Operational Medicine 2001
Weight Loss

Weight loss can be intentional or unintentional.  Intentional weight loss is usually because of dieting, exercise, or both. Intense exercise in the heat can produce significant dehydration with obvious weight loss.  This section will focus on unintentional weight loss.  

Weight loss is significant if it represents > 5-10% of the patient’s weight.  Several items come to mind: a tumor (particularly lymphomas, which are common in young adults), a chronic infection (such as tuberculosis), or thyroiditis.  These conditions are all diagnosable, treatable, and potentially fatal.  Other conditions that can result in weight loss include diabetes mellitus, malabsorbtion, and depression (resulting in anorexia).

History

The history is extremely important.  You must inquire about other concerning symptoms (“B” symptoms: malaise, fatigue, anorexia, and drenching night sweats).  

• “B” symptoms suggest either a malignancy or a chronic infection.  

• Persistent, productive sputum suggests either a lung abscess or tuberculosis.  

• A lung abscess can be seen in those with a history of heavy alcohol ingestion (even binge drinking).  

• Diabetes mellitus, either newly diagnosed (“juvenile”, or insulin-dependent) or chronic and now poorly controlled (non-insulin-dependent, as seen in older, overweight adults) may manifest as weight loss, but anorexia is not seen.  In fact, diabetics have polydipsia, polyphagia, and, consequently, polyuria.  

• Patients with an overactive thyroid may complain of tachycardia, weakness, hyperthermia, sweats, tremor, and diarrhea.  

• Chronic diarrhea should suggest malabsorbtion.  

• Depressed patients may have anorexia and anhedonia (literally, an absence of hedonism, that is, a lack of pleasure from previously enjoyable activities/hobbies). 

Physical Exam

Hyperthyroidism often presents with:

• Tachycardia

• Hyperthermia

• Tremors

• Unusually active bowel sounds

• Rapid deep tendon reflexes

• Abnormal thyroid

A patient with lymphoma may have nontender peripheral lymphadenopathy.  

Productive sputum suggests a lung abscess or TB; fetid breath and poor oral hygiene suggests the former; auscultation of the lungs may reveal abnormalities.  

Signs of wasting are nonspecific, but may be evident: lack of muscle mass, absence of subcutaneous fat.  

Observe the patient’s affect and mood; if significant depression, ask about suicidal intent (desire, plan, feasibility). 

Labs

If possible:

• CBC w/ differential

• ESR (Erythrocyte Sedimentation Rate)

• TFTs

• CMP

• PPD

• Chest X-ray

• Sputum studies (AFB, Gram stain and culture).

• Stool studies as available (O&P, fecal fat stains).

Plan

Treatment is supportive until definitive care is available; reassurance is important.  Activities are as tolerated.  Excessive “B” symptoms may require earlier referral.  One-on-one observation is indicated if the patient is felt to be actively suicidal.

Medevac: The work-up requires referral to a medical center; this referral should be prompt but need not necessarily interrupt the mission.  Your clinical savvy, the patient’s general condition, and your current mission will influence this decision.  A patient with suspected TB should wear a surgical mask (or have a cloth tied around their face) to minimize the spread of respiratory droplets; covering the mouth when coughing is also very useful.  These maneuvers are appropriate even if the patient has TB and is placed on an aerovac.  If the patient cannot wear a mask, the health care provider(s) should.

This section provided by: CDR Wesley Emmons, MC, USNR, Head, Infectious Diseases, Naval Medical Center, Portsmouth VA

Approved for public release; Distribution is unlimited.

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Operational Medicine 2001
Health Care in Military Settings

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