Rapid changes in weight over a few days suggest changes in body fluids not tissues

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In the overweight patient, for example, when did the weight gain begin? Was the patient heavy as an infant or a child? Using milestones appropriate to the patient's age, inquire about weight at the following times: birth, kindergarten, high school or college graduation, discharge from military service, marriage, after each pregnancy, menopause, and retirement. What were the patient's life circumstances during the periods of weight gain? Has the patient tried to lose weight? How? With what results?

Weight loss is an important symptom that has many causes. Mechanisms include one or more of the following: decreased intake of food for reasons such as anorexia, dysphagia, vomiting, and insufficient supplies of food; defective absorption of nutrients through the gastrointestinal tract; increased metabolic requirements; and loss of nutrients through the urine, feces, or injured skin. A person may also lose weight when a fluid-retaining state improves or responds to treatment.

Causes of weight loss include: gastrointestinal diseases, endocrine disorders (diabetes mellitus, hyperthyroidism, adrenal insufficiency), chronic infections; malignancy; chronic cardiac, pulmonary, or renal failure; depression; and anorexia nervosa or bulimia (see Table 3-6, Eating Disorders and Excessively Low BMI, p._).

Try to determine if the drop in weight is proportional to any change in food intake, or whether it has remained normal or even increased.

Weight loss with relatively high food intake suggests diabetes mellitus, hyperthyroidism, or malabsorption. Consider also binge eating (bulimia) with clandestine vomiting.

Symptoms associated with weight loss often suggest a cause, as does a good Poverty, old age, social isolation, psychosocial history. Who cooks and shops for the patient? Where does the patient eat? With whom? Are there any problems with obtaining, storing, preparing, or chewing food? Does the patient avoid or restrict certain foods for medical, religious, or other reasons?

physical disability, emotional or mental impairment, lack of teeth, ill-fitting dentures, alcoholism, and drug abuse increase the likelihood of malnutrition.

Throughout the history, be alert for signs of malnutrition. Symptoms may be subtle and nonspecific, such as weakness, easy fatigability, cold intolerance, flaky dermatitis, and ankle swelling. Securing a good history of eating patterns and quantities is mandatory. It is important to ask general questions about intake at different times throughout the day, such as "Tell e what you typically eat for lunch." "What do you eat for a snack?" When?"

See Table 3-4, Nutrition Screening Checklist, p._.

fatigue and Weakness. Like weight loss, fatigue is a relatively non-Lecific symptom with many causes. It refers to a sense of weariness or loss of energy that patients describe in various ways. "I don't feel like getting up in the morning" ... "I don't have any energy" ... "I just feel blah". . . . "I'm all done in" ... "I can hardly get through the day" . . . "By the time I get to the office I feel as if I've done a day's work." Because fatigue is a normal response to hard work, sustained stress, or grief, try to elicit the life cir-

Fatigue is a common symptom of depression and anxiety states, but also consider infections (such as hepatitis, infectious mononucleosis, and tuberculosis); endocrine disorders (hypothyroidism, adrenal insufficiency, diabetes mellitus, cumstances in which it occurs. When fatigue is unrelated to such situations, further investigation is needed.

panhypopituitarism); heart failure; chronic disease of the lungs, kidneys, or liver; electrolyte imbalance; moderate to severe anemia; malignancies; nutritional deficits; medications.

Use open-ended questions to explore the attributes of the patient's fatigue, and encourage the patient to fully describe what he or she is experiencing. Important clues about etiology are often found in a good psychosocial history, exploration of sleep patterns, and a thorough review of systems.

Infants and children cannot describe fatigue verbally, so inquire about any changes in behavior, such as withdrawal from normal activities, irritability, loss of interest in their surroundings, and excessive sleeping.

Weakness is different from fatigue. It denotes a demonstrable loss of muscle power and will be discussed later with other neurologic symptoms (see pp.__-_).

Fever and Chills. Fever refers to an abnormal elevation in body temperature (see p._for definitions of normal). Ask about fever if patients have an acute or chronic illness. Find out whether the patient has used a thermometer to measure the temperature. (Errors in technique can lead to unreliable information.) Has the patient felt feverish or unusually hot, noted excessive sweating, or felt chilly and cold? Try to distinguish between subjective chilliness and a shaking chill, with shivering throughout the body and chattering of teeth.

Weakness, especially if localized in a neuroanatomic pattern, suggests possible neuropathy or myopathy.

Recurrent shaking chills suggest more extreme swings in temperature and systemic bacteremia.

Feeling cold, goosebumps, and shivering accompany a rising temperature, while feeling hot and sweating accompany a falling temperature. Normally the body temperature rises during the day and falls during the night. When fever exaggerates this swing, night sweats occur. Malaise, headache, and pain in the muscles and joints often accompany fever.

