Mock Patient Scripts: Loss of Appetite (Anorexia)
Loss of appetite, or anorexia, can be a subtle yet significant clue to a wide range of medical and psychological conditions. From common causes like depression to life-threatening diseases such as pancreatic cancer, a structured interview and physical exam are essential in narrowing the diagnosis. This article presents 3 educational mock cases to help you build clinical reasoning and English interview skills for patients presenting with anorexia.
Case 1: Standard Case – “I just haven’t felt like eating lately.”
- Age/Gender: 45-year-old female
- Chief Complaint: Loss of appetite for the past few weeks
- Vital Signs: T 36.5°C / HR 76 / BP 118/70 / RR 14 / SpO₂ 98%
She reports that she hasn’t had much of an appetite for about three weeks and came in today because her coworkers were worried about her recent weight loss and low energy.
🗣️ Structured History
Opening:
“I don’t really know what’s wrong—I just haven’t felt like eating lately.”
Onset & Course:
“It started a few weeks ago. I didn’t think much of it at first, but I’ve barely eaten anything this past week.”
Associated Symptoms:
“I feel tired all the time, and I’ve been sleeping more than usual. I also feel kind of numb… not exactly sad, but not myself either.”
Mood / Function / Appetite / Sleep:
“I’ve lost interest in things I used to enjoy. I haven’t been seeing friends much, and I just want to stay in bed. I sleep over 10 hours a day, but still wake up tired.”
Medical History / Medication:
“Nothing major. Just seasonal allergies. No regular medications.”
Family & Social History (PAM HITS FOSS):
- Previous & Past Medical History: Allergic rhinitis
- Allergy: Pollen
- Medications: None regularly
- Hospitalization / Injury / Trauma / Surgery: None
- Family History: Mother had depression in her 50s
- OBGYN: Regular periods, no pregnancies
- Sexual History: No current partner
- Social History: Office worker, lives alone, doesn’t smoke or drink
Concerns & Questions:
“I’m not sure if this is just stress, or something more serious. Could this be a medical issue?”
🩺 Physical Examination
- General: Appears fatigued but cooperative
- HEENT: No oral ulcers, mucosa moist
- Neck: No lymphadenopathy or goiter
- Cardiovascular: Normal S1/S2, no murmurs
- Respiratory: Clear breath sounds bilaterally
- Abdomen: Soft, non-tender, no hepatosplenomegaly
- Neuro: Alert and oriented ×3, no focal deficits
- Mental status: Blunted affect, mild psychomotor retardation
🧠 Differential Diagnosis
Most likely diagnosis: Major depressive disorder (MDD)
- Supporting points: Anhedonia, hypersomnia, psychomotor slowing, family history, low mood, social withdrawal, appetite loss
- Contradictory points: Denies sadness explicitly (masked presentation)
2nd: Hypothyroidism
- Supporting: Fatigue, weight gain possible, low energy
- Against: No goiter, no cold intolerance, regular menstruation
3rd: GI malignancy
- Supporting: Anorexia, fatigue
- Against: No abdominal symptoms, normal exam, no red flags
🪞 Clinical Reflection
At first glance, this seemed like nonspecific fatigue, but the constellation of symptoms—loss of interest, social withdrawal, family history, and psychomotor changes—strongly suggest masked depression. Even in the absence of overt low mood, it’s important to probe deeper when appetite is affected.
💡 Clinical Pearls
- Loss of appetite can be the first sign of a depressive episode, especially in patients who lack emotional vocabulary.
- Always screen for neurovegetative symptoms: sleep, appetite, energy, concentration, mood.
- Patients with masked depression may present only with somatic symptoms like fatigue or GI discomfort.
- Consider the social context—living alone and work stress can exacerbate mental health issues.
❓ Challenging Questions
Q: “Do I need to take antidepressants?”
A: “That’s one possible option, but not the only one. We’ll first do some blood tests to rule out other causes. If it turns out to be depression, we can discuss both medication and non-medication approaches. You’ll be part of the decision every step of the way.”
Q: “Is this going to get worse?”
A: “It’s possible if left untreated, but many people recover well with support and care. The fact that you came in today is already a strong step forward. We’ll monitor you closely and adjust the plan as we go.”
📝 SOAP Note
S: 45-year-old female presents with 3-week history of appetite loss, fatigue, and social withdrawal. Denies sadness but describes loss of interest and hypersomnia. No GI or systemic complaints. O: T 36.5°C, HR 76, BP 118/70. Physical exam shows blunted affect and mild psychomotor slowing. No focal findings. A: # Loss of appetite with fatigue and social withdrawal # Anhedonia, hypersomnia, mild psychomotor retardation # Family history of depression ddx): Major depressive disorder, hypothyroidism, GI malignancy r/o): GI cause (no red flags), acute infection (no fever or labs), thyroid disease (to be tested) → Given the neurovegetative symptoms and history, masked depression is most likely. Will proceed with screening labs and consider referral for psychiatric evaluation. P: - CBC, TSH, CMP to rule out organic causes - PHQ-9 screening - Discuss trial of CBT or SSRIs if confirmed - Arrange follow-up within 1 week
Case 2: Challenging Case – “I’m eating less and less, but I don’t know why.”
