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History taking
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Unintentional Weight Loss History Taking – OSCE Guide

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Taking a comprehensive history of unintentional weight loss is an important skill often assessed in OSCEs. This guide provides a structured framework for taking a history from a patient with unintentional weight loss in an OSCE setting.

Download the unintentional weight loss history taking PDF OSCE checklist, or use our interactive OSCE checklist.

Background

Weight loss is a common symptom experienced by patients in both primary and secondary care settings. Unintentional weight loss is a phenomenon in which an individual unintentionally experiences a significant reduction in body weight.

The degree of weight loss is often between 5% – 10% of the total body weight and typically occurs within the preceding 3 to 12 months.1

Changes in body weight directly reflect homeostatic changes that depend on several factors, such as food, physical activity, environmental exposures, and hormonal control.2 We often intentionally or unintentionally modify these factors, resulting in a change in body weight that patients do not typically find alarming.

However, an unintentional change in body weight can be a concerning sign of an underlying medical condition and requires careful investigation not to miss a serious cause.

For this reason, unintentional weight loss often requires more urgent specialist review and features as a red-flag symptom in several NICE urgent suspected cancer referral pathways.

Understanding the potential causes and conducting a comprehensive assessment is essential in ruling out more serious causes of weight loss.3 Although this article only covers history taking, a full patient assessment will always include a focused physical examination guided by the history.

Differentiating between cachexia and weight loss

Cachexia and unintentional weight loss are often seen as the same.

Cachexia is a metabolic condition related to an underlying disease process characterised by muscle tissue loss with or without fat loss. Normal homeostatic and cytokinetic signalling is disrupted in cachexia, while these mechanisms are typically preserved in weight loss.

In short, while all patients with cachexia have unintentional weight loss, not all patients with unintentional weight loss have cachexia.4 

One of the most common causes of cachexia is malignancy. Cancer can trigger an inflammatory response in the body, releasing various cytokines and cortisol, altering the body’s metabolism. The metabolism is then shifted towards catabolic processes, thus increasing muscle breakdown whilst inhibiting anabolic processes such as muscle protein synthesis.

The imbalance in energy homeostasis ultimately leads to unintentional muscle and overall weight loss.

Causes of weight loss

There is a broad range of causes of unintentional weight loss, including medical diseases, psychiatric illnesses, and social factors. These conditions may occur in isolation or in combination.

Causes of weight loss may include:5

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Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient, including your name and role.

Confirm the patient’s name and date of birth.

Explain that you’d like to take a history from the patient.

Gain consent to proceed with history taking.

General communication skills

It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).

Some general communication skills which apply to all patient consultations include:

  • Demonstrating empathy in response to patient cues: both verbal and non-verbal.
  • Active listening: through body language and your verbal responses to what the patient has said.
  • An appropriate level of eye contact throughout the consultation.
  • Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
  • Making sure not to interrupt the patient throughout the consultation.
  • Establishing rapport (e.g. asking the patient how they are and offering them a seat).
  • Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
  • Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint:

  • “What’s brought you in to see me today?”
  • “Tell me about the issues you’ve been experiencing.”

Provide the patient with enough time to answer and avoid interrupting them.

Facilitate the patient to expand on their presenting complaint if required:

  • “Ok, can you tell me more about what’s been going on?”
Open vs closed questions

History taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.

History of presenting complaint

Establish weight loss

The patient’s presenting complaint may not include weight loss. You may only identify weight loss with direct questioning as part of the history:

  • “Have you noticed any weight loss recently?” 

Sometimes, it can be difficult for patients to identify they have lost weight (especially in elderly patients), so try asking in a way that is relatable to their everyday life:

  • “Have you noticed your clothes feeling looser than before?” 
  • “Have you had to change your clothes because they are too big?” 
  • “Have you noticed that you’ve gone down a few notches in your belt?”

Quantify weight loss

If possible, clarify the amount of weight that has been lost:

  • “Do you know how much weight have you lost?”
  • “When did you last weigh yourself?”

Time frame

Establish the relevant time frame in which weight loss has occurred:

  • “How long did it take for you to lose that much weight?”
  • “Do you know when you first started losing weight?”

