Unintentional weight loss
In a workup for unintentional weight loss, gather and document weights with dates, appetite and diet, a systems review, the screening results already on file, and the red flags.
General and abdominal: These presentations have a wide differential, so you read results from several sources together.
Key takeaways
- Quote weights with dates so the loss can be measured.
- Ask a full systems review, since the cause is often outside the obvious system.
- Document the red flags, present or absent.
What this presentation is
Unintentional weight loss is often defined as a loss of more than 5% of body weight over 6 to 12 months. Causes include cancer, gastrointestinal disease, endocrine disease, depression and social factors.
Measured weights from earlier records give you the size and speed of the loss. A remembered weight is less reliable.
Gather these sources first
- Recorded weights with dates from earlier visits
- Complete blood count, ferritin, renal and liver function, calcium and phosphate
- Thyroid function, HbA1c and inflammatory markers
- Celiac serology if done
- Chest imaging and endoscopy reports
- The medication list
Document these history questions
- Amount of loss and over what period
- Whether the loss was intended
- Appetite, diet and difficulty eating or swallowing
- Gastrointestinal symptoms and change in bowel habit
- Cough, night sweats and fever
- Mood and social circumstances
- Smoking in pack-years and alcohol
Record these findings
- Current weight and body mass index
- Lymph nodes, abdominal masses and thyroid
- Oral and dental examination
- Hemoglobin, ferritin and inflammatory markers
- Calcium and liver function
Ask about these red flags
Record each one as present or absent. Your local pathway decides what happens when one is present.
- Difficulty swallowing
- Gastrointestinal bleeding
- Change in bowel habit
- Hemoptysis
- A palpable mass or lymphadenopathy
- Iron deficiency anemia
Put these in the assessment draft
- The amount and rate of loss, from measured weights
- A ranked differential with the reasoning
- The results reviewed, with dates
- The red flags asked about and the answers
- A plan with investigations, referral and safety-netting advice
How Workup Desk helps
Add earlier visit notes, results and imaging reports to the workspace. Ask for every recorded weight with its date.
Draft the assessment or a referral letter and edit it. The chat names the note behind each weight it quotes.
Frequently asked questions
Why does the percentage matter more than the pounds?
The same loss in pounds means more in a smaller person. A percentage over a stated period lets the reader judge significance.
General guidance on what to gather and document, not advice about any individual patient. Local guidelines and your clinical judgment govern.