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

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

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