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Hypertension case 2 – A dizzy lady

An 88 year old lady (Agnes) presents to the acute medical unit. She has been having problems with dizziness and fatigue over the past few weeks. She presents following a fall. You take a history

Presenting complaint – Fall – ? cause

HPC- She reports falling following standing from a chair. She remembers feeling a little dizzy prior to her fall. She is unsure if she lost consciousness -if she did it was only for a few seconds. She had no chest pain and no palpitations prior to this. She reports a sore knee but no other injuries. No signs of infection

PMH – Hypertension, osteoporosis, previous breast cancer -treated

Medications – Bendroflumethiazide, amlodipine, adcal D3

NKDA

Social – non-smoker, minimal alcohol intake, lives alone with no package of care

She is convinced that she must have tripped over something but there was nothing on the ground. She is keen to get home.

Are there any other questions you would to ask?

have a think before you reveal what we would suggest.

We need to go into the fall further. Certain characteristics may help you to determine what sort of an event this was

Cardiovascular – She has denied any preceding chest pain or palpitations. She has also denied any head injury or facial injury. These 2 patterns of injuries are more typical of someone blacking out as they have not been able to put their hands out to protect their face. It would be interesting to know if anyone in the family had any cardiovascular issues however at this age any cardiovascular presentation is likely due to degeneration over years

Neurological – We would be thinking seizure here. The most useful thing would be to have a witness to the fall, however in this case that is unavailable. Other questions which would be useful to ask are:

  • Did you injure yourself?
  • Did you bite your tongue?
  • Any incontinence – bladder or bowel?

She denied any of these features

Other

It would be useful to know about anything that would lead you to think this was a trip or balance issue. This would be asking about any rugs or object on the floor that someone could have tripped over.

Changes in eyesight recently or new glasses. Poor vision can increase likelihood of falls.

Any recent changes to medication? Some medications can predispose to falls, most commonly anticholinergic medications, analgesics, anti-hypertensive medications

She tells you she has had some problematic blood pressure readings lately and has been told to try taking 2 of her amlodipine tablets instead of one.

Before moving on with the case have a think. You should have enough information to be forming a differential diagnosis for this lady’s fall.

Write down your top 3 differential diagnoses and see if they fit with the ones we have suggested.

  1. Postural hypotension
  2. Trip over an object as yet unknown
  3. Balance abnormality

You continue with your assessment of this lady and move on to examination.

Cardiovascular
– Warm, well perfused
– Good volume radial pulses,
No radial/radial delay
– JVP not visible
-HS 1+2+0, No Murmurs
-Mild lower leg swelling
Respiratory
-Comfortable at rest,
talking in full sentence
– No signs of cyanosis
– Normal expansion
– Resonant to percussion
– Chest – good AE throughout
Abdominal
– Abdomen moving with respiration
– No scars, hernia or oedema visible
– Abdomen soft and non-tender to
light and deep palpation
– No palpable organomegally
– BS audible

Neurological
– No abnormalities on examination
of cranial nerves
– Normal power (5/5) and tone in
upper and lower limbs
– Sensation -intact throughout
– co-ordination – can walk without
abnormality
– Rhomberg’s test negative
– reflexes intact
Musculoskeletal
– Bruising and swelling to left knee
– Full RoM and able to weight bear on leg
GCS 15
AMT 10/10
BP 148/85, HR 76, Sats 99% RA, RR 17, T 36.8

She has already had blood tests taken during this presentation



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.