Makindo Medical Notes

🩺 OSCE Station – Unintentional Weight Loss

Candidate Instructions 📋

You are a final-year medical student in the GP clinic. A 68-year-old patient presents with unexplained weight loss. Take a focused history, screen for red flags, and outline possible differentials and initial management. You do not need to perform an examination. You have 8 minutes.

Key OSCE Learning Points 🔑

• Weight loss = unintended loss of ≥5% body weight over 6–12 months.
• Broad differential: malignancy, endocrine, gastrointestinal, infection, psychiatric, social.
• Always ask about systemic “B” symptoms (fever, night sweats, lymphadenopathy).
• Screen for red flags → NICE 2-week wait cancer referral. ⚠️

History to Cover 📝

• Onset & Duration: When did the weight loss begin? How much? Over what period?
• Associated Symptoms:
  • GI: dyspepsia, dysphagia, diarrhoea, blood in stool, change in bowel habit.
  • Respiratory: cough, haemoptysis, dyspnoea.
  • Systemic: fevers, night sweats, fatigue, pruritus.
  • Endocrine: polyuria, polydipsia, heat/cold intolerance, tremor.
• Psychiatric: low mood, anhedonia, poor appetite, stress.
• Social: diet, access to food, alcohol, smoking, recent bereavement, social isolation.
• Past Medical History: TB, HIV, diabetes, thyroid disease, IBD, malignancy.
• Medication History: Metformin, SSRIs, chemotherapy, appetite suppressants.
• Family History: Malignancy, thyroid disease, diabetes.

Examiner Prompts 👩‍⚕️

• Patient has lost 1 stone (~6 kg) over 3 months without trying.
• No fevers, sweats, or haemoptysis.
• Reports early satiety and occasional upper abdominal discomfort.
• No change in bowel habit.
• Past history: hypertension only. Non-smoker, moderate alcohol use.

Differential Diagnosis ⚖️

• Malignancy: gastric, pancreatic, bowel, lung, lymphoma.
• Endocrine: diabetes mellitus, hyperthyroidism, Addison’s disease.
• GI: malabsorption (coeliac disease, IBD, chronic pancreatitis).
• Infective: TB, HIV, chronic hepatitis.
• Psychiatric: depression, anorexia nervosa, dementia.
• Social: poverty, neglect, alcoholism.

Investigations 🔬

• Bloods: FBC (anaemia), U&E, LFTs, calcium, CRP/ESR, TFTs, HbA1c, coeliac screen.
• Infective screen: HIV, hepatitis serology, TB if risk factors.
• Cancer screening: FIT test (bowel), PSA (men if appropriate). Tumour markers (CEA, CA19-9) not first-line but may aid follow-up.
• Imaging: Chest X-ray (lung malignancy, TB), abdominal ultrasound/CT if red flags or persistent unexplained weight loss.
• Endoscopy: OGD/colonoscopy if GI red flag symptoms (dysphagia, melaena, PR bleeding, iron-deficiency anaemia).

🧑‍⚕️ Case Examples — Adult Unintentional Weight Loss

• Case 1 (Malignancy — Pancreatic cancer): 🎗️ A 64-year-old man reports 3-month history of weight loss, anorexia, and pale greasy stools. He has painless jaundice and a palpable, non-tender gallbladder (Courvoisier’s sign). CT abdomen shows a pancreatic head mass. Diagnosis: Pancreatic carcinoma with malabsorption. Teaching point: Always consider GI malignancy in older patients with unexplained weight loss.
• Case 2 (Endocrine — Hyperthyroidism): 🦋 A 35-year-old woman presents with anxiety, palpitations, heat intolerance, and 6 kg weight loss despite increased appetite. Exam shows goitre and fine tremor. TFTs: suppressed TSH, raised free T4. Diagnosis: Graves’ disease. Teaching point: Weight loss with hyperphagia suggests thyrotoxicosis; look for systemic features (tachycardia, eye signs).
• Case 3 (Infective — Tuberculosis): 🦠 A 40-year-old migrant presents with cough, night sweats, and 8 kg weight loss over 2 months. CXR shows apical cavitating lesions; sputum is Ziehl–Neelsen positive. Diagnosis: Pulmonary tuberculosis. Teaching point: Chronic infection with systemic features (fever, sweats, weight loss) is a red flag for TB.
• Case 4 (Psychiatric — Depression): 🧠 A 52-year-old man reports poor appetite, insomnia, and 10 kg weight loss over 4 months. He describes low mood, anhedonia, and hopelessness. Diagnosis: Major depressive disorder. Teaching point: Mood disorders are a common but often overlooked cause of weight loss in adults; always screen for depression.
• Case 5 (Gastrointestinal — Coeliac disease): 🌾 A 28-year-old woman presents with chronic diarrhoea, bloating, and 7 kg weight loss. Labs show iron-deficiency anaemia. Coeliac serology is positive, and duodenal biopsy confirms villous atrophy. Diagnosis: Coeliac disease. Teaching point: In young adults, malabsorption (especially coeliac) should be considered in unexplained weight loss with anaemia.