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symptom.weight-loss.v1PRODUCTION
symptom.weight-loss.v1

Unintentional weight loss (outpatient symptom triage)

symptomchronicsubacuteundifferentiatedadultgeriatricpediatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Document ≥5% unintentional body weight loss over 6 mo (or ≥10 lb) — Marton 1981 PMID 24450891 anchor; baseline weight + serial weights; BMI calculation; rule out intentional loss

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Advance rule
Set
Advance when

Unintentional ≥5% / 6 mo confirmed + BMI documented

Patient inputs (38)

B12 (NEJM 2013 PMID 22106456) — neuro-psych deficiency; folate; iron studies (ferritin, transferrin, saturation); guides malabsorption workup

Age shifts priors: pediatric → FTT; adult → infection / GI / endocrine / psychiatric / malignancy; elderly (≥65) → malignancy / geriatric FTT / medication; new WL >50 raises malignancy prior (Marton 1981; Hernandez 2003)

Sex shifts cancer priors (prostate vs ovarian / breast); eating-disorder prevalence higher in young women; alcohol use higher in men

GLP-1 agonist, SGLT2i, metformin, methylphenidate, levothyroxine excess, topiramate, bupropion, sertraline, amphetamine, chemotherapy → drug-induced; deprescribe or substitute (Wong 2014; geriatric weight loss 2018 PMID 30025927)

Alcohol use disorder + stimulant (cocaine, methamphetamine) → substance-induced; functional decline; rule out withdrawal complications (DTs, Wernicke); thiamine before glucose if alcohol use

Hyperthyroidism (Graves, toxic nodule, thyroiditis); uncontrolled DM (T1DM, T2DM with polyuria/polydipsia); adrenal insufficiency (orthostasis, hyperpigmentation, fatigue); hyperparathyroidism (Ca >10.5)

Advanced HFrEF → cardiac cachexia; COPD → pulmonary cachexia; advanced CKD → uremic anorexia; routing to disease-specific engine

HIV risk (sexual, IDU); TB endemic exposure / family contact; chronic infection screen (HBV, HCV, syphilis); route id.hiv-initial.chronic.v1 if HIV+

Family hx CRC / breast / ovarian / prostate / pancreatic → earlier screening; smoking → lung; alcohol → hepatic / pancreatic / oral; HBV/HCV → HCC

PHQ-9 ≥10 (depression screen); Geriatric Depression Scale (GDS) for ≥65 — high prior for depression as cause of WL (~20%)

Anorexia (reduced appetite) suggests systemic illness, cancer cachexia, depression, geriatric FTT; early satiety suggests gastric malignancy, gastroparesis

GI symptoms guide workup: dysphagia → EGD/barium swallow; steatorrhea → fecal elastase; chronic diarrhea → celiac / IBD / SIBO; abdominal pain → CT abdomen / pancreatitis

B-symptoms (fever, drenching night sweats, ≥10% WL) → lymphoma; TB; HIV (NEJM B12 2013 PMID 22106456 alone NOT a marker — but combined screen)

PHQ-9 ≥10 + anhedonia + sleep / energy disturbance → depression (~20% of unintentional WL; route psych.depression.core.v1)

Document current weight; calculate % loss from baseline (≥5% over 6 mo or ≥10 lb defines unintentional WL); serial weights for trajectory

BMI calculation; identify low-BMI threshold for refeeding-syndrome risk (BMI <14 or BMI <16 + rapid loss); pediatric percentile growth chart

Unintentional ≥5% over 6 mo OR ≥10 lb in 6 mo is the operational threshold (Marton 1981 PMID 24450891 — anchor); rapid loss >15% in 6 mo raises malignancy + organic disease prior

Anemia (iron-deficiency → GI workup; macrocytic → B12/folate; pancytopenia → marrow failure / lymphoma); leukocytosis (infection); lymphocytosis (lymphoma / pertussis / CLL)

