What is the initial workup for a 68-year-old female presenting with weakness and loss of appetite?

Initial Workup for a 68-Year-Old Female with Weakness and Loss of Appetite

The initial workup for a 68-year-old female presenting with weakness and loss of appetite should include a complete blood count, comprehensive metabolic panel, thyroid function tests, urinalysis, and age-appropriate cancer screening tests to identify the underlying cause.

Primary Assessment Components

Laboratory Tests

• Complete blood count (CBC) to evaluate for anemia, infection, or malignancy 1
• Comprehensive metabolic panel including:
  • Electrolytes, liver enzymes, and renal function tests 1
  • Blood glucose to rule out diabetes
  • Albumin to assess nutritional status
• Thyroid function tests (TSH) to rule out thyroid disorders 2
• C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to assess for inflammation 2
• Ferritin and iron studies to evaluate for iron deficiency anemia 1
• Vitamin B12 and folate levels to rule out deficiencies that can cause weakness 3, 4
• Lactate dehydrogenase (LDH) measurement 2
• Protein electrophoresis to screen for multiple myeloma 2
• Urinalysis to screen for infection or renal disease 2

Diagnostic Tests

• Chest radiography to screen for pulmonary pathology including malignancy 2
• Fecal occult blood test to screen for gastrointestinal bleeding 2
• Electrocardiogram (ECG) if cardiac symptoms are present 1
• Abdominal CT with contrast if gastrointestinal pathology is suspected 1

Specific Considerations for This Patient

Evaluate for Common Causes of Weakness and Appetite Loss in Elderly

1. Malignancy (accounts for up to one-third of cases of unintentional weight loss) 2

   • Focus on lung and gastrointestinal malignancies
   • Consider appropriate cancer screenings based on age and risk factors

2. Medication-related causes 2

   • Review current medications for those that may cause:
     • Nausea and vomiting
     • Dysgeusia (altered taste)
     • Anorexia
   • Assess for polypharmacy (multiple medications that may interact)

3. Nutritional deficiencies 1, 3

   • Vitamin B12 deficiency (can present with weakness, especially in elderly)
   • Iron deficiency anemia
   • Consider pernicious anemia (particularly with neurological symptoms)

4. Endocrine disorders

   • Thyroid dysfunction
   • Adrenal insufficiency
   • Diabetes mellitus

5. Cardiac disorders 5

   • Heart failure
   • Coronary artery disease

6. Gastrointestinal disorders 5

   • Malabsorption syndromes
   • Celiac disease
   • Inflammatory bowel disease
   • H. pylori infection 1

7. Psychiatric disorders 5

   • Depression (leading cause of involuntary weight loss in elderly)
   • Anxiety
   • Cognitive impairment

8. Social factors 2

   • Isolation
   • Financial constraints affecting food access
   • Ability to prepare meals

Management Approach

1. Treat identified underlying causes 2

   • Direct treatment at specific diagnoses found during workup

2. Nutritional support if malnutrition is present 1

   • Consider oral nutritional supplements if oral intake is inadequate
   • Texture-adapted food if dysphagia is present
   • Consider protein-enriched familiar foods and drinks

3. For frail elderly patients 1

   • Recommend 1.2-1.5 g protein/kg/day if malnourished or at risk
   • Consider physical activity recommendations to maintain muscle mass
   • Individualized resistance exercise to maintain muscle strength

4. If appetite stimulation is needed 6

   • Consider short-term corticosteroids (1-3 weeks) with awareness of side effects
   • Progestins (megestrol acetate) may be considered with awareness of thromboembolism risk

Potential Pitfalls to Avoid

• Failing to screen for reversible causes of appetite loss 6
• Overlooking medication side effects as potential causes 2
• Implementing restrictive diets that may worsen nutritional status 6
• Continuing ineffective treatments without reassessment 6
• Missing rare but serious causes such as parvovirus infection in immunocompromised patients 7

If initial evaluation is unremarkable, a three- to six-month observation period with appropriate follow-up is recommended 2.