Does this change your opinion of what might be happening? Are there any other questions you would like to ask?
Possibility of co-existing infection
You would want to ask for any symptoms of infections?
Agnes reveals that she has had a bit of urinary frequency and dysuria
Given the information we have, what further investigations would you like to undertake?
Select all options that apply
Whilst useful in some settings, (not usually in trying to diagnose UTI) in an individual with urinary symptoms and bloods suggestive of infection it is not the best investigation to undertake. It may be worth taking a urine sample for culture though.
This is an important investigation in any individual without a clear cause for falls. It can diagnose many arrhythmias which would predispose to collapse (eg Stokes Adams, complete heart block). These are unlikely in Agnes’ case as her heart rate is 76 and also she has no history of black out.
The test for and relief of benign paroxysmal positional vertigo these may be useful in some falls, however there is no signs of this here.
This is an important test in any individual with an unexplained fall.
Given the raised inflammatory markers it could be argued that this would be an appropriate investigation for this lady. She does not however have any respiratory symptoms, so may not be the most appropriate at present.
You undertake the investigations for Agnes and find that she has some significant abnormalities
Agnes has a significant postural drop 148/62 supine down to 100/54 on standing. With this she became very dizzy and had to sit down. Her ECG showed no abnormalities (Sinus rhythm 72 bpm).
Given the results you have what do you think may be contributing to her fall?
It is likely that the recent increase in amlodipine has exacerbated this situation. Given the substantial drop in blood pressure on standing it would be worth reducing the amlodipine back to the original dose of 5mg and possibly stopping her Bendroflumethiazide as well.
Would you like this lady to have any follow-up?
It would be wise to have this lady reviewed at her GP to check that her postural hypotension has improved following changes to her medication and if not consider compression stockings or further reduction in antihypertensive dose.
Her BP was 148/85 – would you worry about hypertension at this level?
As stated above older people tend to require a higher BP to maintain cerebral perfusion. At this age and with no other co-morbidities (diabetes, cardiac disease) we would tend to allow a slightly higher blood pressure and would not be chasing to suppress this too far, particularly in the context of known postural hypotension. Also, this was taken in a foreign environment under stressful conditions so is likely to be artificially raised.
Agnes is discharged home with her Daughter staying with her for a few days.
Well Done you have completed the case.