Glucose (DM screen); electrolytes (hyponatremia → SIADH / Addison; hyperkalemia → Addison / CKD); BUN/Cr (uremia); calcium (hyperPTH, malignancy); phosphorus (refeeding-syndrome screen if BMI <14)

LFT (hepatic disease, malignancy, alcohol); albumin (chronic malnutrition / inflammation); prealbumin (acute nutritional status); hypoalbuminemia <3.0 → severe malnutrition / inflammation

TSH (suppressed → hyperthyroid screen → severe → route endo.thyroid-storm.core.v1; elevated → hypothyroid — paradoxical WL rare but possible)

HbA1c ≥6.5% or fasting glucose ≥126 → DM screen (route endo.dm2.core.v1); type-stratify (T1DM in young + DKA-prone)

CRP / ESR — inflammatory screen (IBD, vasculitis, malignancy, infection); ESR >100 nonspecific but raises concern for malignancy / infection / vasculitis

Universal HIV screening (CDC, USPSTF) — route id.hiv-initial.chronic.v1 if positive; B-symptoms + risk factors → priority screen

UA — hematuria (renal malignancy); proteinuria (renal disease, paraprotein cast nephropathy); glucose (DM)

CXR — lung mass, TB, COPD emphysematous changes, HF (cardiomegaly, congestion); first-line lung screen; raises lung-cancer prior in smoker + WL

Hypoglycemia + AMS + hypotension + severe anemia (Hb <7) + tachycardia + dehydration → ED for stabilization; refeeding-syndrome risk if BMI <14 or rapid loss >15%

Tissue-transglutaminase IgA + total IgA — celiac screen if iron-deficiency, B12 deficiency, hypoalbuminemia, diarrhea; positive → confirm with EGD biopsy

Fecal elastase <200 µg/g → exocrine pancreatic insufficiency (chronic pancreatitis); fecal calprotectin (IBD screen); stool studies + occult blood

Adrenal insufficiency (Addison) — low morning cortisol (<5 µg/dL) + elevated ACTH; orthostasis + hyperkalemia + hyponatremia + hyperpigmentation + fatigue

SPEP / UPEP / sFLC — monoclonal gammopathy (multiple myeloma, MGUS); especially if anemia, hypercalcemia, renal failure, bone pain (CRAB criteria)

CT C/A/P — occult malignancy (lung, GI, pancreas, lymphoma, renal, hepatic, ovarian); use in age >50 + alarm features + workup-negative; alternative low-dose lung CT for smokers per USPSTF

Colonoscopy (CRC) + EGD (gastric, esophageal, celiac biopsy) — age >50 OR alarm features (iron-deficiency anemia, hematochezia, dysphagia, melena); risk-stratified

Mammogram (USPSTF: 50-74 q2y or 40-74 individualized) — breast cancer screen in WL workup for women

TTE — reduced EF → cardiac cachexia (route cardio.hfref.core.v1); valvular disease; pericardial effusion (malignancy, TB)

Oral / dental disease, ill-fitting dentures, dysphagia, odynophagia → mechanical PO; ENT / GI / dental referral; barium swallow if dysphagia

Social isolation + food insecurity + socioeconomic stress → particularly in elderly; geriatrics.frailty-polypharmacy.core.v1 routing; social work referral

TB IGRA / Quantiferon — endemic exposure, B-symptoms, chronic cough; co-route to TB engine if positive + clinical suspicion