Fev er has many causes. Focus your questions on the timing of the illness and its associated symptoms. Become familiar with patterns of infectious ^diseases that may affect your patient. Inquire about travel, contact with sick persons, or other unusual exposures. Be sure to inquire about medications, since they may cause fever. In contrast, recent ingestion of aspirin, aceta-{minophen, corticosteroids, and nonsteroidal anti-inflammatory drugs may mask it and affect the temperature recorded at the time of the physical examination.

Feelings of heat and sweating also accompany menopause. Night sweats occur in tuberculosis and malignancy.

Important Topics for Health Promotion and Counseling

■ Optimal weight and nutrition

■ Blood pressure and diet

Optimal Weight and Nutrition. Less than half of U.S. adults maintain a healthy weight (BMI >19 but <25). Obesity has increased in every segment of the population, regardless of age, gender, income, ethnicity, or socioeconomic group. More than half of people with non-insulin-dependent diabetes and roughly 20% of those with hypertension or elevated cholesterol are overweight or obese. Increasing obesity in children has been linked to rising rates of childhood diabetes. Once excess weight or unhealthy nutritional patterns are detected, take advantage of the excellent materials available to promote weight loss and good nutrition. Even reducing weight by 5% to 10% can improve blood pressure, lipid levels, and glucose tolerance and reduce the risk of developing diabetes or hypertension.

Once you have assessed food intake and nutritional status and the patient's motivation to change eating behaviors, you are ready to begin health counseling. First, explain the components of a healthy diet and encourage patients to select appropriately sized servings from each of the five major food groups: grains such as bread, cereal, rice, and pasta; fruits; vegetables; dairy products; and meat and beans. Be prepared to help adolescents and adults over age 50 identify foods rich in calcium. Advise pregnant women to increase intake of iron and folic acid, and older adults to increase intake of vitamin D.

See Table 3-2, Healthy Eating: Food Groups and Servings per Day, p._, and Table 3-5. Food Guide

See Table 3-7, Nutrition Counseling: Sources of Nutrients, p._.

Exercise. Fitness is a key component of both weight control and weight loss. Currently, 30 minutes of moderate activity, defined as walking 2 miles in 30 minutes on most days of the week or its equivalent, is recommended. Patients can increase exercise by such simple measures as parking further away aom their place of work or using stairs instead of elevators. A safe goal for eight loss is 12 to 2 pounds per week.

Blood Pressure and Diet. With respect to blood pressure, there is "diable evidence that regular and frequent exercise, decreased sodium itake and increased potassium intake, and maintaining a healthy weight rill reduce risk of developing hypertension as well as lower blood pressure adults who are already hypertensive. Explain to patients that most of the sodium in our diet comes from salt (sodium chloride). Inform your patients that the recommended daily allowance (RDA) of sodium is

See Table 3-8, Patients With Hypertension: Recommended Changes in Diet, p._.

<2400 mg, or 1 teaspoon, per day. Patients need to read food labels closely, especially the Nutrition Facts panel. Low sodium foods are those with sodium listed at less than 5% of the RDA of <2400 mg. For nutritional interventions to reduce risk of cardiac disease, turn to pp.___and pp.__.

Preview: Recording the Physical Examination— The General Survey and Vital Signs

Your write-up of the physical examination begins with a general description of the patient's appearance, based on the General Survey. Note that initially you may use sentences to describe your findings; later you will use phrases. The style below contains phrases appropriate for most write-ups. Unfamiliar terms are explained in the next section, "Techniques of Examination." Choose vivid and graphic adjectives, as if you are painting a picture in words. Avoid cliches such as "well-developed" or "well-nourished" or "in no acute distress," since they could apply to any patient and do not convey the special features of the patient before you. Record the vital signs taken at the time of your examination. They are preferable to those taken earlier in the day by other providers. (Common abbreviations for blood pressure, heart rate, and respiratory rate are self-explanatory.)

"Mrs. Scott is a young, healthy-appearing woman, well-groomed, fit, and in good spirits. Height is 5'4", weight 135 lbs, BP 120/80, HR 72 and regular, RR 16, temperature 37.5°C." OR:

"Mr. Jones is an elderly male who looks pale and chronically ill. He is alert, with good eye contact but unable to speak more than two or three words at a time due to shortness of breath. He has intercostal muscle retraction when breathing and sits upright in bed. He is thin, with diffuse muscle wasting. Height is 6'2", weight 175 lbs, BP 160/95, HR 108 and irregular, RR 32 and labored, temperature 101.2°F."

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