# Tired and unwell for weeks, a 79-year-old: a case to work up

> An internal medicine case for medical students: a 79-year-old tired and unwell for five or six weeks who has lost interest in things. What to ask, red flags, first tests and a broad differential.

- Internal Medicine · Advanced · about 25 minutes
- Web page: https://www.medikarya.in/case-studies/79-year-old-man-who-has-been-tired-and-unwell-for-weeks
- Work up this patient: https://www.medikarya.in/case-studies/79-year-old-man-who-has-been-tired-and-unwell-for-weeks

## How the patient presents

A 79-year-old retired shopkeeper has been tired and generally unwell for 5 or 6 weeks and has lost interest in things. His daughter has brought him in.

## Why tiredness and feeling unwell in an older adult matters

Vague tiredness in an older person has a long list of causes, physical and psychological, and they often come together. A structured history and a sensible first set of tests find most of the treatable ones; consider depression, but only after looking for physical illness.

## What to ask in the history

- When it started and how it has changed
- Weight loss, appetite, fever, sweats
- Mood, sleep, interest, memory
- Breathlessness, chest pain
- Bowel changes, bleeding
- Urinary symptoms
- Pain
- New or changed medicines
- Alcohol
- Who he lives with, any recent loss, what he can still do

## Red flags

- Weight loss
- Bleeding from the bowel or in the urine
- New confusion
- Low mood with thoughts of self-harm
- Fever
- Falls

## What to examine

- Pallor, jaundice, lymph nodes, hydration, weight
- Heart, lungs, abdomen, rectal examination
- Thyroid
- Neurological examination and a cognitive screen
- A mood screen

## First investigations

- Full blood count, ESR and CRP
- Kidney function, sodium and calcium
- Glucose, liver function, thyroid function
- Vitamin B12, folate, ferritin
- Urine test
- Chest X-ray
- Further tests as the findings direct

## Differential diagnosis of tiredness and feeling unwell in an older adult

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

### Blood and metabolic

- Anaemia
- High calcium
- Low sodium
- Thyroid disease
- Diabetes
- Kidney failure

### Cancer

- Bowel
- Lung
- Prostate
- Myeloma
- Lymphoma

### Infection

- Tuberculosis
- Endocarditis
- Urinary infection

### Mind

- Depression
- Early dementia

### Medicines

- Side effects
- Too many medicines together

## Common mistakes

- Calling it depression before looking for physical illness.
- Forgetting to check the calcium.
- Not reviewing his medicines.

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A study guide for medical students, not medical advice. Follow your institution's protocols in practice.