Name:
A 77-Year-Old with Weight Loss
Description:
A 77-Year-Old with Weight Loss
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T00H06M14S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
♪ (music) ♪
CATHY: Hi, welcome to Harrison's Podclass where we discuss important concepts in internal medicine. I'm Cathy Handy.
CHARLIE: I'm Charlie Wiener and we're coming to you from the Johns Hopkins School of Medicine. ♪ (music) ♪
CATHY: Welcome to Episode 25: A 77-Year-Old with Weight Loss.
CHARLIE: So, the question reads, a 77-year-old woman seeks your opinion because she has lost weight over the last nine months. She reports her weight has fallen from 165 lbs to 140 lbs without any effort on her part to lose weight. She had a hip fracture after a fall three months ago that was successfully surgically repaired, and she now reports that her mobility is improving. She denies any fevers and night sweats. Her review of systems is completely negative, and she reports an intact but really not voracious appetite.
CHARLIE: Her only medication is warfarin, and she has a well-controlled INR over the past four weeks. She's a lifelong non-smoker, has one glass of wine less than twice a week. So, Cathy, what do you think so far?
CATHY: Well, we hear that this is an elderly woman who has unintentional weight loss-- in this case, it's been 25 lbs over the past nine months, and we know that can be difficult to achieve. So, I started thinking about weight loss being clinically significant when it's 10 lbs-- or if you're on the kilogram scale, that's 4.5 kgs-- or up to 5% of body weight over a period of 6-12 months. She meets that criteria, so definitely warrants further evaluation.
CHARLIE: It's important because involuntary weight loss is frequently insidious and can have important medical or psychological implications. It's particularly a common complaint in the elderly. and it can often serve as a harbinger of serious underlying disease.
CATHY: Yes, it's definitely pretty common. There are some estimates that it occurs in about a quarter of elderly or frail patients when they're presenting to the outpatient setting. Weight loss in older persons is associated with a variety of bad things. So, you can get hip fractures, and her recent hip fracture may have been a result or at least in part caused by her recent weight loss. You can also get pressure ulcers, impaired immune function, and decreased functional status overall.
CATHY: So, you also have to remember and look for documentation of weight loss. So, you look back and compare it to prior weights because up to half the people who claim to have lost weight have no actual documented weight loss.
CHARLIE: So, what are you thinking about etiologies of unintentional weight loss?
CATHY: Most elderly patients who present with involuntary weight loss have either a malignancy, sometimes it can be a chronic, inflammatory, or infectious disease. One common thing that's forgotten about often is dental disease as a cause. There are metabolic disorders, like hyperthyroidism or diabetes, malabsorption, or GI functional disease. And finally, I think about psychiatric disorders, like depression, which can be common also in elderly patients. Sometimes there are multiple causes contributing, and about a quarter of the time, you can't identify a cause, despite a thorough investigation.
CHARLIE: Alright, so let's move to the question. The question reads, all of the following should be ordered to evaluate her involuntary weight loss, except for a) a C-reactive protein; b) a complete blood count; c) a complete metabolic panel, including renal, hepatic, and calcium; d) a low-dose CT of the chest; or e) thyroid function tests.
CATHY: Before we start talking about testing, we should emphasize that the first step after a good history is really a complete physical examination, and numerous studies have demonstrated that in patients who have unintentional weight loss and they were eventually found to have a malignancy, that physical exam findings were noted in up to half of cases.
CHARLIE: Okay. So, let's say, at this point, there are no focal findings on physical examination. How would you approach the patient and the tests that I listed?
CATHY: So, the question asks us about which of these is the least reasonable at this time. So, first, we mentioned that a possible cause could be a chronic inflammatory, infectious disease. And a CRP wouldn't be my first choice necessarily, but it's definitely a reasonable part of the workup. So, if I was suspicious about an underlying chronic inflammatory disease, like GCA, for example, you could definitely start with either a CRP or an ESR.
CATHY: And one of those is elevated in the vast majority of cases, but remember that it's notoriously non-specific, so it definitely doesn't give you a diagnosis.
CHARLIE: Right, many patients with malignancies may also have an elevated CRP or ESR. What about the CBC and the complete metabolic panel?
CATHY: So, a CBC is definitely a good place to start to look for evidence of infection, or you can also find significant anemia or abnormalities in her counts that might suggest a malignant hematologic problem. And a CMP with evaluation of liver and kidney function as well as serum calcium are also important. And we mentioned that thyroid dysfunction is another common cause, so you'd also want to check the thyroid function tests.
CHARLIE: So, it sounds like you really don't want to do a low-dose CT scan of the chest?
CATHY: Yeah. Among the tests listed, that's the one that I really wouldn't perform at this visit, mostly because we don't routinely obtain screening in low-risk patients who don't have any symptoms to suggest that you would find something on CT. So, despite being elderly, which puts her at an increased risk of cancers, we also know that she is a lifelong non-smoker, she has absolutely no pulmonary or thoracic symptoms, and we don't hear about any other exposures.
CATHY: So, a primary lung cancer is pretty low on my differential. She absolutely should have age-appropriate cancer screening tests, if they aren't up to date, but I wouldn't do a low-dose CT scan at this time.
CHARLIE: Okay. So, the answer in this case is let's not get a low-dose CT scan. Anything else you want to comment on that's not mentioned here?
CATHY: Yes. So, the history and physical exam are key, so I'd make sure I did a thorough medication review, definitely a dietary history and neurologic exam. And also remember to do cognitive and mood screening. And if the initial evaluation is unrevealing, many would recommend close follow-up before any additional testing.
CHARLIE: Great. So, the teaching point here is that unintentional weight loss is a common problem, particularity among the elderly. The causes are broad and include malignant, infectious, inflammatory, metabolic, and psychiatric disorders. A thorough history and physical is the vital first step, and initial testing should really be targeted towards the more common causes.
CATHY: And to read more about this, you can check out Harrison's chapter on Cardinal Manifestations of Disease. ♪ (music) ♪