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningrefeeding_syndrome_risk_bmi_under_14_rapid_loss
    BMI <14 OR rapid WL >15% in 6 mo OR severe eating disorder + low BMI — refeeding-syndrome risk; inpatient + slow refeeding (10-20 kcal/kg/d initial); phosphorus + Mg + thiamine repletion BEFORE caloric load
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsevere_thyrotoxicosis_hyperthyroid_storm
    WL + heat intolerance + tachycardia + AF + high-output HF + AMS + T >38.5°C — severe thyrotoxicosis / impending thyroid storm; route endo.thyroid-storm.core.v1
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsevere_depression_with_suicidal_ideation
    WL + PHQ-9 ≥20 + active suicidal ideation with plan OR severe psychotic depression — emergent psychiatric admission; route psych.depression.core.v1
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningeating_disorder_cardiac_instability
    WL + restrictive eating / binge-purge + BMI <16 + cardiac instability (HR <40, QTc >500, K <2.5, Mg <1.5, orthostasis) — eating disorder with medical instability; admit + multidisciplinary team
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremalignancy_red_flag_features
    Unintentional WL + age >50 + ANY alarm feature (iron-deficiency anemia, hematochezia, dysphagia, persistent abdominal pain, palpable mass, B-symptoms, family hx CRC, smoker, alcohol use, HBV/HCV) — malignancy workup STAT (Marton 1981 PMID 24450891; Hernandez 2003)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverenew_dm_with_dka_or_severe_hyperglycemia
    WL + polyuria + polydipsia + glucose >300 + ketones + acidosis OR new T1DM presentation — DKA; route endo.dka.core.v1; new T2DM with severe hyperglycemia → endo.dm2.core.v1
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecardiac_cachexia_advanced_hf
    WL + advanced HFrEF (EF <30 + functional class III-IV) + diuretic dependence + nutritional decline — cardiac cachexia; route cardio.hfref.core.v1 + GDMT + nutritional support
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehiv_chronic_infection_tb_wl
    WL + B-symptoms + risk factors (sexual, IDU, endemic) + lymphadenopathy + chronic cough — HIV / TB / chronic infection; HIV positive → route id.hiv-initial.chronic.v1; TB positive → public health + RIPE + airborne isolation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderategeriatric_failure_to_thrive_severe
    Elderly (≥65) + significant WL + functional decline + decreased social engagement + cognitive decline + polypharmacy — geriatric FTT; route geriatrics.frailty-polypharmacy.core.v1; comprehensive geriatric assessment; deprescribing review; nutritional + psychosocial support
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateckd_uremic_anorexia_advanced
    WL + advanced CKD (eGFR <30) + uremic symptoms (nausea, anorexia, pruritus, restless legs) — uremic anorexia; route neph.ckd.core.v1 + dietary phosphorus + protein modulation + dialysis planning
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

outpatient playbook — drug actions (12)

