What is the appropriate workup for a 71-year-old female presenting to the emergency department with decreased appetite, dysgeusia (impaired taste), hot flashes, cold extremities, bloating, and nausea, who denies dyspnea or chest pain?

Emergency Department Workup for a 71-Year-Old Female with Decreased Appetite and Multiple Nonspecific Symptoms

The emergency department workup for this 71-year-old female with decreased appetite, dysgeusia, hot flashes, cold extremities, bloating, and nausea should include a 12-lead ECG, basic laboratory tests (CBC, BMP, cardiac biomarkers), and chest X-ray as the initial diagnostic approach, with additional targeted testing based on these findings. 1

Initial Assessment and Vital Signs

• Complete set of vital signs (temperature, blood pressure, heart rate, respiratory rate, oxygen saturation)
• Focused physical examination with attention to:
  • Cardiovascular system: Heart sounds, peripheral pulses, signs of perfusion
  • Abdominal examination: Tenderness, distention, hepatomegaly
  • Skin assessment: Color, temperature (especially of extremities)
  • Hydration status

First-Line Diagnostic Tests

Cardiac Evaluation

• 12-lead ECG within 10 minutes of arrival 1
  • Look for ST-segment changes, T-wave inversions, or other abnormalities
• Cardiac biomarkers (troponin, preferably high-sensitivity) 1
  • Consider serial measurements (0,3,6 hours) if initial result is negative but clinical suspicion remains high

Basic Laboratory Tests

• Complete blood count (CBC)
  • To assess for anemia, infection, or other hematologic abnormalities
• Basic metabolic panel (BMP)
  • To evaluate electrolyte imbalances, renal function
• Liver function tests 2
  • Particularly important given the patient's GI symptoms and decreased appetite
• Thyroid function tests
  • Hot flashes and GI symptoms could suggest thyroid dysfunction

Imaging

• Chest X-ray 1
  • To evaluate for pulmonary causes of symptoms or cardiac enlargement
• Consider point-of-care ultrasonography (POCUS) 1
  • Can rapidly assess for cardiac function, pericardial effusion, or abdominal pathology

Second-Line Tests Based on Initial Findings

If Cardiac Etiology Suspected

• Echocardiography 1
  • Particularly if ECG abnormalities or elevated cardiac biomarkers are present
• Additional cardiac biomarkers (BNP/NT-proBNP) 1
  • Especially if heart failure is suspected

If Gastrointestinal Etiology Suspected

• Abdominal ultrasound
  • To evaluate for gallbladder disease, liver abnormalities
• Amylase/lipase
  • To assess for pancreatitis

If Metabolic/Endocrine Etiology Suspected

• Comprehensive metabolic panel
• HbA1c (if diabetes suspected)
• Additional thyroid studies if initial tests are abnormal

Differential Diagnosis Considerations

1. Cardiac conditions 1

   • Non-ST elevation myocardial infarction (women often present with atypical symptoms)
   • Heart failure (can present with nausea, decreased appetite)

2. Gastrointestinal disorders

   • Gastritis/peptic ulcer disease
   • Gallbladder disease
   • Pancreatitis
   • Gastroesophageal reflux disease

3. Endocrine disorders

   • Thyroid dysfunction (particularly hyperthyroidism with hot flashes)
   • Adrenal insufficiency

4. Medication effects

   • Review current medications for potential side effects

Important Pitfalls to Avoid

• Do not dismiss atypical presentations in elderly women 3

  • Older women frequently present with non-classic symptoms of serious conditions like ACS
  • Nausea and decreased appetite may be the only presenting symptoms of cardiac ischemia

• Do not rely on response to nitroglycerin as a diagnostic test 3

  • Relief with nitroglycerin does not confirm cardiac etiology
  • Non-cardiac conditions like esophageal spasm may also respond to nitroglycerin

• Do not delay ECG and cardiac biomarker testing

  • Even in the absence of chest pain, cardiac causes must be ruled out in elderly patients with vague symptoms

• Do not overlook thyroid dysfunction

  • Hot flashes, GI symptoms, and appetite changes are classic presentations

Follow-up Testing

Based on initial test results, consider:

• CT abdomen/pelvis if abdominal pathology suspected
• Stress testing if cardiac ischemia suspected but initial tests are negative
• Endoscopy if significant GI symptoms persist without clear cause

By following this systematic approach, you can efficiently evaluate this patient's concerning but nonspecific symptoms while ensuring that potentially life-threatening conditions are not missed.