{"id":4864,"date":"2020-07-27T10:19:47","date_gmt":"2020-07-27T10:19:47","guid":{"rendered":"http:\/\/edren.org\/ren\/?page_id=4864"},"modified":"2020-07-27T10:19:50","modified_gmt":"2020-07-27T10:19:50","slug":"hypertension-case-2-a-dizzy-lady","status":"publish","type":"page","link":"https:\/\/edren.org\/ren\/education\/other-resources\/hypertension-tutorial\/hypertension-case-2-a-dizzy-lady\/","title":{"rendered":"Hypertension case 2 &#8211; A dizzy lady"},"content":{"rendered":"\n<div class=\"wp-block-media-text alignwide is-stacked-on-mobile\" style=\"grid-template-columns:33% auto\"><figure class=\"wp-block-media-text__media\"><img loading=\"lazy\" decoding=\"async\" width=\"762\" height=\"1024\" src=\"http:\/\/edren.org\/ren\/wp-content\/uploads\/2020\/07\/older-couple-762x1024.jpg\" alt=\"\" class=\"wp-image-4865\" srcset=\"https:\/\/edren.org\/ren\/wp-content\/uploads\/2020\/07\/older-couple-762x1024.jpg 762w, https:\/\/edren.org\/ren\/wp-content\/uploads\/2020\/07\/older-couple-223x300.jpg 223w, https:\/\/edren.org\/ren\/wp-content\/uploads\/2020\/07\/older-couple-768x1032.jpg 768w, https:\/\/edren.org\/ren\/wp-content\/uploads\/2020\/07\/older-couple-112x150.jpg 112w, https:\/\/edren.org\/ren\/wp-content\/uploads\/2020\/07\/older-couple.jpg 829w\" sizes=\"auto, (max-width: 762px) 100vw, 762px\" \/><\/figure><div class=\"wp-block-media-text__content\">\n<p>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<\/p>\n\n\n\n<p>Presenting complaint \u2013 Fall &#8211; ? cause<\/p>\n<\/div><\/div>\n\n\n\n<p>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<\/p>\n\n\n\n<p>PMH \u2013 Hypertension, osteoporosis, previous breast cancer -treated<\/p>\n\n\n\n<p>Medications \u2013 Bendroflumethiazide, amlodipine, adcal D3<\/p>\n\n\n\n<p>NKDA<\/p>\n\n\n\n<p>Social \u2013 non-smoker, minimal alcohol intake, lives alone with no package of care<\/p>\n\n\n\n<p>She is convinced that she must have tripped over something but there was nothing on the ground. She is keen to get home.<\/p>\n\n\n\n<p style=\"color:#e31515\" class=\"has-text-color has-medium-font-size\"><strong>Are there any other questions you would to ask?<\/strong><\/p>\n\n\n\n<p><em>have a think before you reveal what we would suggest.<\/em><\/p>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-51643\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Reveal<\/strong><\/button><div id=\"ac-51643\" class=\"c-accordion__content\">\n<div class=\"wp-block-group has-very-light-gray-background-color has-background\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<p>We need to go into the fall further. Certain characteristics may help you to determine what sort of an event this was<\/p>\n\n\n\n<p><strong>Cardiovascular<\/strong> \u2013 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<\/p>\n\n\n\n<p><strong>Neurological \u2013 <\/strong>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:<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Did you injure yourself?<\/li><li>Did you bite your tongue?<\/li><li>Any incontinence \u2013 bladder or bowel?<\/li><\/ul>\n\n\n\n<p><span style=\"color:#313131\" class=\"tadv-color\">She denied any of these features<\/span><\/p>\n\n\n\n<p><strong>Other<\/strong><\/p>\n\n\n\n<p>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.<\/p>\n\n\n\n<p>Changes in eyesight recently or new glasses. Poor vision can increase likelihood of falls.<\/p>\n\n\n\n<p>Any recent changes to medication? Some medications can predispose to falls, most commonly anticholinergic medications, analgesics, anti-hypertensive medications<\/p>\n<\/div><\/div>\n<\/div><\/div>\n\n\n\n<p>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.<\/p>\n\n\n\n<p>Before moving on with the case have a think. You should have enough information to be forming a differential diagnosis for this lady&#8217;s fall.<\/p>\n\n\n\n<p style=\"color:#db1515\" class=\"has-text-color has-medium-font-size\"><strong>Write down your top 3 differential diagnoses and see if they fit with the ones we have suggested.<\/strong><\/p>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-83862\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Reveal<\/strong><\/button><div id=\"ac-83862\" class=\"c-accordion__content\">\n<ol class=\"wp-block-list\"><li>Postural hypotension<\/li><li>Trip over an object as yet unknown<\/li><li>Balance abnormality<\/li><\/ol>\n\n\n\n<p><\/p>\n<\/div><\/div>\n\n\n\n<p>You continue with your assessment of this lady and move on to examination.