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.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Primary (simple) obesity | Excess caloric intake ± ↓activity; gradual; no endocrine symptoms; BMI ≥ 25 (Asian) or ≥ 23 overweight [5] | 「你平時食嘢份量大唔大？有冇食宵夜、飲汽水？」 |
| Metabolic syndrome | Central obesity + HT + dyslipidaemia + ↑glucose | Measure waist circumference: ≥90cm (M), ≥80cm (F) in Chinese [5] | |
| Serious Not To Miss | Hypothyroidism | Cold intolerance, constipation, fatigue, dry skin, weight gain with decreased appetite, bradycardia, delayed reflexes [2] | 「你有冇怕凍、便秘、皮膚好乾？」 |
| Cushing syndrome | Moon face, buffalo hump, truncal obesity, purple striae, proximal myopathy, easy bruising; most common cause = exogenous steroid [3] | 「你有冇食過類固醇？身上有冇紫色紋？」 | |
| Insulinoma / Hypothalamic tumour | Hypoglycaemic episodes; headache, visual field defects | 「你有冇試過頭暈出冷汗好似低血糖咁？有冇頭痛？」 | |
| New-onset T2DM (comorbidity) | Polyuria, polydipsia, blurred vision | 「有冇成日口渴、小便多？」 | |
| Pitfalls | PCOS | Young female, oligomenorrhoea, hirsutism, acne, weight gain | 「月經幾耐嚟一次？面同身有冇毛多咗？」 |
| Fluid retention (HF/nephrotic/cirrhosis) | Pitting oedema, SOB, ascites – weight gain is water not fat | 「有冇腳腫？肚脹？」 | |
| OSA (co-exists with obesity) | Snoring, witnessed apnoea, EDS | 「有冇打鼻鼾？日頭好眼瞓？」 | |
| Masquerades | Depression | Low mood, anhedonia, ↑appetite (atypical), ↓activity, comfort eating | 「心情點？有冇對嘢冇晒興趣？食嘢有冇變多咗去令自己舒服啲？」 |
| Drug-induced weight gain | Temporal link to starting a new medication [4] | 「你幾時開始食呢隻藥？體重係咪食藥之後先開始升？」 | |
| GH deficiency (adult) | Weight gain with ↑ fat mass / ↓ lean body mass, fatigue [6] | 「你有冇覺得肌肉少咗、肚腩大咗？」 | |
| Trying to Tell Me Something? | Body image distress / relationship issue | Partner criticism, bullying, desire to lose weight for wedding/event | 「係咪有人講咗啲嘢令你擔心？你最擔心啲咩？」 |
| Binge eating disorder | Episodes of uncontrolled eating + guilt | 「你有冇試過控制唔到咁食好多嘢，食完之後好內疚？」 |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, intro, rapport | 「你好，我係X醫生，今日會同你傾吓，了解吓你嘅情況。你可以叫我X醫生。」 | Friendly opening; establishes trust → interpersonal marks |
| 0:30–1:30 | Chief complaint + HPI – onset, duration, amount of weight gain, distribution, timeline, appetite change, diet, exercise | 「你今日嚟主要想睇咩問題呀？」→「你大概重咗幾多？幾時開始㗎？」→「你食嘢有冇多咗？定係食少咗都照肥？」 | Defines CC precisely; differentiates excess intake vs secondary causes |
| 1:30–2:30 | Screen for secondary causes – thyroid Sx (cold intolerance, constipation, dry skin, fatigue), Cushing Sx (striae, easy bruising, moon face), PCOS (menstrual irregularity, hirsutism), medications, mood | 「你有冇怕凍、便秘、皮膚乾？」→「有冇食緊任何藥，例如類固醇、精神科藥？」→「月經正唔正常？」 | Distinguishes primary vs secondary obesity – key DDx marks |
| 2:30–3:30 | Red flags + complications – SOB, chest pain, snoring/EDS (OSA), polyuria/polydipsia (DM), joint pain, visual changes | 「你有冇打鼻鼾，日頭好眼瞓？」→「有冇成日口渴、去廁所多咗？」 | Screens serious complications & comorbidities; earns systematic history marks |
| 3:30–4:30 | ICE + psychosocial – why today, what patient thinks is the cause, worries, expectations; mood/stress/work/family; diet & activity detail | 「你自己覺得點解會肥咗？」→「你最擔心啲咩？」→「你今日嚟最想我幫到你咩？」→「最近心情點呀？瞓得好唔好？」 | ICE = high-mark CRF items; uncovers hidden agenda (e.g. body image distress, relationship concern, depression) |
| 4:30–5:15 | PMH, FH, SH, Drug Hx – DM/HT/lipids/PCOS/thyroid FH; smoking/alcohol; occupation; previous attempts at weight loss | 「屋企人有冇糖尿、高血壓、甲狀腺問題？」→「你有冇試過減肥？點減㗎？」 | Completes biopsychosocial picture; drug causes are a classic trap |
| 5:15–6:00 | Summarise, check understanding, close | 「等我總結吓：你大概半年前開始重咗十磅，食嘢差唔多但少咗做運動，你擔心係咪有病，想驗吓身。啱唔啱？」→「我哋之後可以安排驗血同跟進。你仲有冇嘢想問？」 | Demonstrates summarising + checking → interpersonal marks; safety-net |