- Age/Gender: 63-year-old male
- Chief Complaint: Unexplained loss of appetite and weight
- Vital Signs: T 36.8°C / HR 84 / BP 132/76 / RR 16 / SpO₂ 97%
He came to clinic after realizing he’s been eating significantly less over the past month, and his daughter noticed he had lost weight and looked “weaker.”
🗣️ Structured History
Opening:
“I haven’t really felt hungry lately. Food just doesn’t seem appealing.”
Onset & Course:
“It’s been going on for about a month. I first thought it was stress or maybe age, but it’s been getting worse.”
Associated Symptoms:
“I feel tired all the time, and I sometimes have this dull ache in my upper belly. No nausea or vomiting, though. I’ve also noticed more constipation lately.”
Mood / Function / Appetite / Sleep:
“I’m not depressed or anything. I still go for walks, but I get tired easily. I’ve lost about 4–5 kg without trying.”
Medical History / Medication:
“High blood pressure, controlled with amlodipine. Recently diagnosed with type 2 diabetes six months ago.”
Family & Social History (PAM HITS FOSS):
- Previous & Past Medical History: Hypertension, newly diagnosed diabetes
- Allergy: None
- Medications: Amlodipine 5mg daily
- Hospitalization / Injury / Trauma / Surgery: Appendectomy in his 30s
- Family History: Father died of stomach cancer
- OBGYN: N/A
- Sexual History: Heterosexual, married
- Social History: Retired teacher, non-smoker, occasional wine
Concerns & Questions:
“I’m worried something might be seriously wrong. I don’t usually lose weight like this.”
🩺 Physical Examination
- General: Mildly cachectic, alert and oriented
- HEENT: Pale conjunctiva, no lymphadenopathy
- Chest: Clear breath sounds bilaterally
- Cardiovascular: Normal heart sounds
- Abdomen: Mild epigastric tenderness, no palpable mass, no hepatosplenomegaly
- Neuro: Normal strength and sensation
🧠 Differential Diagnosis
Most likely diagnosis: Pancreatic cancer (tail)
- Supporting points: Unexplained anorexia and weight loss, new-onset diabetes, epigastric discomfort, family history of GI malignancy
- Contradictory points: No jaundice, no steatorrhea, no palpable mass
2nd: Gastric cancer
- Supporting: Weight loss, early satiety, epigastric pain, family history
- Against: No melena or hematemesis, pain not worsened by meals
3rd: Functional dyspepsia
- Supporting: Mild epigastric discomfort, no alarming features at surface level
- Against: Age >60, weight loss, systemic signs → not benign
🪞 Clinical Reflection
Any patient over 60 with new-onset diabetes, weight loss, and vague GI symptoms deserves a careful workup. Pancreatic cancer often presents insidiously, especially if located in the tail. Anchoring on benign causes could delay critical diagnosis.
💡 Clinical Pearls
- Always consider malignancy in elderly patients with weight loss and anorexia.
- Pancreatic tail tumors are less likely to cause jaundice, making them harder to catch early.
- New-onset diabetes in older adults can be a paraneoplastic sign.
- Don’t be reassured by absence of pain or jaundice—systemic signs matter more.
❓ Challenging Questions
Q: “Could this be cancer?”
A: “That is one of the possibilities we need to consider seriously. Your symptoms and recent weight loss raise concern, so we’ll do imaging and blood work to find out more. If it is cancer, catching it early improves your options.”
Q: “What kind of tests will I need?”
A: “We’ll start with some blood tests and a detailed abdominal scan, like a CT. Depending on what we find, we might need further evaluation. You’ll be informed at each step.”
📝 SOAP Note
S: 63-year-old male presents with 1-month history of decreased appetite and 5 kg unintentional weight loss. Mild epigastric discomfort and fatigue. No overt GI bleeding. Recent diabetes diagnosis. O: T 36.8°C, HR 84, BP 132/76. Mild epigastric tenderness. Cachectic appearance. No mass or jaundice. A: # Unexplained anorexia and weight loss # Recent-onset diabetes and GI symptoms # Concern for malignancy ddx): Pancreatic cancer, gastric cancer, functional dyspepsia r/o): Functional dyspepsia (age + systemic features), viral illness (subacute, no fever) → Given age, new-onset diabetes, weight loss, and GI discomfort, pancreatic cancer is a top concern. Prompt imaging and malignancy screening are warranted. P: - Abdominal CT with contrast - CBC, LFTs, tumor markers (CA 19-9) - Refer to gastroenterology - Nutritional counseling, hydration support - Follow-up in 3–5 days or sooner if condition worsens
Case 3: Interesting Case – “I just don’t have an appetite after COVID.”
