What is the best approach for an older man with a past medical history (PMH) of thoracic aortic aneurysm (TAA), erectile dysfunction (ED), gastroesophageal reflux disease (GERD), dyslipidemia, hypertension (HTN), osteoarthritis (OA), thrombocytopenia (low platelets), tremor, lymphopenia (low lymphocytes), poor balance, Schatzki's ring, hiatal hernia, chronic gastritis, diverticulosis, and internal hemorrhoids, who presents with weight loss and diminished appetite, after a chest computed tomography (CT) scan, Galleri test, endoscopic examinations, and laboratory tests have failed to reveal a cause?

Workup for Unexplained Weight Loss and Diminished Appetite in an Older Man

In this older man with extensive negative workup including chest CT, Galleri test, endoscopy, and labs, further imaging is unlikely to yield a diagnosis and should be avoided unless new symptoms or findings emerge; instead, focus on functional assessment, medication review, and empiric nutritional support while monitoring for evolution of occult disease. 1

Why Additional Imaging is Not Recommended

• Low diagnostic yield after comprehensive evaluation: When chest CT, endoscopy (presumably upper and lower given his GI history), and laboratory testing are negative, the incremental yield of additional cross-sectional imaging is minimal 1
• Approximately 25% of elderly patients with unintentional weight loss have no identifiable cause despite thorough workup 1
• His thoracic aortic aneurysm has already been evaluated with chest CT, which is the appropriate imaging modality for TAA surveillance 2, 3

Critical Next Steps Instead of More Imaging

Medication Review (High Priority)

• Polypharmacy is a leading cause of unintentional weight loss in elderly patients 1
• Review ALL medications for those causing nausea, vomiting, dysgeusia (altered taste), or anorexia 1
• Paradoxically, reduction of psychotropic medications can unmask anxiety or other conditions causing weight loss 1
• Given his multiple conditions (HTN, GERD, dyslipidemia, tremor), he likely takes 5+ medications—each should be scrutinized

Depression and Psychosocial Assessment

• Depression is the leading cause of involuntary weight loss, especially in older adults 1
• Screen formally for depression using validated tools 4
• Anxiety occurs in 15-20% of patients with aortic disease and can contribute to poor appetite 4
• Assess his living situation, ability to shop for and prepare food, social isolation, and financial constraints 1

Functional and Environmental Factors

• Evaluate his interest in and ability to eat food—does he have dental problems, difficulty swallowing beyond the known Schatzki's ring, or problems with food preparation? 1
• His poor balance and tremor may impair his ability to shop, cook, or feed himself effectively
• Consider occupational therapy evaluation for adaptive equipment

Disease-Specific Considerations from His PMH

Thoracic Aortic Aneurysm Management

• His TAA requires surveillance imaging based on size, not symptoms of weight loss 2
• Ensure he is on appropriate medical therapy: beta-blockers and/or ARBs reduce aortic growth rate by approximately 50% 2
• Weight loss itself is not a symptom of TAA unless rupture or dissection is occurring, which would present with acute chest/back pain 2, 5

GI Pathology Already Identified

• His Schatzki's ring, hiatal hernia, and chronic gastritis could all contribute to early satiety and reduced intake
• If endoscopy was done but symptoms persist, consider repeat dilation of Schatzki's ring if present (general medical knowledge)
• Optimize GERD management to reduce gastritis symptoms that may suppress appetite

Hematologic Abnormalities

• Low platelets and low lymphocytes warrant hematology consultation if not already done—these could indicate occult bone marrow pathology, chronic infection, or autoimmune disease 1
• Complete blood count with differential should be reviewed for other cytopenias

Empiric Management While Monitoring

Nutritional Support

• Provide nutritional counseling and consider high-calorie supplementation 1
• Ameliorate symptoms that interfere with eating (nausea, early satiety, reflux) 1
• Consider referral to dietitian for meal planning adapted to his functional limitations

Surveillance Strategy

• Monitor weight monthly—if weight stabilizes or improves with supportive measures, continue current approach 1
• If weight loss continues (>5% over 3 months) or new symptoms develop, then reconsider additional workup 1
• Repeat basic labs (CBC, CMP, TSH) in 3 months to assess for evolution of occult disease 1

Common Pitfalls to Avoid

• Avoid "imaging for reassurance"—more scans without clinical indication expose him to radiation, contrast nephropathy risk (given age), and incidental findings requiring further workup 2
• Do not overlook medication-induced causes—this is reversible and frequently missed 1
• Avoid assuming "it's just old age"—unintentional weight loss in elderly patients carries increased risk for infection, depression, and death and requires active management 1
• Do not delay nutritional support while searching for a diagnosis—empiric treatment is appropriate when workup is negative 1

When to Reconsider Imaging

• Development of new localizing symptoms (abdominal pain, change in bowel habits, neurologic deficits)
• New abnormalities on physical examination
• Progressive cytopenias or other laboratory abnormalities
• Continued weight loss despite 3 months of supportive interventions
• New chest/back pain concerning for aortic dissection—this would require immediate CT angiography 2