Weight Loss (unintentional)
Unintentional weight loss is a clinically significant involuntary decrease in body weight, typically defined as a loss of more than 5% of baseline body weight over 6 to 12 months, often indicating an underlying medical, psychiatric, or nutritional disorder.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Depression / psychological | Low mood, anhedonia, ↓appetite, sleep disturbance | 「最近心情點？有冇覺得咩都冇意思？」 | ~25% |
| New / poorly controlled DM | 3Ps: polyuria, polydipsia, polyphagia + weight loss [2] | 「有冇成日口渴、去好多次廁所、食好多嘢但仲係瘦？」 | ~10% | |
| Hyperthyroidism | Weight loss + ↑appetite, heat intolerance, tremor, tachycardia [3] | 「怕唔怕熱？心跳快唔快？手有冇震？」 | ~10% | |
| Serious Not To Miss | Malignancy (GI, lung, lymphoma) | Constitutional Sx (fever, night sweats), mass, haemoptysis, PR bleeding, lymphadenopathy | 「有冇夜晚出汗、痰有血、大便有血？有冇摸到頸或者腋下有粒嘢？」 | ~5% |
| TB | Chronic cough, night sweats, haemoptysis, contact history, immigrant | 「有冇接觸過肺癆病人？」PE: apical crackles | ~1% | |
| HIV/AIDS | Risk behaviours, recurrent infections, oral thrush | 「有冇高危性行為或者共用針嘴？」 | < 1% | |
| Pitfalls | CKD | Fatigue, nocturia, poor appetite [7] | 「夜晚要唔要起身去廁所？有冇覺得好攰？」 | ~2% |
| Chronic pancreatitis | Epigastric pain radiating to back, steatorrhoea, alcohol history [6] | 「有冇肚痛㩒到背脊？大便有冇好油好臭？」 | ~1% | |
| Coeliac disease / malabsorption | Chronic diarrhoea, steatorrhoea, bloating, iron/folate deficiency | 「有冇成日肚瀉、肚脹？」 | < 1% | |
| Masquerades | Depression | Low mood, anhedonia, poor sleep, guilt, poor concentration | 「情緒低落？冇胃口？」 | ~25% |
| DM (as above) | 3Ps, FHx, obesity/acanthosis | 血糖檢查 | ~10% | |
| Anaemia | Pallor, fatigue, ↓exercise tolerance | PE: conjunctival pallor | ~5% | |
| Drugs (polypharmacy) | New medication temporal association | 「最近有冇轉藥或者加新藥？」 | ~5% | |
| Trying to Tell Me Something? | Cancer phobia / health anxiety | Relative recently diagnosed with cancer; excessive worry | 「你最擔心啲咩？屋企人最近有冇人病？」 | ~20% |
| Social isolation / elder neglect | Lives alone, nobody cooking, financial difficulty | 「平時邊個煮飯畀你食？經濟上有冇困難？」 | ~10% | |
| Eating disorder | Body image distortion, purging, excessive exercise | 「你覺得自己肥唔肥？有冇催吐？」 | ~5% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, intro, rapport | 「你好，我係X醫生，今日由我同你傾吓，請坐。你點稱呼呀？」 | Friendly opening, use patient's name → interpersonal marks |
| 0:30–1:00 | Open-ended chief complaint | 「你今日嚟想睇啲咩呀？」then 「你可唔可以講多少少呢？」 | Let patient tell their story; captures CC and HPI naturally |
| 1:00–2:30 | Symptom analysis + red flags | 「輕咗幾多？幾耐嘅事？有冇刻意減肥㗎？」「食嘢胃口點呀？有冇肚痛、嘔、大便有血？」「有冇夜晚出汗、發燒？有冇頸腫？」 | Quantify weight loss, timeline, appetite, constitutional symptoms, malignancy red flags → HPI completeness |
| 2:30–3:30 | Systems review / targeted Hx | 「心跳有冇快咗？怕唔怕熱？手有冇震？」(thyroid) 「有冇成日口渴、去好多廁所？」(DM) 「有冇咳、氣喘、痰有冇血？」(lung CA) 「最近情緒點呀？瞓得好唔好？」(depression) | Covers key DDx discriminators |
| 3:30–4:30 | PMHx, DHx, FHx, Social Hx | 「之前有冇其他病？食緊咩藥？有冇敏感？」「屋企人有冇癌症、甲狀腺、糖尿？」「你食唔食煙？飲唔飲酒？做咩工作㗎？」 | Drug/social history often holds hidden clues; smoking → lung CA |
| 4:30–5:15 | ICE + hidden agenda | 「你自己覺得點解會瘦咗呢？」(Ideas) 「你最擔心啲咩？」(Concerns) 「你嚟到想我幫你做啲咩呢？」(Expectations) | ICE is a dedicated CRF field; hidden agenda often = cancer fear |
| 5:15–5:45 | Summarise + check understanding | 「等我總結吓：你話最近瘦咗X磅，冇刻意減肥，仲有… 我有冇漏咗啲咩？」 | Shows active listening, allows correction |
