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Case - March 23, 2005 1:26:00 PM
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Dr.Wagner
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From: Indianapolis
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Just got off the phone with a great friend of mine from PT school. He wanted a "curbside" consult.
So I will present this as a nice case/exercise...and probe a bit.
A 70 year old pleasant NH resident comes to the PT area with an order to Evaluate and Treat for
generalized weakness.
PMH: IDDM, CAD, BPH, "orthostatic hypotension"
Question to you ( DO NOT LOOK THIS UP, ANSWER FROM THE TOP OF YOUR HEAD...HONOR SYSTEM)
Define "orthostatic hypotension"
What other info from the chart would you like to know?
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: Case - March 23, 2005 1:39:00 PM
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SJBird55
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I thought orthostatic hypotension was a drop in blood pressure with the initial change in position such as from sit to stand.
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Re: Case - March 23, 2005 1:40:00 PM
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SJBird55
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I'm not familiar with what BPH stands for..
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Re: Case - March 23, 2005 1:52:00 PM
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Dr.Wagner
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Benign prostatic hypertrophy (BPH)
I'll wait for some more responses.
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Dr. Wagner DO
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Re: Case - March 23, 2005 2:15:00 PM
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KAK
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Off the top of my head- Orthostatic Hypotension: A failure of the vascular system to respond to a change in position (anything upright- sitting or standing). The effect of gravity causes a drop in BP. This then causes decreased cerebral blood flow accompanied by lightheadedness or passing out. This typically occurs after a period of bed rest.
I would want to know if this was a current problem or something that occurred in the past associated with a period of bed rest. If the history didn’t fit, and it was a current problem, I’d wonder if medications could be a contributing factor. I’d also look further into his cardiac history.
SJ- I think BPH stands for benign prostrate hypertrophy
KAK
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Re: Case - March 23, 2005 2:23:00 PM
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Dr.Wagner
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Nice "clincial" definition...but give me the objective measurements...
Secondary question, "is everyone who stands up and feels 'dizzy' orthostatic?" How do you strictly determine the diagnosis?
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Dr. Wagner DO
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Re: Case - March 23, 2005 2:43:00 PM
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dross
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Orthostatic hypotension is a drop in 20mmhg systolic pressure when going from supine to standing in the presence of symptoms (dizziness, tachy, diphoresis possibley).
I want to know meds (diuretics and anti-hypertenives). I want to a BMP and CBC for K, Na, hg/hct. If the h/h is low then work up colon cancer. If the Na/K are abnormal look at the meds. Thats the best I can do with the limited hx. Do we get more?
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Re: Case - March 23, 2005 2:51:00 PM
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SJBird55
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ah.. okay on the BPH.
If they are, then I'm orthostatic. LOL
I think that to determine orthostatic hypotension the person would have those particular complaints, but clinically there would be an immediate decrease in blood pressure with the positional change... but in a bit of time the blood pressure would appear to be normal. And now I'm sure you're going to ask the range of change... I honestly don't know - I tend to look up that kind of stuff because that's what reference books are for. But, I'd guess it would be a 20-30 mm Hg change?
Generalized weakness for an eval and treat doesn't tell me much.
When did it start? Did he fall? Did he fall because of the orthostatic hypotension? Has he been hospitalized? Has he been ill? Why does he think he has generalized weakness? Has there been a change in his medications? What medications have been prescribed (along with what over the counter stuff is he taking or herbs/supplements/alternative med stuff)? Is the weakness all day or only during certain times during the day? Is pain a variable? What are his fingernail beds like? Any edema in his lower extremities? How does he seem to move from various positions? Any constitutional signs?
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Re: Case - March 23, 2005 3:06:00 PM
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Dr.Wagner
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chirx, d@mnit boy!
you are a resident, no?
You cannot play.
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Dr. Wagner DO
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Re: Case - March 23, 2005 3:24:00 PM
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dross
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From: NJ
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Yeah but today Im just a chiropractor having a good day.
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Re: Case - March 23, 2005 3:40:00 PM
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KAK
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I’m going to go with chrix (sorry you can’t play) :( "a drop in systolic pressure of 20mmHg". I also got to wondering (while baking my daughter’s 16th birthday cake!), if diabetic neuropathy can involve the nerves of the vascular system leading to orthostatic hypotension.
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Re: Case - March 23, 2005 5:56:00 PM
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Jon Newman
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Isn't there some sort of 5 minute rule or something to that extent. Take BP's immediately and again after 5 min. True orthostatic hypotension is when the BP's remain lowered at the 5 min mark. At least that's what our neurologist orders.
jon
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Re: Case - March 23, 2005 6:17:00 PM
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Dr.Wagner
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This is all true... (drop in systolic by 20, or diastolic by 10 or increase heart rate by roughly 20)
My question to my friend was "so what are his pressures"...he had no idea.
So, in the clinic do PT's take any blood pressures or vitals...what would YOU do?
What in his history may lead to a clue of an origin?
