A 79-year-old man comes to your office accompanied by his daughter, who is concerned that the patient has become more remote and less interested in participating in his usual activities over the past 6 months. He voices no complaints, but does note some difficulties getting to and maintaining sleep and feeling more short of breath with exertion than usual. He denies chest pain/pressure, orthopnea, and paroxysmal nocturnal dyspnea. His wife died eight months ago from breast cancer. He lives independently and performs all of his activities of daily living.
On examination, he is in no acute distress. He has some difficulty in rising from a chair and stepping up to the examination table. His temperature is 37.1 C (98.8 F) , pulse is 114/min and irregular, blood pressure is 148/76 mm Hg, and respirations are 16/min. BMI is 19 kg/m². Jugular venous pressure is normal. Cardiac examination reveals an irregularly irregular rhythm with a 2/6 systolic ejection murmur along his upper left sternal border. Lungs are clear to auscultation. Abdominal and extremity examinations are within normal limits. There are no focal neurologic findings. He has 4/5 proximal muscle strength in his lower extremities. Results of the five item Geriatric Depression Screen are 1/5. Complete blood count, serum chemistries, liver function panel, and chest x-ray reveal no abnormalities. EKG shows atrial fibrillation.
Which of the following is the most reasonable next step in managing this patient?

Question

Quizplus · Accepted Answer

Recognition of a constellation of symptoms that are explained by a single pathophysiologic event is a common approach in clinical medicine. Unfortunately, due to multiple concurrent medical problems and often atypical presentations of disease, this "pattern recognition" approach often does not work in the geriatric population. For example, the typical symptoms of hyperthyroidism may not be present in the elderly population and about one third of older individuals with hyperthyroidism demonstrate apathy rather than hyperactivity. However, in this case, the combination of weight loss (low BMI), insomnia, and atrial fibrillation suggests the patient is hyperthyroid. Atrial fibrillation occurs in about 10-20% of individuals with hyperthyroidism and may be especially prevalent in an older hyperthyroid population. Screening for hyperthyroidism is commonly done in patients presenting with atrial fibrillation. Other common complaints in older individuals with hyperthyroidism include shortness of breath of unclear cause and constipation (paradoxically). (Choice A) Weight loss, insomnia, and apathy are cardinal manifestations of depression. However, depression does not explain this patient's atrial fibrillation. Moreover, the patient's responses to screening questions do not support a diagnosis of depression. Finally, antidepressant therapy may be associated with significant adverse effects in an elderly population and such therapy is not indicated in this case. (Choice B) In patients with unintentional weight loss, underlying cancer is always a concern. This patient does not have physical examination findings suggestive of cancer, is not anemic (seen in some gastrointestinal cancers or a hematologic malignancy), and has a normal chest x-ray. Some of his symptoms and signs are not explainable by cancer (atrial fibrillation). (Choice D) New onset atrial fibrillation should be investigated for reversible causes, especially in the elderly. Although coronary artery disease may cause new onset atrial fibrillation, this patient's gradual onset of his other symptoms are more suggestive of hyperthyroidism. (Choice E) This patient has evidence of proximal muscle weakness, which can be explained by several causes in the aging population, including polymyositis and hyperthyroidism. Polymyositis would not explain atrial fibrillation or the patient's other symptoms. Educational objective: Hyperthyroidism may present with apathy in older individuals. Shortness of breath, weight loss, and atrial fibrillation occur more commonly in older patients. Screening for hyperthyroidism should be done in older individuals presenting with new onset atrial fibrillation. __________ References: Older subjects with hyperthyroidism present with a paucity of symptoms and signs: a large cross-sectional study. (http://www.ncbi.nlm.nih.gov/pubmed/20392869)

A 79-Year-Old Man Comes to Your Office Accompanied by His