| 5:45–6:00 | Plan + safety net + close | 「我會幫你安排抽血同檢查。如果期間你有發燒、嘔血、體重繼續跌，要即刻返嚟睇。」「你仲有冇嘢想問？」 | Safe closing, safety-net line, empowers patient |
Hidden agenda tip: In FM stations on weight loss, the patient often fears cancer but hasn't said it. Ask: 「你有冇擔心自己係咪有咩大病？」 — this unlocks the concern and scores ICE marks.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Quantify | How much weight lost? Over what period? | 「你瘦咗幾多磅？幾耐嘅事呀？」 | ≥5% in 6–12 months is clinically significant [1] | Organic cause likely |
| Intentionality | Were you trying to lose weight? Dieting/exercise? | 「你有冇刻意減肥、節食或者做多咗運動？」 | Distinguishes intentional vs unintentional | Intentional → less alarming |
| Appetite | How is your appetite? Eating more or less? | 「食嘢胃口點？食多咗定少咗？」 | Weight loss + increased appetite → DM or hyperthyroidism [2][3] | Thyrotoxicosis, DM |
| Constitutional | Any fever, night sweats? | 「有冇發燒、夜晚出汗？」 | B-symptoms → lymphoma, TB, malignancy | Lymphoma, TB, occult CA |
| GI | Any nausea, vomiting, abdominal pain, change in bowel habit, blood in stool? | 「有冇作嘔、嘔、肚痛？大便正唔正常？有冇血？」 | GI malignancy screen | Gastric/colorectal CA, IBD, chronic pancreatitis |
| Resp | Any cough, haemoptysis, shortness of breath? | 「有冇咳？痰有冇血？氣唔氣喘？」 | Lung CA screen | CA lung |
| Thyroid | Heat intolerance? Palpitations? Tremor? Loose stools? | 「怕唔怕熱？心跳有冇快咗？手有冇震？有冇肚瀉？」 | Thyrotoxicosis: weight loss despite good appetite, heat intolerance, tremor, palpitations [3] | Graves' disease, toxic nodule |
| DM | Polyuria, polydipsia, polyphagia? | 「有冇成日口渴、去好多次廁所、食好多嘢？」 | 3Ps of DM [2] | New DM / poorly controlled DM |
| Psych | Mood? Interest in things? Sleep? Concentration? | 「最近心情點呀？有冇覺得咩都冇興趣？瞓得好唔好？」 | Depression is a masquerade causing weight loss | Depression, anorexia nervosa |
| Eating pattern | Any fear of gaining weight? Restricting food? Purging? | 「你有冇特別控制食嘢份量？有冇催吐？」 | Eating disorders, especially younger females | Anorexia nervosa [4] |
| Swallowing | Any difficulty swallowing? | 「食嘢有冇覺得吞唔到落去？」 | Oesophageal/oropharyngeal pathology | Oesophageal CA, stricture |
| Drug Hx | Any new medications? Herbal remedies? | 「最近有冇食新藥？有冇食中藥或者保健品？」 | Drug-induced weight loss (metformin, GLP-1 RA, thyroxine, stimulants) | Drug side-effect |
| PMHx | Any chronic disease? Previous surgery? | 「之前有冇其他病？做過手術未？」 | CKD, CLD, COPD, HIV, previous GI surgery | Underlying chronic disease |
| FHx | Family history of cancer, thyroid disease, DM? | 「屋企人有冇癌症、甲狀腺或者糖尿病？」 | Hereditary risk | Familial cancers, MEN |
| Social | Smoking? Alcohol? Occupation? Who lives at home? | 「食唔食煙？飲唔飲酒？做咩工作？同邊個住？」 | Smoking → lung/GI CA; alcohol → CLD; social isolation → poor nutrition | CA lung, cirrhosis, social neglect |
| Functional | Can you do daily activities? Any weakness? | 「日常生活自己搞唔搞得掂？有冇覺得冇力？」 | Frailty phenotype: unintentional weight loss, exhaustion, weakness [5] | Frailty in elderly |
| Sexual/menstrual (if relevant) | Periods regular? Any pregnancy possible? | 「月經正唔正常？有冇可能懷孕？」 | Amenorrhoea + weight loss → anorexia nervosa, hyperthyroidism | Eating disorder, thyroid |
Case Report Form Answer Builder
- CC: Unintentional weight loss of __ kg over __ weeks/months
- HPI key points to capture:
- Amount & duration of weight loss (quantify!)