Appetite

Ask about appetite:

  • “How has your appetite been lately?”
  • “Has your appetite changed at all?”
  • “Has anyone expressed that they are concerned about the amount you are eating?”

Establish caloric intake

Ask about what they eat and how much they eat:

  • “Can you describe your usual eating habits and meal patterns?”
  • “Can you talk me through a typical day of meals?”

Diet and exercise

Establish how much exercise and what kind of exercise they are doing:

  • “Do you exercise regularly?”

Establish whether they are currently on a diet and what type of diet this is (weight gain or weight loss). Weight loss in the context of calorie restriction is far less concerning than weight loss during caloric excess.

  • “Are you currently on a diet?”
  • “Are you trying to lose any weight?”

Associated symptoms

Unintentional weight loss is a non-specific symptom, but it is often associated with other symptoms that point towards an underlying cause (see systemic enquiry section).

It is important to identify any associated symptoms, especially red flag symptoms. 

Red flags in patients with weight loss

In a patient with weight loss, the following red flags should be screened for:

  • Rapid unintentional weight loss over a short period (often noticed incidentally by the patient or others around them)
  • Constitutional/’B’ symptoms including night sweats, lethargy and malaise: “How have your energy levels been recently?”, “Have you noticed any night sweats?
  • Dysphagia (oesophageal/oral malignancy): “Have you had any difficulty swallowing recently?”
  • Melaena or change in bowel habit (gastrointestinal malignancy):“Have you noticed any blood or black tarry stool?”
  • Unresolving cough with or without haemoptysis (lung cancer): “Have you had a persistent cough or any haemoptysis?”

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns, and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.

The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred, and not overly formulaic.

It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.

Ideas

Explore the patient’s ideas about the current issue:

  • “What do you think the problem is?”
  • “What are your thoughts about what is happening?”
  • “It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”

Concerns

Explore the patient’s current concerns:

  • “Is there anything, in particular, that’s worrying you?”
  • “What’s your number one concern regarding this problem at the moment?”
  • “What’s the worst thing you were thinking it might be?”

Expectations

Ask what the patient hopes to gain from the consultation:

  • “What were you hoping I’d be able to do for you today?”
  • “What would ideally need to happen for you to feel today’s consultation was a success?”
  • “What do you think might be the best plan of action?

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.

Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.

Signposting examples

Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”

What you plan to cover next: “Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.”

Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.

Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.

Some examples of symptoms you could screen for in each system include:

  • Systemic: night sweats, fever, fatigue, lumps and bumps
  • Cardiovascular: chest pain, palpitations, ankle swelling
  • Respiratory: shortness of breath, cough, haemoptysis
  • Endocrine: thirst, polyuria, flushing, headache, sweating, neck swelling
  • Rheumatological: joint pains and stiffness, Raynaud’s, rashes, hair loss, mouth ulcers
  • Gastrointestinal: change in bowel habit, vomiting, early satiety, distension, dysphagia, gastrointestinal blood loss (haematemesis, melaena or fresh rectal bleeding)
  • Neurological: persistent headache, motor, sensory or visual disturbances of insidious/subacute/gradual onset

Past medical history

Ask if the patient has any medical conditions: 

  • “Do you have any medical conditions?”
  • “Are you currently seeing a doctor or specialist regularly?”

Ask if the patient has previously undergone any surgery (e.g. gastrointestinal surgery):

  • “Have you ever previously undergone any operations or procedures?”
  • “When was the operation/procedure, and why was it performed?”

If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition, including hospital admissions.