Uncovering the hidden agenda: Weight gain patients often present with a surface complaint but the real reason may be body image distress, a partner's comment, fear of diabetes/cancer, depression causing comfort eating, or medication side effects they want to stop. Ask 「其實係咩原因令你今日決定嚟睇醫生？」 early.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset/Amount | How much weight have you gained and over what period? | 「你重咗幾多磅？幾耐之內重㗎？」 | Quantifies severity; rapid gain → secondary cause | Cushing, hypothyroidism, drug-related, fluid retention |
| Appetite | Has your appetite increased, decreased, or stayed the same? | 「你食嘢有冇多咗？定係差唔多照肥？」 | Weight gain with decreased appetite → hypothyroidism; weight gain despite normal intake → endocrine [1] | Hypothyroidism, Cushing |
| Diet/Lifestyle | What do you eat in a typical day? How active are you? | 「你平時一日食啲咩？有冇做運動？」 | Primary obesity = excess intake/↓activity | Simple obesity |
| Thyroid Sx | Cold intolerance, constipation, fatigue, dry skin, hair loss? | 「你有冇怕凍、便秘、成日攰、皮膚乾、甩頭髮？」 | Hypothyroidism classic symptoms [2] | Hypothyroidism |
| Cushing Sx | Easy bruising, stretch marks, round face, muscle weakness? | 「你有冇容易瘀、出現紫色紋、面圓咗、手腳冇力？」 | Cushing syndrome features [3] | Cushing syndrome |
| Menstrual/PCOS | Periods regular? Excess facial hair? Acne? | 「月經準唔準？有冇面毛多咗？暗瘡多咗？」 | PCOS → weight gain + menstrual irregularity | PCOS |
| Mood/Sleep | How is your mood? Sleeping well? Interest in things? | 「最近心情點？瞓得好唔好？有冇對嘢冇晒興趣？」 | Depression → comfort eating, ↓activity; atypical depression ↑appetite | Depression, binge eating |
| Medications | Any current medications – steroids, psychiatric meds, insulin, anticonvulsants? | 「你有冇食緊任何藥？例如類固醇、精神科藥、糖尿藥？」 | 5 drug classes causing weight gain: antidepressants, antipsychotics, DM meds (insulin/SU/TZD), glucocorticoids, anticonvulsants (valproate) [4] | Drug-induced weight gain |
| OSA | Snoring? Daytime sleepiness? Partner noticed apnoeas? | 「你有冇打鼻鼾？日頭好眼瞓？枕邊人有冇話你瞓覺時停咗呼吸？」 | OSA is a comorbidity of obesity and a secondary HT cause | OSA |
| DM screen | Increased thirst, urination, blurred vision? | 「你有冇成日口渴、去廁所多咗、睇嘢矇？」 | Screen for new-onset DM as comorbidity | T2DM |
| FH | Family history of obesity, DM, thyroid, heart disease? | 「屋企人有冇肥、糖尿、甲狀腺問題、心臟病？」 | Genetic predisposition; metabolic syndrome clustering | Familial obesity, metabolic syndrome |
| Smoking/Alcohol | Smoking, alcohol intake? | 「你有冇食煙？飲酒多唔多？」 | CV risk factors; alcohol = extra calories; MAFLD | CV risk, fatty liver |
| Previous attempts | Have you tried losing weight before? How? | 「你有冇試過減肥？用咩方法？」 | Gauges health-seeking behaviour and motivation | Eating disorder, yo-yo dieting |
| Functional impact | How does weight affect your daily life / work / self-image? | 「體重對你日常生活、做嘢、自信有冇影響？」 | Functional/psychosocial impact for biopsychosocial model | Body image distress, social isolation |
| Red flag – oedema | Any leg swelling, SOB lying flat? | 「有冇腳腫、瞓低時氣喘？」 | Fluid retention mimics weight gain → heart failure, nephrotic syndrome, cirrhosis | HF, nephrotic syndrome, cirrhosis |
Case Report Form Answer Builder
- CC: Weight gain of ___ kg over ___ months
- HPI high-yield points to capture:
- Onset, duration, amount (kg or % body weight)
- Appetite: increased / decreased / unchanged
- Diet pattern, portion size, snacking, sugary drinks
- Physical activity level and recent changes
- Associated symptoms: fatigue, cold intolerance, constipation (hypothyroid); striae, bruising (Cushing); menstrual irregularity (PCOS); mood change (depression); snoring (OSA); polyuria/polydipsia (DM)
- Medication history (steroid, psychiatric, DM meds, anticonvulsants)
- Previous weight loss attempts
- Functional impact on daily life