  1. 1. lifestyle (caloric supplementation + oral nutrition supplements + swallowing assessment)
    Target 30-35 kcal/kg/d for replenishment; oral nutrition supplements (Ensure, Boost) 1-3 servings/d; high-protein diet (1.2-1.5 g/kg/d) • PO • daily
    trigger: All unintentional WL with no severe comorbidity
    First-line; dietitian referral; addresses caloric deficit and prevents cachexia progression
  2. 2. deprescribe offending medications
    N/A • N/A • one-time + monitor
    trigger: Medication-induced WL pattern + recent (within 6 mo) new med
    GLP-1 agonist, SGLT2i (slow loss expected); metformin (mild loss); methylphenidate (significant loss); levothyroxine excess; topiramate; bupropion; substitute with appetite-neutral alternatives
  3. 3. mirtazapine (for depression-induced WL + insomnia)
    15-30 mg PO at bedtime • PO • daily
    trigger: Depression + WL + insomnia phenotype (route psych.depression.core.v1 for full eval)
    Mirtazapine has appetite-stimulating effect; useful when depression + insomnia + WL co-occur; sertraline more standard SSRI but may cause GI side effects + WL
  4. 4. methimazole (for hyperthyroidism)
    5-30 mg PO daily • PO • daily
    trigger: Hyperthyroidism (TSH <0.1 + T4/T3 elevated) — route endo.thyroid-storm.core.v1 if severe
    First-line antithyroid; cautious in pregnancy (PTU preferred in T1); RAI / surgery for definitive
  5. 5. pancreatic enzyme replacement (for EPI)
    Pancrelipase 25,000-75,000 USP lipase units with meals • PO • with each meal + snack
    trigger: Exocrine pancreatic insufficiency (fecal elastase <200 + chronic pancreatitis / cystic fibrosis / pancreatic cancer)
    Replaces deficient enzymes; weight gain + steatorrhea improvement expected
  6. 6. gluten-free diet (for celiac)
    Strict gluten-free diet — multidisciplinary • PO • lifelong
    trigger: Celiac disease (TTG-IgA positive + EGD biopsy confirms villous atrophy)
    Symptom resolution + weight gain over 6-12 mo; long-term DEXA monitoring
  7. 7. IBD-directed therapy (route gi.crohns / gi.ulcerative-colitis)
    Per IBD engine (mesalamine, biologics — infliximab, vedolizumab) • PO / IV / SC • per protocol
    trigger: Crohn / UC with weight loss
    Address active disease; route to IBD engine; nutritional support adjunct
  8. 8. megestrol acetate (appetite stimulant)
    400-800 mg PO daily • PO • daily
    trigger: Severe anorexia + cachexia (especially HIV / cancer) failing nutritional support
    Low-grade evidence; thromboembolism risk; AVOID in CHF, history of VTE, advanced age; use cautiously
  9. 9. dronabinol (cannabinoid appetite stimulant)
    2.5-10 mg PO BID • PO • BID
    trigger: HIV / cancer-related anorexia failing other strategies
    Synthetic THC; tolerability issues in elderly (CNS effects); approved for AIDS-related anorexia
  10. 10. antiretroviral therapy (ART) for HIV
    Per id.hiv-initial.chronic.v1 • PO • daily
    trigger: Confirmed HIV infection
    Route to HIV engine; ART suppresses viral load + restores immune function + reverses cachexia
  11. 11. GDMT + diuresis adjustment + nutritional support for cardiac cachexia
    Per cardio.hfref.core.v1 • PO + IV • per protocol
    trigger: HFrEF with cachexia
    GDMT (β-blocker, ACE-I/ARNI, MRA, SGLT2i); cardiac cachexia is poor prognostic marker
  12. 12. CGA + deprescribing for geriatric FTT (route geriatrics.frailty-polypharmacy)
    Per geriatrics.frailty-polypharmacy.core.v1 • multimodal • ongoing
    trigger: Elderly + functional decline + WL + decreased social engagement
    CGA; deprescribe high-burden medications; address social determinants; nutritional counseling; advance directives

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Documented ≥5% body weight loss over 6 mo + no clear cause + age >50 + family hx OR alarm features (anemia, B-symptoms, new pain, mass, hematochezia) — malignancy dominant (~30% of unintentional WL >5%; lung / GI / pancreas / lymphoma / renal / hepatic top etiologies — Marton 1981, Wong 2014, Hernandez 2003); Weight loss + anhedonia / depressed mood / appetite loss / functional impairment / sleep disturbance + PHQ-9 ≥10 — depression / anxiety / substance use (~20% of unintentional WL; route psych.depression.core.v1); WL + diarrhea / steatorrhea / abdominal pain / iron-deficiency / B12 deficiency / hypoalbuminemia — GI malabsorption (celiac, IBD — route gi.crohns/UC, chronic pancreatitis with EPI, SIBO); evaluate with TTG-IgA, fecal calprotectin, fecal elastase, stool studies.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Unintentional weight loss (outpatient symptom triage)** (symptom.weight-loss.v1).
Phenotype framing: Malignancy (~30%) — lung / GI / pancreas / lymphoma / renal / hepatic / ovarian / prostate; Psychiatric (~20%) — depression / anxiety / substance / eating disorder; GI malabsorption (~15%) — celiac, IBD, EPI, SIBO; Endocrine (~10%) — hyperthyroid, DM, adrenal, hyperPTH; Infection (~5%) — HIV, TB, occult; Cardiac/Pulmonary/Renal cachexia (~5%); Medication / substance (~5%); Geriatric FTT (~5% — elderly); Eating disorder (variable); Undiagnosed (~5-10% self-resolve or chronic — Marton 1981; Wong 2014)
Scope: Document ≥5% unintentional body weight loss over 6 mo (or ≥10 lb) — Marton 1981 PMID 24450891 anchor; baseline weight + serial weights; BMI calculation; rule out intentional loss

No severity triggers fired against current inputs.

