GIM Question 33 Instructor

A nurse notifies you that a patient of yours has a blood pressure of 90/65. The day before his BP was 110/75.

1. What is your differential diagnosis for this acute drop in BP?
   The differential diagnosis for acute hypotension includes:
   • Hypovolemia 2⁰ to decreased fluid intake
   • Acute bleed
   • Shock
     • Hypovolemic (typically acute bleed)
     • Cardiogenic – MI, arrhythmia, cardiac tamponade, pulmonary embolism
     • Septic
     • Anaphylactic (i.e. medication, environment, food)
   • Medication-induced
     • Diuretic
     • Vasodilators – hydralazine, nitroglycerine, calcium channel blockers
     • Antihypertensives – alpha blockers, beta blockers, calcium channel blockers
2. What is the definition of orthostatic hypotension?
   Orthostatic hypotension is defined as:
   • Systolic BP drop ≥20mmHg from lying to standing
   • Diastolic BP drop ≥10mmHg from lying to standing

   These postural changes are often accompanied by an increase in heart rate increase ≥30bpm from lying to standing

3. How would you assess this patient?
   Initial assessment of this patient includes the following:
   • Stabilize ABCs
   • History – chest pain, palpitations, dyspnea, light-headedness, presyncope/syncope, blood in stool/melena, hemoptysis
   • Repeat vitals with orthostatic vitals
   • Physical exam – cardiac, JVP, respiratory, abdominal, skin
   • Assess volume status and daily Ins/OUTs
   • Review patient’s MAR for medications:
     • New mediations?
     • Doubling medications?
   • If suspicious for ACS/MI – ECG, troponin, CK

Resource
Lanier JB, Mote MB and Clay EC. Evaluation and Management of Orthostatic Hypotension. Am Fam Physician. 2011, 84:527-536.