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Dr. Wagner DO
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Re: Case - March 23, 2005 6:50:00 PM
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VagusX
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Off the top of my head I don't have much of a clue. I would go ahead and take his pressures yes. I would compare values in supine to those in sitting. Maybe something significant would show up. If the patients pressures are significantly lower in a gravity position as compared to the antigravity position then maybe I would come up with soemthing. At this point I am taking BP only because you are asking me to. If a guy came in with Orthostatic Hypertention I would teach how to get up slowly and try to modify the activity that was causing his OH
Remember I'm not looking anything up.
From his history. The guy is from NH. I grew up in NH and there is snow on the ground still and its wet. I bet the guy was shoveling snow and he got "woozy" from the up down motion of shoveling. CAD would confound any blood flow issue to the brain.
Oh yeah and then I'd find out what chirx asked for :)
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Re: Case - March 23, 2005 7:44:00 PM
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Synergy
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From: Forney, TX
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I'm not sure if the O.H. he is experiencing is a result of his IDDM, but maybe there is something going on with his medications (agree with SJ). What's he taking for his CAD and his BPH?
My mother has CAD and she's on a regimen of medications from beta blockers to nitrates. She doesn't have O.H. and rarely if ever has bouts of dizziness.
I think the next step I'd take is to find out the types/dosages of meds he's taking and the potential side effects that he may incur from each of them...specifically from the BPH meds since I've dealt with my mothers heart disease for quite some time and have yet to see this side-effect.
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Chris Adams, PT, MPT
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Re: Case - March 24, 2005 1:24:00 AM
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Andrew M. Ball PT PhD
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Wouldn't we start with a general health screening? Ask questions about fatigue, malaise, weakness, chills/fever/low grade fever of more than 100 that lasted for more than 2 weeks, unexplalined weight loss/gain of more than 5% body weight, nausea, or parathesia?
The answers to these questions aren't going to be all that sensitive, but they are the are the initial medical screening questions taught in just about any DPT program. They will begin to clue a clinician in to organ system dysfunctions ranging from depression/anxiety, to infection, to liver disfunction, to cancer, to rheumatic disorders.
With orthostatic hypotension, and weakness we'd also want to subjectively screen the cardiovascular, pulmonary, GI, and endocrine systems. So, patient, any dyspnea, orthopenea, palpitations, pain/sweats, suncope, peripheral edema or cough? Any Tachypenea, Hemoptysis, Sputum, stridor, wheezing or clubbing? Any Nausea, vomiting, heartburn? Constipation, changes in bowel color, caliber, continence, constipation? Finally, any arthralgia, myalgia, muscle cramps, heat/cold intolerance, skin or hair changes? Finally, what medications is the guy taking? Corticosteriods, Beta-Blockers, Ca Channel Blockers, ACE Inhibitors, Diuretics, and Digoxin can all cause general muscle weakness, and (I THINK, but don't remember, would have to look up) more than a few can have orthostatic hypotension as a side effect.
Drew
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Dr. Andrew M. Ball, PT, DPT, Ph.D.
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Re: Case - March 24, 2005 1:45:00 AM
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Diane
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From: Vancouver, B.C., Canada
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Given the fact the person is 70, there could be a lot of things going on. Isn't there a rule about that? Under 60 look for a single cause for all the S&S, after 60, multiple? I don't know what CAD or IDDM stand for. Is the guy well enough hydrated? Kidneys OK?
If he's been adequately/medically cleared then we put on a PT hat and try to think what might be going on neuromuscularlyskeletally.
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Re: Case - March 24, 2005 2:11:00 AM
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SJBird55
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From: Michigan
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Wags... I don't know if most most physical therapsists do take vitals. My cousin is a nurse for a cardiologist. She hasn't noticed that any physical therapists, in particular home health physical therapists, taking blood pressures. I know when I did a stint in home health I had to rationalize to my employer why I needed a BP cuff.... and then at the hospital outpatient setting same thing. I finally got a BP cuff, but whenever I had a large arm, well, I went and borrowed the physicians' large cuff next door. So, I'm going to say that probably most therapist do not take vitals. None of the other therapists in the clinic where I worked used the BP cuff...
Diane... coronary artery disease..... insulin dependent diabetes with that m word. :) I'm terrible at any abbreviations.
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Re: Case - March 24, 2005 2:35:00 AM
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tucker
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From: Texas
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I'm going to go with..the orthostatic hypotension is likely a side-effect of one of the patient's medications...several medications have this as a side-effect. What are the meds? Metoprolol, Propranolol? If not, my next guess would be hemoglobin <10.
We have BP readily available with every patient in the ICUs and pay close attention to it...either cuff or art line.
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Re: Case - March 24, 2005 2:43:00 AM
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SJBird55
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From: Michigan
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Just a side track here... chirx... I'd like to know why immediately you are ordering lab tests. For some reason, I think that physicians are so dependent on test results that they immediately order them. Why wouldn't it be better to spend some time with this gentleman (I'm assuming he isn't in the emergency room)... ask a bunch of good questions, come up with the most apparent working diagnosis and then potentially order lab tests to verify that diagnosis? Why do physicians immediately generally want to run tests? I'm not saying I'm against lab work and diagnostic testing, but I just don't understand the rationale for ordering the tests especially in this instance - there is hardly any information to go on.
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