What is the appropriate workup for an 85-year-old male presenting with fatigue and cough to the office?

Workup for Fatigue and Cough in an 85-Year-Old Male

The appropriate workup for an 85-year-old male presenting with fatigue and cough should include a chest radiograph, spirometry, detailed history focusing on duration of symptoms, and laboratory tests to rule out common causes of these symptoms.

Initial Assessment

History

• Duration of cough: Determine if acute (<3 weeks) or chronic (>8 weeks) 1
• Cough characteristics: Dry or productive, presence of blood, timing (day/night)
• Associated symptoms: Fever, weight loss, night sweats, chest pain, dyspnea
• Medication review: Particularly ACE inhibitors (common cause of chronic cough) 1
• Smoking status: Current, former, or never smoker
• Occupational history: Exposure to irritants or allergens 1
• Past medical history: Focus on cardiac, pulmonary, and malignancy history

Physical Examination

• Vital signs including oxygen saturation
• Upper airway examination (to assess for Upper Airway Cough Syndrome)
• Lung examination (crackles, wheezes, decreased breath sounds)
• Cardiac examination (murmurs, irregular rhythm, signs of heart failure)
• Assessment for peripheral edema

First-Line Investigations

1. Chest radiograph (mandatory) 1

   • To rule out pneumonia, malignancy, heart failure, tuberculosis

2. Spirometry (mandatory) 1

   • To assess for obstructive or restrictive lung disease

3. Basic laboratory tests:

   • Complete blood count (to assess for infection, anemia)
   • Basic metabolic panel (to assess renal function)
   • Thyroid function tests (hypothyroidism can cause fatigue)
   • Inflammatory markers (ESR, CRP)

Further Investigations Based on Initial Findings

If Acute Cough (<3 weeks)

• If otherwise healthy with no concerning features, likely viral and self-limiting 1
• Further investigation indicated if:
  • Hemoptysis
  • Prominent systemic illness
  • Suspicion of foreign body
  • Suspicion of lung cancer 1

If Chronic Cough (>8 weeks)

Consider these common causes and appropriate tests:

1. Upper Airway Cough Syndrome (UACS)

   • Trial of first-generation antihistamine/decongestant combination for 2-4 weeks 2

2. Asthma/Cough Variant Asthma

   • Bronchial provocation testing if spirometry is normal 1
   • Trial of inhaled corticosteroids for 4 weeks 2

3. Gastroesophageal Reflux Disease (GERD)

   • Trial of proton pump inhibitor with lifestyle modifications for 4-8 weeks 2
   • Consider 24-hour esophageal pH monitoring if diagnosis uncertain

4. ACE Inhibitor-Induced Cough

   • Discontinue ACE inhibitor; symptoms may take up to 4 weeks to resolve 1

5. Chronic Bronchitis/COPD

   • Assess smoking history
   • Spirometry to confirm airflow obstruction

For Fatigue Evaluation

• Screen for depression and anxiety
• Assess sleep quality and potential sleep disorders
• Consider anemia workup (CBC, iron studies)
• Evaluate for heart failure (BNP/NT-proBNP, echocardiogram if indicated)
• Consider thyroid function tests 1

Advanced Testing (If Initial Workup Inconclusive)

• High-resolution CT scan of the chest if other targeted investigations are normal 1
• Bronchoscopy if suspicion of foreign body or endobronchial lesion 1
• Echocardiogram if suspicion of heart failure
• Sleep study if sleep-disordered breathing suspected

Red Flags Requiring Urgent Evaluation

• Hemoptysis
• Significant weight loss
• Persistent fever
• Severe dyspnea
• Hypoxemia
• Abnormal chest radiograph findings 1

Special Considerations for Elderly Patients

• Lower threshold for chest imaging due to higher risk of malignancy
• Consider medication side effects as potential causes of both symptoms
• Evaluate for heart failure, which can present with both fatigue and cough
• Consider COVID-19 testing, especially if fever is present 1
• Be aware that elderly patients may present atypically with serious conditions

Common Pitfalls to Avoid

• Attributing symptoms to age without proper investigation
• Missing ACE inhibitor-induced cough (discontinue ACE inhibitors in all patients with troublesome cough) 1
• Inadequate duration of empiric therapy (typically 2-8 weeks needed) 2
• Overlooking non-respiratory causes of cough (cardiac, GERD)
• Failing to consider malignancy in elderly patients with persistent symptoms

Remember that in an 85-year-old patient, multiple etiologies may coexist, and a systematic approach is essential to identify all contributing factors.