<\/p>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td><strong>Cardiovascular<\/strong><br>&#8211; Warm, well perfused<br>&#8211; Good volume radial pulses,<br>No radial\/radial delay<br>&#8211; JVP not visible<br>-HS 1+2+0, No Murmurs<br>-Mild lower leg swelling<\/td><td><strong>Respiratory<\/strong><br>-Comfortable at rest, <br>talking in full sentence<br>&#8211; No signs of cyanosis<br>&#8211; Normal expansion<br>&#8211; Resonant to percussion<br>&#8211; Chest &#8211; good AE throughout<\/td><\/tr><tr><td><strong>Abdominal<\/strong><br>&#8211; Abdomen moving with respiration<br>&#8211; No scars, hernia or oedema visible<br>&#8211; Abdomen soft and non-tender to <br>light and deep palpation<br>&#8211; No palpable organomegally<br>&#8211; BS audible<br><br><br><\/td><td><strong>Neurological<\/strong><br>&#8211; No abnormalities on examination<br>of cranial nerves<br>&#8211; Normal power (5\/5) and tone in<br>upper and lower limbs<br>&#8211; Sensation -intact throughout<br>&#8211; co-ordination &#8211; can walk without<br>abnormality<br>&#8211; Rhomberg&#8217;s test negative<br>&#8211; reflexes intact<\/td><\/tr><tr><td><strong>Musculoskeletal<\/strong><br>&#8211; Bruising and swelling to left knee<br>&#8211; Full RoM and able to weight bear on leg<\/td><td>GCS 15<br>AMT 10\/10<br>BP 148\/85, HR 76, Sats 99% RA, RR 17, T 36.8<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p><\/p>\n\n\n\n<p>She has already had blood tests taken during this presentation <\/p>\n\n\n\n<figure class=\"wp-block-image size-large is-resized\"><img loading=\"lazy\" decoding=\"async\" src=\"http:\/\/edren.org\/ren\/wp-content\/uploads\/2020\/07\/blood-results.png\" alt=\"\" class=\"wp-image-4899\" width=\"427\" height=\"197\" srcset=\"https:\/\/edren.org\/ren\/wp-content\/uploads\/2020\/07\/blood-results.png 600w, https:\/\/edren.org\/ren\/wp-content\/uploads\/2020\/07\/blood-results-300x139.png 300w, https:\/\/edren.org\/ren\/wp-content\/uploads\/2020\/07\/blood-results-150x69.png 150w\" sizes=\"auto, (max-width: 427px) 100vw, 427px\" \/><\/figure>\n\n\n\n<!--nextpage-->\n\n\n\n<p class=\"has-medium-font-size\"><strong><span style=\"color:#db1515\" class=\"tadv-color\">Does this change your opinion of what might be happening? Are there any other questions you would like to ask?<\/span><\/strong><\/p>\n\n\n\n<p><\/p>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-75421\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Reveal<\/strong><\/button><div id=\"ac-75421\" class=\"c-accordion__content\">\n<div class=\"wp-block-group has-very-light-gray-background-color has-background\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<p>Possibility of co-existing infection<\/p>\n\n\n\n<p>You would want to ask for any symptoms of infections?<\/p>\n\n\n\n<p>Agnes reveals that she has had a bit of urinary frequency and dysuria<\/p>\n<\/div><\/div>\n<\/div><\/div>\n\n\n\n<p><\/p>\n\n\n\n<p>Given the information we have, what further investigations would you like to undertake?<\/p>\n\n\n\n<p><em>Select all options that apply<\/em><\/p>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-72323\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Urine dip<\/strong><\/button><div id=\"ac-72323\" class=\"c-accordion__content\">\n<p class=\"has-background has-very-light-gray-background-color\">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.<\/p>\n<\/div><\/div>\n\n\n\n<p><\/p>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-23033\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>ECG<\/strong><\/button><div id=\"ac-23033\" class=\"c-accordion__content\">\n<p class=\"has-background has-very-light-gray-background-color\">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&#8217; case as her heart rate is 76 and also she has no history of black out.<\/p>\n\n\n\n<p><\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-21399\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Dix Halpike\/Epley Manoeuvres<\/strong><\/button><div id=\"ac-21399\" class=\"c-accordion__content\">\n<p class=\"has-background has-very-light-gray-background-color\">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.