What is the workup for a 66-year-old male with hypercholesterolemia (high cholesterol) and chronic venous insufficiency (CVI) of the left leg presenting with fatigue?

From the Guidelines

The workup for a 66-year-old male with high cholesterol, venous insufficiency, and fatigue should begin with a comprehensive history and physical examination, followed by laboratory testing, including a complete blood count, comprehensive metabolic panel, thyroid function tests, fasting glucose, lipid panel, and D-dimer test if deep vein thrombosis is suspected, as recommended by recent guidelines 1. Initial labs should include:

• A complete blood count to assess for anemia
• Comprehensive metabolic panel to evaluate organ function
• Thyroid function tests (TSH, free T4) to rule out hypothyroidism
• Fasting glucose to screen for diabetes Given his high cholesterol, a lipid panel should be checked to assess cardiovascular risk, with a focus on LDL-C as the primary target for treatment, as per the 2016 ESC/EAS guidelines for the management of dyslipidaemias 1. Specific to his venous insufficiency, a D-dimer test may be considered if deep vein thrombosis is suspected, and the Clinical Etiologic Anatomic Pathophysiologic (CEAP) classification system should be used to categorize the severity of venous disease, as recommended by the 2023 ACR Appropriateness Criteria for lower extremity chronic venous disease 1. Additional tests based on initial findings might include:
• Ferritin, vitamin B12, and folate levels to evaluate nutritional causes of fatigue
• Electrocardiogram and possibly echocardiogram to assess cardiac function, particularly important given his age and cholesterol history
• Sleep apnea screening, as it commonly causes fatigue in older adults, and physical activity counseling, as recommended by the 2021 systematic review of rehabilitation and exercise recommendations in oncology guidelines 1 The patient's medication list should be reviewed for drugs that might contribute to fatigue, including statins which he may be taking for hypercholesterolemia, and consideration should be given to the potential benefits of aerobic exercise, resistance training, and combined exercise modalities on cholesterol and lipid profile, as discussed in the 2014 review on differential effects of exercise modalities on cholesterol and lipid profile 1. This systematic approach addresses common causes of fatigue while considering his specific comorbidities, and prioritizes his morbidity, mortality, and quality of life as the primary outcome, in line with the principles of evidence-based medicine 1.

From the FDA Drug Label

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From the Research

Patient Workup

The patient is a 66-year-old male with high cholesterol and venous insufficiency of the left leg, presenting with fatigue. The workup for this patient should include:

• A complete blood count (CBC) to evaluate for anemia, as it is a common cause of fatigue 2, 3, 4
• Red cell indices, such as mean corpuscular volume (MCV) and red cell distribution width (RDW), to help diagnose the cause of anemia 2, 3
• Reticulocyte count to screen for hemolysis or blood loss 2
• Testing for specific causes of anemia, such as iron deficiency or vitamin B12 deficiency 2
• Evaluation of liver and kidney function, as abnormalities in these tests can be associated with fatigue and anemia 5
• Lipid profile to assess the patient's cholesterol levels and risk of cardiovascular disease 3, 5
• Physical examination and history to evaluate the patient's venous insufficiency and its potential contribution to fatigue
• Imaging studies, such as a Doppler ultrasound, to evaluate the patient's venous insufficiency and rule out other causes of fatigue, such as deep vein thrombosis 6

Laboratory Tests

The following laboratory tests may be ordered as part of the patient's workup:

• Complete blood count (CBC) with differential and platelet count 3, 4
• Red cell indices, including MCV, RDW, and mean hemoglobin concentration 2, 3
• Reticulocyte count 2
• Electrolyte panel to evaluate kidney function 5
• Liver function tests, including aspartate aminotransferase (AST) and alanine aminotransferase (ALT) 5
• Lipid profile, including total cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides 3, 5

Additional Evaluation

The patient's fatigue may be multifactorial, and additional evaluation may be necessary to determine the underlying cause. This may include:

• Evaluation of the patient's medication list to determine if any medications are contributing to fatigue
• Assessment of the patient's sleep patterns and overall health status
• Consideration of other potential causes of fatigue, such as hypothyroidism or adrenal insufficiency 2