- Age/Gender: 28-year-old female
- Chief Complaint: Persistent loss of appetite since COVID infection
- Vital Signs: T 36.9°C / HR 78 / BP 112/68 / RR 14 / SpO₂ 99%
She recovered from COVID-19 about 2 months ago but has had ongoing fatigue and appetite loss since then. Her family encouraged her to get checked.
🗣️ Structured History
Opening:
“I got over COVID a while back, but I still don’t feel like eating… it’s just weird.”
Onset & Course:
“It started after I tested negative. I thought it would go away, but I still feel off—especially with food.”
Associated Symptoms:
“Mostly fatigue and no appetite. I also have some brain fog and occasional headaches, but no fever or cough anymore.”
Mood / Function / Appetite / Sleep:
“I’m sleeping okay, but I wake up tired. I’ve lost about 3 kg, and I force myself to eat. I’ve gone back to work part-time, but I can’t last a full day.”
Medical History / Medication:
“Previously healthy, no chronic conditions. Not on any medication.”
Family & Social History (PAM HITS FOSS):
- Previous & Past Medical History: Mild COVID-19 infection 2 months ago
- Allergy: None
- Medications: None
- Hospitalization / Injury / Trauma / Surgery: None
- Family History: Mother has hypothyroidism
- OBGYN: Regular cycles
- Sexual History: Heterosexual, in a relationship
- Social History: Works in marketing, lives with roommate, non-smoker
Concerns & Questions:
“I’m just tired of feeling like this. Is this still from COVID? Will I ever feel normal again?”
🩺 Physical Examination
- General: Thin but well-nourished appearance, somewhat fatigued
- HEENT: Normal, no pallor or dehydration
- Neck: No lymphadenopathy or thyroid enlargement
- Cardiovascular: Normal S1/S2
- Respiratory: Clear lungs, normal effort
- Abdomen: Soft, non-tender, no organomegaly
- Neuro: Alert, mild slowed response but no focal deficits
🧠 Differential Diagnosis
Most likely diagnosis: Post-COVID syndrome (Long COVID)
- Supporting points: Recent COVID infection, persistent fatigue, appetite loss, cognitive symptoms, no other findings
- Contradictory points: None apparent
2nd: Subclinical hypothyroidism
- Supporting: Fatigue, weight loss, family history
- Against: No cold intolerance, no menstrual changes, normal exam
3rd: Adjustment disorder or depression
- Supporting: Anorexia, fatigue, post-illness stress
- Against: Denies low mood or loss of pleasure, actively working
🪞 Clinical Reflection
This case shows how subtle and persistent post-viral symptoms can be, especially in young healthy patients. Long COVID should be considered in any patient with unexplained fatigue and anorexia following recent infection, especially when labs and physical exams are unremarkable.
💡 Clinical Pearls
- Loss of appetite may be part of the fatigue and dysregulation seen in post-viral syndromes.
- Always screen for red flags like weight loss, fever, or localizing symptoms to rule out organic disease.
- Validation and reassurance are key—patients with Long COVID often feel dismissed.
- Functional recovery plans (e.g., graded activity) can help more than medications.
❓ Challenging Questions
Q: “Is Long COVID even real?”
A: “Yes, it’s increasingly recognized by medical professionals around the world. Many people continue to have symptoms after the acute phase. It’s not in your head—we believe you and we’ll work on a recovery plan together.”
Q: “Do I need to see a specialist?”
A: “That depends on how things evolve. Right now, we’ll run some basic labs to rule out other causes. If symptoms persist or worsen, we can involve a post-COVID care clinic or specialists as needed.”
📝 SOAP Note
S: 28-year-old woman with ongoing anorexia and fatigue 2 months after recovering from COVID-19. Reports brain fog and occasional headaches. No systemic or localizing symptoms. O: T 36.9°C, HR 78, BP 112/68. Physical exam: mild fatigue, otherwise normal. No focal deficits. A: # Persistent appetite loss post-COVID # Fatigue, mild cognitive complaints # No signs of systemic disease ddx): Post-COVID syndrome, hypothyroidism, adjustment disorder r/o): Major depression (no anhedonia), infection (no fever), GI causes (no pain or diarrhea) → Likely post-COVID syndrome given recent infection and persistent mild symptoms. Will monitor closely and support functional recovery. P: - CBC, TSH, CMP to rule out medical causes - Educate patient on Long COVID and expected course - Encourage pacing and activity regulation - Follow-up in 2 weeks
📚 Related Articles
🔍 References
- Mayo Clinic. Loss of Appetite: Symptoms and Causes
- NIH Post-COVID Conditions. https://www.nhlbi.nih.gov/covid
- BMJ 2020;370:m3489. “Management of post-acute COVID-19 in primary care.”
- Uptodate: Approach to the adult patient with fatigue and anorexia
📘 Recommended Resources
- First Aid for the USMLE Step 2 CS – High-yield patient encounter strategies
- OET Preparation Guide – Occupational English Test for Healthcare Professionals
- ティアニー先生の臨床推論入門（日本語）– Clinical reasoning for generalists
- ダ・ヴィンチのカルテ – 99 real-world diagnostic cases