<\/p>\n<\/div><\/div>\n\n\n\n<p><\/p>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-65814\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Erect and Supine blood pressure<\/strong><\/button><div id=\"ac-65814\" class=\"c-accordion__content\">\n<p class=\"has-background has-very-light-gray-background-color\">This is an important test in any individual with an unexplained fall. <\/p>\n<\/div><\/div>\n\n\n\n<p><\/p>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-46451\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Chest X-ray<\/strong><\/button><div id=\"ac-46451\" class=\"c-accordion__content\">\n<p class=\"has-background has-very-light-gray-background-color\">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.<\/p>\n<\/div><\/div>\n\n\n\n<p><\/p>\n\n\n\n<p>You undertake the investigations for Agnes and find that she has some significant abnormalities<\/p>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-56078\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Reveal<\/strong><\/button><div id=\"ac-56078\" class=\"c-accordion__content\">\n<p class=\"has-background has-very-light-gray-background-color\">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).<\/p>\n<\/div><\/div>\n\n\n\n<p><\/p>\n\n\n\n<p class=\"has-medium-font-size\"><strong><span style=\"color:#e41414\" class=\"tadv-color\">Given the results you have what do you think may be contributing to her fall?<\/span><\/strong><\/p>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-42987\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Contributing Factors<\/strong><\/button><div id=\"ac-42987\" class=\"c-accordion__content\">\n<p class=\"has-background has-very-light-gray-background-color\">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.<\/p>\n<\/div><\/div>\n\n\n\n<p><\/p>\n\n\n\n<p class=\"has-medium-font-size\"><span style=\"color:#df1414\" class=\"tadv-color\"><strong>Would you like this lady to have any follow-up?<\/strong><\/span><\/p>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-13671\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Follow-up?<\/strong><\/button><div id=\"ac-13671\" class=\"c-accordion__content\">\n<p class=\"has-background has-very-light-gray-background-color\">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.<\/p>\n<\/div><\/div>\n\n\n\n<p><\/p>\n\n\n\n<p class=\"has-medium-font-size\"><span style=\"color:#e41515\" class=\"tadv-color\"><strong>Her BP was 148\/85 \u2013 would you worry about hypertension at this level?<\/strong><\/span><\/p>\n\n\n\n<div class=\"wp-block-pb-accordion-item c-accordion__item js-accordion-item no-js\" data-initially-open=\"false\" data-click-to-close=\"true\" data-auto-close=\"true\" data-scroll=\"false\" data-scroll-offset=\"0\"><button id=\"at-35732\" class=\"c-accordion__title js-accordion-controller c-accordion__title--button\" role=\"button\"><strong>Are you worried?<\/strong><\/button><div id=\"ac-35732\" class=\"c-accordion__content\">\n<p class=\"has-background has-very-light-gray-background-color\">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 press<span style=\"background-color:#eeeeee\" class=\"tadv-background-color\">u<\/span>re 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.<\/p>\n<\/div><\/div>\n\n\n\n<p><\/p>\n\n\n\n<p>Agnes is discharged home with her Daughter staying with her for a few days. <\/p>\n\n\n\n<p>Well Done you have completed the case.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>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 \u2013 Fall &#8211; ? cause HPC- She reports falling following standing from a\u2026<\/p>\n<p> <a class=\"continue-reading-link\" href=\"https:\/\/edren.org\/ren\/education\/other-resources\/hypertension-tutorial\/hypertension-case-2-a-dizzy-lady\/\"><span>Continue reading<\/span><i class=\"crycon-right-dir\"><\/i><\/a> <\/p>\n","protected":false},"author":7,"featured_media":0,"parent":4128,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"class_list":["post-4864","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/4864","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/users\/7"}],"replies":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/comments?post=4864"}],"version-history":[{"count":3,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/4864\/revisions"}],"predecessor-version":[{"id":4901,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/4864\/revisions\/4901"}],"up":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/4128"}],"wp:attachment":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/media?parent=4864"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}