Examples: "Concerned about unexplained weight gain despite unchanged diet" / "Worried about possible medical cause of weight gain" / "Partner commented on weight; wants health check" / "Feeling low and notices increasing weight"
Pick the one that best reflects why today — often a trigger event (partner's comment, clothes not fitting, health scare in family).
| Likely Content | Exact Wording for CRF | |
|---|---|---|
| Ideas | "I think it might be my thyroid" / "Maybe my medication is making me fat" / "I eat the same as before so something must be wrong" | Patient thinks weight gain may be due to a medical condition (e.g. thyroid problem / medication side effect) |
| Concerns | "I'm worried I might get diabetes like my father" / "I'm worried about my appearance" | Patient is worried about developing diabetes or other complications; concerned about body image |
| Expectations | "I want a blood test to check" / "I want to know how to lose weight" / "I want to change my medication" | Patient expects investigation (blood test) to rule out medical cause and/or advice on weight management |
Primary (simple/exogenous) obesity — supported by: gradual weight gain, excess caloric intake and/or ↓physical activity, no features of secondary endocrine cause, BMI ≥ 25 (Asian cut-off) [5]
High Yield
In a GC station, the most common diagnosis is simple obesity unless the stem gives clear endocrine red flags. However, if the patient has clear features of hypothyroidism or Cushing's, shift your most likely diagnosis accordingly. Always justify with the minimum supporting evidence.
| DDx | Key Discriminator |
|---|---|
| 1. Hypothyroidism | Weight gain with decreased appetite + cold intolerance + constipation + fatigue + bradycardia + delayed reflexes [2] |
| 2. Drug-induced weight gain | Temporal relationship between starting a drug (steroid / antipsychotic / antidepressant / insulin / valproate) and weight gain [4] |
| 3. Depression with comfort eating | Low mood, anhedonia, sleep disturbance, ↑appetite (atypical), ↓activity, guilt |
| Domain | Problem |
|---|---|
| Biological | Obesity-related comorbidity risk (e.g. T2DM, dyslipidaemia, hypertension, OSA, MAFLD) |
| Psychological | Low self-esteem / body image distress / possible depressive symptoms leading to comfort eating |
| Social | Reduced physical activity / social withdrawal due to weight; occupational impact (e.g. sedentary job); family/relationship strain |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Primary obesity | Elevated BMI ≥ 25 (Asian) + increased waist circumference (≥90cm M, ≥80cm F) [5] | Measure weight & height → calculate BMI; tape measure at iliac crest level | Confirms obesity and central fat distribution; correlates with metabolic risk |
| Hypothyroidism | Delayed relaxation of ankle jerk (slow-relaxing reflex) [2] | Tap Achilles tendon with reflex hammer; observe slow return of foot to neutral | Pathognomonic for hypothyroidism; quick to elicit in FM station |
| Cushing syndrome | Purple (wide >1cm) abdominal striae + proximal myopathy [3] | Inspect abdomen for striae; test ability to stand from squatting without using arms | Purple striae and proximal weakness distinguish Cushing from simple obesity |
| Drug-induced weight gain | No specific physical sign | Review drug chart; ask about temporal link | Diagnosis is clinical/historical; no pathognomonic sign in brief FM station |
| Depression | Psychomotor retardation / flat affect | Observe during consultation: reduced eye contact, slow speech, blunted affect | Supports depression as a contributing factor |
Top Traps That Lose Marks
- Forgetting to ask about medications — drug-induced weight gain is a classic masquerade and an easy CRF mark. Five drug classes: antidepressants, antipsychotics, DM meds, glucocorticoids, anticonvulsants [4].