- Intentional vs unintentional (no dieting/exercise change)
- Appetite: increased / decreased / normal
- Associated symptoms: constitutional (fever, night sweats), GI (change in bowel habit, dysphagia, abdominal pain, GI bleeding), respiratory (cough, haemoptysis), endocrine (3Ps, heat intolerance, tremor)
- Functional impact on daily life
- Relevant PMHx, DHx, FHx, social history
- Examples: "To find out why I am losing weight" / "Worried about cancer" / "Family insisted I come because I look thinner"
- Phrase the best single answer: "Patient noticed progressive unintentional weight loss over X months and is worried it may indicate a serious illness."
- Remember: RFC ≠ presenting symptom. The RFC is why they came today — often a trigger event (e.g., someone commented, clothes no longer fit, relative diagnosed with cancer).
| Likely Content | Exact Wording for CRF | |
|---|---|---|
| Ideas | "Maybe I have cancer" / "Maybe my thyroid" / "Maybe stress" | "Patient thinks the weight loss may be due to cancer / stress / thyroid problem." |
| Concerns | Fear of cancer, fear of serious illness, worried about being too thin | "Patient is worried that the weight loss indicates a malignancy." |
| Expectations | Wants blood tests, scan, referral, reassurance | "Patient would like investigations (blood tests / imaging) to identify the cause." |
- Depends on the stem. For a middle-aged/elderly patient with weight loss + constitutional symptoms + smoking → malignancy (e.g., gastric CA, lung CA). For weight loss + ↑appetite + heat intolerance → hyperthyroidism. For weight loss + 3Ps → DM.
- Minimum supporting evidence: quantified unintentional weight loss + the key symptom cluster + one risk factor.
GC 063 high yield: Two classical endocrine conditions causing weight loss despite increased appetite are DM and hyperthyroidism [3]. If appetite is decreased, think malignancy, depression, or chronic disease.
| DDx | One Key Discriminator |
|---|---|
| Malignancy (e.g., gastric CA, lung CA, lymphoma) | Constitutional symptoms (night sweats, fatigue), mass/lymphadenopathy, smoking, age > 50 |
| Hyperthyroidism | Weight loss + increased appetite + heat intolerance + tremor + tachycardia |
| DM (new or poorly controlled) | 3Ps (polyuria, polydipsia, polyphagia) + FHx, ± acanthosis nigricans |
| Depression (reserve if needed) | Low mood, anhedonia, ↓appetite, sleep disturbance, no organic red flags |
| Domain | Example |
|---|---|
| Biological | Unintentional weight loss requiring investigation to exclude malignancy/endocrine disease; malnutrition risk |
| Psychological | Anxiety / fear about having cancer; possible underlying depression contributing to poor appetite |
| Social/Functional | Reduced ability to carry out work/daily activities due to fatigue and weakness; impact on family (caregiver worry); financial burden of investigations |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Hyperthyroidism | Diffuse goitre with bruit / fine tremor / lid lag / tachycardia | Inspect and palpate neck from behind; ask patient to extend hands and place paper on dorsum; check pulse rate | Thyroid enlargement + hypermetabolic signs confirm thyrotoxicosis [3] |
| DM | Acanthosis nigricans / signs of complications (peripheral neuropathy, foot ulcer) | Inspect neck folds, axillae; monofilament test on feet | Insulin resistance marker; diabetic complications suggest long-standing DM [2] |
| Malignancy (gastric CA) | Palpable epigastric mass / left supraclavicular lymphadenopathy (Virchow's node) | Palpate epigastrium; palpate left supraclavicular fossa | Virchow's node = advanced GI malignancy; epigastric mass = gastric tumour [8] |
| Malignancy (lung CA) | Clubbing / supraclavicular lymphadenopathy / signs of SVC obstruction | Inspect nail beds; palpate cervical + supraclavicular nodes | Clubbing + lymphadenopathy in a smoker = high suspicion lung CA [9] |
| Lymphoma | Painless, rubbery, non-tender lymphadenopathy | Palpate cervical, axillary, inguinal nodes systematically | Generalised lymphadenopathy + B-symptoms (fever, night sweats, weight loss > 10%) [10] |
| Depression | Psychomotor retardation / flat affect / poor eye contact | Observe during consultation | No reliable FM physical sign — best clue is clinical interview using PHQ-2/9 screening |
| Malnutrition | Temporal wasting / loss of subcutaneous fat / loose skin | Inspect temporal fossa, hand interossei, general body habitus | Clinical manifestation of gross malnutrition: severe wasting, loss of subcutaneous fat [1] |
| CKD | Peripheral oedema / uraemic pallor | Inspect conjunctivae; press pretibial area for pitting oedema | Pallor (anaemia of CKD) + oedema suggest advanced renal disease [7] |
GC 185 high yield: Magnitude of weight loss is a rough predictor of its effect on clinical outcome [1]. Document exact amount and percentage.
