

Endocrinological:

Hypothyroidism– Constipation
– Cold intolerance
– Weight gain
Diabetes– Polydipsia/thirst
– Polyuria
– Weight loss
– Visual disturbance

Psychological:

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

Respiratory:

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

Others:

Other differentialsStress, Post-viral fatigue, Organ failure, Drugs (e.g. recreational, β-blockers, diuretics), Malignancy, Chronic inflammatory diseases (e.g. connective tissue diseases), Chronic infection (e.g. TB), Addison’s disease / adrenal insufficiency

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
  2. Find more stations here
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