Plan

No regimen axis selected (engine has no regimen_axes or could not match).

Setting playbook (outpatient) — Pattern-anchored unintentional weight loss triage (≥5% over 6 mo): cause stratification across malignancy (~30%) / psychiatric (~20%) / GI malabsorption / endocrine / infection / cardiac-pulmonary-renal cachexia / medication-induced / substance / eating disorder / geriatric FTT / pediatric FTT; targeted Tier 1 → Tier 2 workup; route to disease-specific engine; address cause (deprescribe, SSRI, thyroid tx, ART, GDMT, biofeedback for eating disorder, CGA for geriatric FTT)
1. lifestyle (caloric supplementation + oral nutrition supplements + swallowing assessment) Target 30-35 kcal/kg/d for replenishment; oral nutrition supplements (Ensure, Boost) 1-3 servings/d; high-protein diet (1.2-1.5 g/kg/d) PO daily — All unintentional WL with no severe comorbidity (First-line; dietitian referral; addresses caloric deficit and prevents cachexia progression)
2. deprescribe offending medications N/A N/A one-time + monitor — Medication-induced WL pattern + recent (within 6 mo) new med (GLP-1 agonist, SGLT2i (slow loss expected); metformin (mild loss); methylphenidate (significant loss); levothyroxine excess; topiramate; bupropion; substitute with appetite-neutral alternatives)
3. mirtazapine (for depression-induced WL + insomnia) 15-30 mg PO at bedtime PO daily — Depression + WL + insomnia phenotype (route psych.depression.core.v1 for full eval) (Mirtazapine has appetite-stimulating effect; useful when depression + insomnia + WL co-occur; sertraline more standard SSRI but may cause GI side effects + WL)
4. methimazole (for hyperthyroidism) 5-30 mg PO daily PO daily — Hyperthyroidism (TSH <0.1 + T4/T3 elevated) — route endo.thyroid-storm.core.v1 if severe (First-line antithyroid; cautious in pregnancy (PTU preferred in T1); RAI / surgery for definitive)
5. pancreatic enzyme replacement (for EPI) Pancrelipase 25,000-75,000 USP lipase units with meals PO with each meal + snack — Exocrine pancreatic insufficiency (fecal elastase <200 + chronic pancreatitis / cystic fibrosis / pancreatic cancer) (Replaces deficient enzymes; weight gain + steatorrhea improvement expected)
6. gluten-free diet (for celiac) Strict gluten-free diet — multidisciplinary PO lifelong — Celiac disease (TTG-IgA positive + EGD biopsy confirms villous atrophy) (Symptom resolution + weight gain over 6-12 mo; long-term DEXA monitoring)
7. IBD-directed therapy (route gi.crohns / gi.ulcerative-colitis) Per IBD engine (mesalamine, biologics — infliximab, vedolizumab) PO / IV / SC per protocol — Crohn / UC with weight loss (Address active disease; route to IBD engine; nutritional support adjunct)
8. megestrol acetate (appetite stimulant) 400-800 mg PO daily PO daily — Severe anorexia + cachexia (especially HIV / cancer) failing nutritional support (Low-grade evidence; thromboembolism risk; AVOID in CHF, history of VTE, advanced age; use cautiously)
9. dronabinol (cannabinoid appetite stimulant) 2.5-10 mg PO BID PO BID — HIV / cancer-related anorexia failing other strategies (Synthetic THC; tolerability issues in elderly (CNS effects); approved for AIDS-related anorexia)
10. antiretroviral therapy (ART) for HIV Per id.hiv-initial.chronic.v1 PO daily — Confirmed HIV infection (Route to HIV engine; ART suppresses viral load + restores immune function + reverses cachexia)
11. GDMT + diuresis adjustment + nutritional support for cardiac cachexia Per cardio.hfref.core.v1 PO + IV per protocol — HFrEF with cachexia (GDMT (β-blocker, ACE-I/ARNI, MRA, SGLT2i); cardiac cachexia is poor prognostic marker)
12. CGA + deprescribing for geriatric FTT (route geriatrics.frailty-polypharmacy) Per geriatrics.frailty-polypharmacy.core.v1 multimodal ongoing — Elderly + functional decline + WL + decreased social engagement (CGA; deprescribe high-burden medications; address social determinants; nutritional counseling; advance directives)

