Comprehensive Workup for Weakness in an 86-Year-Old Female in the Emergency Room
A thorough workup for an 86-year-old female presenting with weakness in the Emergency Room should include a systematic evaluation of cardiovascular, neurological, metabolic, and functional causes, with special attention to common geriatric syndromes.
Initial Assessment
History
- Characterize the weakness:
- Generalized vs. focal
- Acute vs. gradual onset
- Associated symptoms (fever, pain, dyspnea, falls)
- Recent medication changes
- Recent falls or trauma
Physical Examination
- Vital signs with orthostatic measurements
- Complete neurological examination including:
- Mental status assessment using validated tools
- Muscle strength testing using Medical Research Council (MRC) scale
- Cranial nerve examination
- Sensory testing
- Coordination and gait assessment
- Cardiovascular examination
- Respiratory examination
- Abdominal examination
- Skin examination for signs of infection or pressure injuries
Diagnostic Testing
Laboratory Tests
- Complete blood count (CBC)
- Comprehensive metabolic panel (CMP)
- Thyroid function tests
- Inflammatory markers (ESR, CRP)
- Cardiac biomarkers (troponin)
- Urinalysis
- Blood cultures if febrile
Imaging and Other Studies
- 12-lead ECG
- Chest X-ray
- Consider neuroimaging (CT or MRI brain) if:
- Focal neurological deficits
- Altered mental status
- Rapid progression of symptoms 1
- Consider additional testing based on initial findings:
- EMG/nerve conduction studies if peripheral neuropathy suspected 1
- Echocardiogram if cardiac etiology suspected
Common Causes of Weakness in Elderly Patients
Cardiovascular Causes
- Orthostatic hypotension
- Acute coronary syndrome
- Arrhythmias
- Heart failure exacerbation
Neurological Causes
- Stroke or TIA
- Parkinson's disease
- Myopathy or neuropathy
- Normal pressure hydrocephalus
Metabolic/Systemic Causes
- Dehydration
- Electrolyte abnormalities
- Infection (UTI, pneumonia)
- Medication side effects
- Anemia
- Thyroid disorders
- Malnutrition
Functional Causes
- Deconditioning
- Frailty
- Sarcopenia
Special Considerations for Geriatric Patients
Delirium Assessment
- Screen for delirium using validated tools
- Evaluate for underlying causes if present 2
Medication Review
- Review all medications, especially:
- Anticholinergics
- Benzodiazepines
- Antipsychotics
- Opioids 1
Functional Assessment
- "Get up and go test" to assess mobility
- Evaluate need for assistive devices
- Screen for fall risk 2
Management Approach
- Stabilize acute medical conditions
- Address reversible causes (electrolyte abnormalities, medication effects)
- Consider early physical therapy consultation
- Assess need for admission vs. safe discharge
- Arrange appropriate follow-up
Pitfalls to Avoid
- Attributing weakness solely to age: Weakness is not a normal part of aging and requires thorough investigation
- Missing occult infections: Elderly patients may not present with typical signs of infection
- Overlooking medication side effects: Always review medication list thoroughly
- Inadequate functional assessment: Failure to assess baseline and current functional status
- Incomplete neurological examination: Subtle neurological deficits may be missed without thorough examination
By following this systematic approach, emergency physicians can effectively evaluate and manage weakness in elderly patients, improving outcomes and quality of life 1, 2.