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Re: Case - March 24, 2005 2:47:00 AM
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jma
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In addition, I would like to know how "active" this patient is. A sedentary individual who also happens to be overweight, taking lots of meds, can have orthostatic hypertension as well.
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Re: Case - March 24, 2005 2:59:00 AM
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Jon Newman
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The things in his history that are interesting to me are the fact that he is a NH resident at 70 years of age suggesting other issues not already mentioned--possible dementia or other mobility issues that have this fellow spending lots of time not moving and possibly having poor nutritional intake.
How is his hydration/electrolytes?
He has IDDM--is his autonomic nervous system working properly?
jon
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Re: Case - March 24, 2005 3:13:00 AM
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KAK
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Wags
I routinely take a base BP and pulse during the eval on my elderly and medically involved patients (outpatient setting). I frequently get complaints of “lightheadedness” or “not feeling right today”. One of the first things I do is check their vitals; from the eval, I have a “normal” to compare to.
I would check his BP supine and compare to sitting/standing.
Clue to origin? IDDM (diabetic neuropathy) or cardiac issue. I'm not sure how BPH would contribute unless there is a common med used for this that could be it's cause.
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Re: Case - March 24, 2005 3:19:00 AM
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KAK
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Maybe the origin is a simple as the nursing home doen't get him out of bed enough- therefore the generalized weakness and the orthostatic hypotension.
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Re: Case - March 24, 2005 4:13:00 AM
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JLS_PT_OCS
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I would agree with Drew that the medical screening questionnaire is first and that our first responsibility is to see if this patient really belongs in our clinic.
I do take vitals in the clinic when needed (though in an outpatient ortho/sports clinic I don't really see anyone with any degree of medical complexity recently), though that isn't often. Certainly this seems to be one of those cases.
Certainly a more detailed hx as revealed by a screen would be important. In a patient of this age, medical history, and with dizziness or "orthostatic hypotension" there are a lot of things that need to be looked at, and that needs to happen in the office of an actual physician, not a PT or chiro or athletic trainer. The good thing about the training we get as PTs is that we have a very sharp radar for those who need a further medical workup. This gentlemen's case is making my spidey sense tingle. So to speak.
I would be interested in speaking with this gentleman's physician about him and discussing the case before initiating treatment (especially with such little info, and we all know that sometimes happens in the imperfect world of medical records).
Diane, CAD is coronary artery disease, IDDM is insulin dependent diabetes mellitus. They are american-style abbreviations, you guys probably use different ones. I ran into an MD from the UK once who said it was scary how different the terms and abbreviations are, even though we speak the same language!
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Case - March 24, 2005 4:21:00 AM
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Ref_in_Rehab
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While I don't routinely take BP measurements on every patient, if they complain of dizziness or have the "orthostatic hypotension" diagnosis, of course I'm going to check it out.
As far as his history giving a hint- along with the questions regarding how long he has been "weak", how long in the nursing home, etc. I would wonder if his diabetes is well controlled? Maybe his BG levels are out of whack? That certainly could explain weakness and fatigue/dizziness with any exertion similar to cardiac problems.
Sean
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Re: Case - March 24, 2005 4:28:00 AM
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Yogi
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Wags, 10 years ago I didn't take BP in home health. I do now, and so far in two years part time I've sent one to ER with family, and family called EMT for two. I know they did the one guy some good, one I don't know about, and the other continued HTN, but it equalized one side to the other.
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Re: Case - March 24, 2005 4:36:00 AM
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dross
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SJBird,
I dont want to take away from the case but I can answer your question. No matter what the hx tells you in this situation, the least you will order is a CBC and a BMP. I didnt say I wouldnt take a complete hx, that goes without saying. But basic lab work to us like ROM testing to you.
This is one of those cases where you shoot first and ask questions latter. 60, orthostasis.....
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Re: Case - March 24, 2005 4:39:00 AM
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dross
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From: NJ
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One more thing. Im not a PT. I dont know what you guys do in your evaluations as far as work up hx, physical etc. So things that have been drilled into me to do may not be the same as you.
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Re: Case - March 24, 2005 4:47:00 AM
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hmgross
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I have a nursing background so I am stepping back, reading but not addressing the original question. Just want to say my PT education (MA program)including cardiopulmonary, medical screening--vitals, etc. which I do fairly often for my patients with med. histories that would indicate appropriate monitoring.
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Holly Gross PT
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Re: Case - March 24, 2005 6:00:00 AM
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JLS_PT_OCS
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The general consensus seems to be that this patient needs a further evaluation from an MD.
I, for one, would definitely be on the phone with the physician, just to clarify some things and make sure we were both on the same page.