- Not screening for depression — depression is both a cause (comfort eating, ↓activity) and a consequence (body image distress) of weight gain. Missing it loses both DDx and biopsychosocial marks.
- Assuming obesity = simple obesity without asking about endocrine symptoms — always screen for hypothyroidism, Cushing, PCOS.
- Confusing fluid retention with fat gain — ask about oedema, SOB, ascites to avoid missing HF/nephrotic syndrome/cirrhosis.
- Not quantifying the weight gain — "How much?" and "Over how long?" are essential for CRF HPI.
- Ignoring ICE — ICE is heavily weighted. If you don't ask, you can't write it.
- Writing "overweight" instead of a proper diagnosis — write "Primary/simple obesity" or the specific secondary cause.
Must-not-miss red flags → urgent referral:
- Rapid weight gain + purple striae + proximal weakness → Cushing syndrome → refer endocrinology
- Weight gain + bradycardia + hypothermia + confusion → myxoedema → emergency
- Weight gain + headache + visual field defect → pituitary tumour → urgent MRI + referral
- Leg swelling + SOB → heart failure / nephrotic syndrome → urgent workup
Safety-net closing line: 「如果你喺覆診之前有任何唔舒服，例如好攰、心口痛、氣喘、或者情緒好差，記得即刻返嚟或者去急症。」
High Yield Summary
What to ASK: Quantify gain (kg, duration); appetite (↑/↓/same); diet & activity; thyroid Sx; Cushing Sx; menstrual Hx (PCOS); medications (5 drug classes); mood/sleep; OSA; DM Sx; ICE + hidden agenda.
What to WRITE: CC = "Weight gain of X kg over Y months." Most likely Dx = Primary obesity (if no secondary features). DDx = Hypothyroidism / Drug-induced / Depression. Biopsychosocial = metabolic risk / body image distress / social/occupational impact. Physical sign = ↑BMI + ↑waist circumference.
What NOT to MISS: Drug causes, depression, hypothyroidism, Cushing, PCOS, fluid retention masquerading as weight gain. Always ask ICE.
Active Recall - Family Medicine Clinical Test
[1] GC 063. I am losing weight and sweating all the time.pdf (thyroid symptoms and weight change); Block A - I am losing weight and sweating all the time_ causes of severe, weight loss; thyrotoxicosis; hypothyroidism.pdf [2] MBBS Final MB (Medicine) (Felix PY Lai).pdf p.1560 (hypothyroidism signs and symptoms); MBBS Final MB (Pediatrics) (Felix PY Lai).pdf p.664 (endocrine causes of short stature/weight gain) [3] Block A - I have fluctuating BP_ cushing syndrome; adrenal diseases and tumours; other endocrine tumours.pdf p.14 (Cushing clinical features); Ryan Ho Chemical Path.pdf p.29-30 (diagnosis of Cushing syndrome) [4] Block A - I am overweight, doctor_ obesity; Hyperlipidaemia.pdf p.8 (drugs causing weight gain, endocrine secondary causes) [5] Ryan Ho Endocrine.pdf p.116 (BMI Asian cut-offs, waist circumference, metabolic syndrome); Block A - I am overweight, doctor_ obesity; Hyperlipidaemia.pdf p.4 (waist circumference Chinese values) [6] MBBS Final MB (Medicine) (Felix PY Lai).pdf p.1541 (GH deficiency → weight gain, ↑fat mass/↓lean body mass)
Vulvar Irritation Or Dermatitis
Vulvar irritation or dermatitis is an inflammatory condition of the vulvar skin caused by contact irritants, allergens, or underlying dermatoses, presenting with erythema, pruritus, and discomfort.
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.