Exam Discriminators and Traps
Top Traps That Lose Marks
- Forgetting to quantify: Always ask how many kg/lbs and over what time period. ≥5% in 6–12 months = clinically significant.
- Not asking if intentional: The entire approach changes if the patient was deliberately dieting.
- Missing appetite status: Weight loss with ↑appetite (DM, hyperthyroid) vs ↓appetite (malignancy, depression, CKD) is the key branch point.
- Skipping ICE: ICE is a scored CRF field. The hidden concern in weight loss is almost always cancer fear.
- Not screening for depression: Depression is the classic masquerade — easy to forget when focused on organic causes.
- Forgetting drug history: GLP-1 receptor agonists, metformin, thyroxine, stimulants, laxative abuse → iatrogenic weight loss.
- Overlooking elderly frailty: In older patients, unintentional weight loss is one of the 5 criteria of the Fried frailty phenotype [5].
| Red Flag | Concern | Action |
|---|---|---|
| Progressive weight loss + dysphagia | Oesophageal / gastric CA | Urgent OGD referral |
| Haemoptysis + weight loss + smoking | Lung CA | Urgent CXR → CT thorax |
| Palpable mass (abdomen, breast, lymph node) | Malignancy | Urgent imaging + biopsy |
| B-symptoms (fever > 2 wks, drenching night sweats, > 10% weight loss in 6 months) | Lymphoma / TB / occult CA | CBC, LDH, CXR, CT; consider haematology referral [10] |
| New-onset DM symptoms with marked weight loss | Severe DM or pancreatic CA | Fasting glucose/HbA1c; consider CT pancreas if suspicion high [2] |
「我會幫你安排驗血（包括血糖、甲狀腺功能、腎肝功能、血常規）同基本檢查。如果期間你體重繼續跌、有嘔血、痰有血、或者發高燒，要即刻返嚟或者去急症室。」
High Yield Summary
What to ASK: Quantify weight loss (kg + duration) → intentional? → appetite ↑/↓ → constitutional symptoms → GI/resp/thyroid/DM screen → depression screen → drug history → ICE (cancer fear).
What to WRITE on CRF: Exact weight loss amount and duration; appetite status; key positive and negative findings; ONE main RFC (why today?); ICE with patient's own words; most likely Dx with supporting evidence; 3 DDx with discriminators; 3 biopsychosocial problems; one physical sign.
What NOT TO MISS: (1) Quantify the weight loss, (2) Ask if intentional, (3) Screen appetite — the ↑ vs ↓ appetite branch is the single most important discriminator, (4) Cancer fear = almost always the hidden concern, (5) Depression as masquerade, (6) Drug history, (7) Red flags for urgent referral.
Active Recall - Family Medicine Clinical Test
[1] GC 185. Feed him up before surgery Surgical nutrition, Enteral and parenteral feeding.pdf (slides on clinical manifestation of malnutrition, magnitude of weight loss as predictor) [2] Block A - Polyuria and polydipsia_ glucose metabolism; diabetes mellitus; diabetic ketoacidosis.pdf (3Ps, weight loss with increased appetite in DM) [3] GC 063. I am losing weight and sweating all the time.pdf; Block A - I am losing weight and sweating all the time_ causes of severe, weight loss; thyrotoxicosis; hypothyroidism.pdf (thyrotoxicosis, weight loss + increased appetite) [4] Ryan Ho Psychiatry.pdf (anorexia nervosa clinical features, p.209) [5] GC 054. Frailty in the older people.pdf (Fried frailty phenotype, slide 7) [6] Block A - Upper abdominal pain_ peptic ulcer; pancreatitis and gallstone.pdf (chronic pancreatitis symptoms) [7] Block A - Chronic Kidney Disease and its Complications.pdf (poor appetite, weight loss in CKD) [8] GC 212. Weight loss and vomiting gastric cancer; abdominal imaging.pdf (gastric cancer presentation) [9] Ryan Ho Respiratory.pdf (lung CA clinical presentation, p.141) [10] MBBS Final MB (Medicine) (Felix PY Lai).pdf (CLL/lymphoma B-symptoms, p.1409)
Weight Gain
An increase in body weight over time, resulting from excess caloric intake, fluid retention, increased muscle mass, or underlying medical conditions such as hypothyroidism or Cushing syndrome.
Wrist Pain
Wrist pain is a common musculoskeletal complaint arising from injury, overuse, or systemic conditions affecting the bones, joints, tendons, ligaments, or nerves of the wrist.