A little communication goes a long way... especially when you are out of your depth. That's why they call me with acute back pain and sports injuries...can't say how helpful that back-and-forth communication has been in the past, indispensable.
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Case - March 24, 2005 7:01:00 AM
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SJBird55
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I'm not in that general consensus then, Jason. If that patient walked in the door and I was supposed to be evaluating him, well, I'd ask the 20 million questions first and get a good history and as much subjective information as I could. Sometimes things just work out fine where physical therapy services are warranted. If, through my evaluative findings I felt that I had strong concerns and felt that the risk of treatment outweighed any benefit or if I still had questions, then sure, I'd contact the MD. The basic questions to even derive a decision at this point in time haven't even been answered yet, in my opinion.
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Re: Case - March 24, 2005 7:55:00 AM
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jimptdpt
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From: Medway, Ma, usa
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How about this as a shot in the dark. Since he lives in New Hampshire and chronic Lyme disease can give you weakness and orthostatic hyoptension. I would question him a little along those lines, ie history of fever, neck pain. etc.
Jim Hosker PT, DPT, OCS
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Re: Case - March 24, 2005 8:06:00 AM
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jimptdpt
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Ok. I just thought of something. I'm guessing the NH stands for Nursing Home, not New Hampshire. So my last post doesn't make to much sence. I guess this is why JCAHO hates abbreviations.
Jim Hosker PT, DPT, OCS
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Re: Case - March 24, 2005 8:21:00 AM
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JLS_PT_OCS
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SJ-
I see where you are coming from.
I just think that these types of cases are sort of...difficult because often so little info is provided.
I base my decision to call in another provider's experience based on the limited information we currently have, and it is insufficient.
I remember this is why I hated role-playing so much during all those oral exams...attempts to make things as "realistic" as possible often only serve to confuse things further, especially when the tester has an idea of what one piece of information should be important, the testee another. And both are really opinions, and not standard of care type stuff.
But I do think this sort of thing has value in this venue to get all of us thinking, especially when different folks (like Wags in this case) share their expertise. A great use for the forum board.
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Case - March 24, 2005 5:56:00 PM
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Dr.Wagner
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HAHAHAHAHA!!
Yep, NH stands for nursing home, I almost crapped my pants when I read "pt from New Hampshire". Fantastic.
Ok, this really is not a case of "the right answer", but rather to see what are the approaches to this patient.
Overall, the history may lead to an answer 1. iatrogenic; meds may cause side effects (specifically beta blockers and his med for BPH, Flomax) 2. Dehydration is HUGE in this patient population (a reason for labs) 3. cardiogenic 4. neurogenic 5. Unknown
Overall, if the Orthostasis was profound, this is a patient that should seek medical attention and should be seen as acutely abnormal, so calling the doc is ABSOLUTELY appropriate.
Thank You for your answers...I simply wanted to know some of the approaches and to see what was available to you and how you would approach it.
He had an "idea" but not a good grasp of this basic condition. Thank you.
By the way, this also helps as I may be "coordinating" a medical managament of selected diseases/ pathology type course for a PT school next year...I have been asked, and now I suppose I will see the time I have on hand.
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Re: Case - March 24, 2005 7:58:00 PM
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Synergy
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Thanks for posting this case Wags! Please feel free to do so more often in the future as I feel that it enhances our critical thinking.
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Chris Adams, PT, MPT
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Re: Case - March 25, 2005 3:21:00 AM
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JLS_PT_OCS
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This is definitely a great idea and use for the forum.
We often do not have a "good grasp of this basic condition" when it is out of our scope, hence the referral/communication.
I have found that things in the musculoskeletal world that seem "basic" to me are really like rocket science to some physicians. I had one on the phone the other day, trying to explain to him why it was bad to put a patient NWB on crutches with an ankle sprain using a posterior splint. He of course referred him to me at the TWO WEEK followup when "he" felt therapy was appropriate. Wow. You can imagine the contracture we had there. He did have an "idea" of how to treat the injury, but as Wags pointed out, he did not have a good grasp of this basic condition, and how to proceed.
So I really feel that back and forth communication and willingness to ask for assistance/consultation are critical in today's healthcare environment.
I have learned a tremendous amount from other healthcare providers and they from me, in this way.
Wags -- keep 'em coming!
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Case - March 27, 2005 2:19:00 PM
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chiroortho
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You're all full of it. I'm disappointed. Wagner, I thought you were residency trained.
Now to school you dingbats.
Orthostatic hypotension: The immediate vasovagal effect that occurs when your orthopedist gives you static.
Don't post any more cases here until you get your act together.
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Greg Priest, DC, DABCO
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Re: Case - March 28, 2005 6:19:00 AM
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JLS_PT_OCS
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From: USA
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Greg, you're right, I think that happened to me once.... I nearly jumped off the table!!
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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