Non-pharmacologic actions:
- Dietitian referral — caloric supplementation + protein optimization + swallowing assessment (especially elderly + dysphagia)
- Social work referral — food insecurity, isolation, housing, financial stressors
- Psychiatry referral — depression, anxiety, eating disorder, substance use
- Specialty referrals: GI (malabsorption, IBD, dysphagia), endocrine (refractory hyperthyroid / adrenal / hyperPTH), oncology (suspected malignancy), cardiology (HFrEF cachexia), pulmonology (COPD cachexia), nephrology (uremic anorexia)
- Eating-disorder multidisciplinary team if anorexia / bulimia
- Hospice / palliative care consult for terminal disease
- Smoking cessation counseling
- Alcohol detox + counseling (thiamine before glucose if heavy use → Wernicke prevention)
- Comprehensive geriatric assessment + deprescribing if ≥65

Monitoring

Setting (outpatient) monitoring:
- Serial weights weekly initially → monthly; trajectory documented
- BMI + body composition assessment q3 mo
- CBC + BMP + albumin + prealbumin at 1-3 mo (trend nutritional status)
- PHQ-9 trend if depression-treated (4-6 wk after SSRI initiation)
- TSH 6 wk after thyroid therapy adjustment
- HbA1c 3 mo after DM therapy
- Cancer screening result + downstream routing
- Symptom diary: appetite, GI symptoms, fatigue, mood
- Geriatric CGA q3-6 mo if ≥65
- Eating-disorder labs (K, Mg, phosphate, transferrin) if BMI <18.5

Follow-up plan: Lifestyle counseling (caloric supplementation, oral nutrition supplements, swallowing assessment); deprescribing review; chronic disease optimization; cancer screening intervals; psych follow-up (CBT, SSRI); eating-disorder multidisciplinary; geriatric long-term planning (advance directives, GOC); pediatric NASPGHAN FTT pathway
- Close-out criterion: Long-term plan documented + follow-up scheduled

Monitoring phase: Serial weights monthly until trajectory established; repeat CBC + BMP + albumin / prealbumin at 1-3 mo; depression response to SSRI at 4-6 wk + PHQ-9 trend; TSH at 6 wk after thyroid therapy; HbA1c at 3 mo after DM tx; colonoscopy result follow-up; CT findings follow-up; geriatric CGA reassessment q3-6 mo

Disposition

Current setting: outpatient — Pattern-anchored unintentional weight loss triage (≥5% over 6 mo): cause stratification across malignancy (~30%) / psychiatric (~20%) / GI malabsorption / endocrine / infection / cardiac-pulmonary-renal cachexia / medication-induced / substance / eating disorder / geriatric FTT / pediatric FTT; targeted Tier 1 → Tier 2 workup; route to disease-specific engine; address cause (deprescribe, SSRI, thyroid tx, ART, GDMT, biofeedback for eating disorder, CGA for geriatric FTT)

Disposition criteria:
- Home (most): stepwise outpatient workup + lifestyle counseling + return precautions
- Outpatient subspecialty: GI / endocrine / onc / psych / cardiology / pulmonology / nephrology / dietitian / eating-disorder specialist / geriatric team
- ED: severe anemia, hypoglycemia, hypotension, dehydration, BMI <14 / refeeding-syndrome risk, severe thyrotoxicosis, DKA, suicidal ideation, eating-disorder cardiac instability
- Inpatient: severe malnutrition with slow refeeding, severe electrolyte derangement, eating disorder with medical instability, geriatric FTT failing outpatient
- Hospice / palliative care: terminal malignancy or end-stage organ disease with goals-of-care aligned