Examples of relevant medical conditions

Relevant medical conditions in the context of unintentional weight loss include:

  • Cancer: particularly cancers of the gastrointestinal tract, pancreas, lung, or haematological malignancies
  • Gastrointestinal disorders: coeliac disease, Crohn’s disease, ulcerative colitis, and chronic pancreatitis can impair nutrient absorption and cause weight loss
  • Endocrine disorders: hyperthyroidism, diabetes, and adrenal insufficiency can alter metabolism and lead to weight loss
  • Chronic infections: HIV/AIDS, tuberculosis, and many other chronic infections can cause weight loss due to increased energy expenditure and decreased appetite
  • Mental health conditions: depression, anxiety, and eating disorders can affect appetite
  • Heart failure: congestive heart failure can result in fluid retention and changes in metabolism, leading to muscle wasting
  • Neurological disorders: Alzheimer’s disease, Parkinson’s disease, and motor neurone disease can affect eating habits and lead to weight loss
  • Autoimmune diseases: rheumatoid arthritis and systemic lupus erythematosus can cause inflammation and lead to weight loss.
  • Liver disease: cirrhosis or hepatitis can affect nutrient metabolism and lead to weight loss.

Allergies

Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:

  • “Are you currently taking any prescribed medications or over-the-counter treatments?”

If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form and route.

Ask the patient if they’re currently experiencing any side effects from their medication:

  • “Have you noticed any side effects from the medication you currently take?”
  • “Do you think your cough started after you began taking any of your current medications?”
Medication examples

Patients may be taking medications to help them lose weight (e.g. orlistat, GLP-1 agonists).

Other medications may cause weight loss as a side effect. These include:

  • Topiramate
  • SGLT2 inhibitors (e.g. dapagliflozin)
  • Fluoxetine
  • Laxatives

Family history

Ask the patient if there is any family history of gastrointestinal conditions (e.g. inflammatory bowel disease) or malignancy. 

  • “Do any of your parents or siblings have any medical conditions?” 

Clarify at what age the disease developed (disease developing at a younger age is more likely to be associated with genetic factors).

If one of the patient’s close relatives are deceased, sensitively determine the age at which they died and the cause of death:

  • “I’m really sorry to hear that, do you mind me asking how old your dad was when he died?”
  • “Do you remember what medical condition was felt to have caused his death?”

Social history

General social context

Explore the patient’s general social context including:

  • the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them (e.g. stairlift)
  • who else the patient lives with and their personal support network
  • what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)
  • if they have any carer input (e.g. twice daily carer visits)

Smoking

Record the patient’s smoking history, including the type and amount of tobacco used.

Calculate the number of ‘pack-years’ the patient has smoked for to determine their cardiovascular risk profile:

  • pack-years = [number of years smoked] x [average number of packs smoked per day]
  • one pack is equal to 20 cigarettes

See our smoking cessation guide for more details.

Smoking is a major risk factor for developing COPD, lung cancer and cardiovascular disease.

Alcohol

Record the frequency, type and volume of alcohol consumed on a weekly basis.

See our alcohol history taking guide for more information.

Excessive alcohol use is associated with malnutrition. 

Recreational drug use

Ask the patient if they use recreational drugs, and if so, determine the type of drugs used and their frequency of use.

Intravenous drug use increases the risk of developing blood-borne infections, including HIV, hepatitis B/C and bacterial infections (e.g. endocarditis).

Travel history

If the patient’s symptoms suggest an infective aetiology, take a travel history to assess exposure risk.

Closing the consultation

Summarise the key points back to the patient.

Ask the patient if they have any questions or concerns that have not been addressed.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.

Reviewer

Dr Bahig Aziz

Geriatric registrar

Eastbourne District General Hospital

References

  1. Wong, C. J. (2014). Involuntary weight loss. Medical Clinics, 98(3), 625-643.
  2. Guyenet, S. J., & Schwartz, M. W. (2012). Regulation of food intake, energy balance, and body fat mass: implications for the pathogenesis and treatment of obesity. The Journal of Clinical Endocrinology & Metabolism, 97(3), 745-755.
  3. BMJ Best Practice. Assessment of unintentional weight loss. 2023. Available from: [LINK]
  4. Evans, W. J., Morley, J. E., Argilés, J., Bales, C., Baracos, V., Guttridge, D., … & Anker, S. D. (2008). Cachexia: a new definition. Clinical nutrition, 27(6), 793-799.
  5. McMinn, J., Steel, C., & Bowman, A. (2011). Investigation and management of unintentional weight loss in older adults. Bmj, 342.

 

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