Escalation triggers (move to higher acuity):
- Severe anemia (Hb <7) + symptomatic → ED for transfusion + workup
- Hypoglycemia + AMS + hypotension → ED for D50 + IVF + stabilization
- BMI <14 or rapid loss >15% in 6 mo → ED for refeeding-syndrome prevention + inpatient slow refeeding (phosphorus + Mg + thiamine before food)
- Severe thyrotoxicosis (T >38.5 + AF + AMS + HF) → route endo.thyroid-storm.core.v1 + ED
- New DKA in T1DM (glucose >300 + ketones + acidosis) → route endo.dka.core.v1
- New malignancy on imaging or labs → oncology referral STAT
- Severe depression + suicidal ideation → ED for psychiatric eval + safety plan
- Eating disorder + cardiac instability (HR <40, QTc >500, K <2.5) → ED + medical stabilization
- Active TB on testing → public health reporting + airborne precautions + ID + RIPE
- Severe geriatric FTT failing outpatient → inpatient eval + GOC discussion
- Acute decompensated HF (cardiac cachexia) → route cardio.acute-hf.core.v1 + ED

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] BMI <14 OR rapid WL >15% in 6 mo OR severe eating disorder + low BMI — refeeding-syndrome risk; inpatient + slow refeeding (10-20 kcal/kg/d initial); phosphorus + Mg + thiamine repletion BEFORE caloric load
- [LIFE_THREATENING] WL + heat intolerance + tachycardia + AF + high-output HF + AMS + T >38.5°C — severe thyrotoxicosis / impending thyroid storm; route endo.thyroid-storm.core.v1
- [LIFE_THREATENING] WL + PHQ-9 ≥20 + active suicidal ideation with plan OR severe psychotic depression — emergent psychiatric admission; route psych.depression.core.v1

Citations

- 1981 Marton (PMID 24450891 — verify), 2014 Wong unintentional WL, 2003 Hernandez evaluation, 2013 NEJM B12 (PMID 22106456), 2018 geriatric weight loss (PMID 30025927 — verify), 2011 Fearon cachexia mechanisms (PMID 25060842 — verify), 2014 Anorexia of Aging (PMID 22072542 — verify) + USPSTF cancer screening + Camaschella NEJM IDA 2015 (PMID 32513860) [PMID:24450891](https://pubmed.ncbi.nlm.nih.gov/24450891/)
- Cited evidence (PMID 32513860) [PMID:32513860](https://pubmed.ncbi.nlm.nih.gov/32513860/)
- Cited evidence (PMID 22072542) [PMID:22072542](https://pubmed.ncbi.nlm.nih.gov/22072542/)
- Cited evidence (PMID 22106456) [PMID:22106456](https://pubmed.ncbi.nlm.nih.gov/22106456/)
- Cited evidence (PMID 30025927) [PMID:30025927](https://pubmed.ncbi.nlm.nih.gov/30025927/)

Last reconciled with current guidelines: 2026-05-14.
References
  • 1981 Marton (PMID 24450891 — verify), 2014 Wong unintentional WL, 2003 Hernandez evaluation, 2013 NEJM B12 (PMID 22106456), 2018 geriatric weight loss (PMID 30025927 — verify), 2011 Fearon cachexia mechanisms (PMID 25060842 — verify), 2014 Anorexia of Aging (PMID 22072542 — verify) + USPSTF cancer screening + Camaschella NEJM IDA 2015 (PMID 32513860) — PMID:24450891
  • Cited evidence (PMID 32513860) — PMID:32513860
  • Cited evidence (PMID 22072542) — PMID:22072542
  • Cited evidence (PMID 22106456) — PMID:22106456
  • Cited evidence (PMID 30025927) — PMID:30025927