Texila American University

Case Report Format

Student Name: Dr.Shahzad Ahmad

Program/Specialization: Family Medicine

Hospital/Clinic Name: Salabiakhat Centre

Year of Study: 3rd Semester 2016

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INSTRUCTIONS
 All the fields are mandatory.
 Each field carries mark.
 Type the details in the respective columns.

EVALUATION CRITERIA
CRITERIA MARKS PROGRAM CHAIR
MARKS
Title 5
Abstract and summary 10
History 15
Examination 15
Diagnosis / Differential diagnosis 5
Investigations and interventions 10
Treatment 10
Discussion 15
Learning points 5
References 5
Communication and presentation 5
TOTAL MARKS 100

PROGRAM CHAIR COMMENTS:

PC’s SCORE
ORTHOSTATIC HYPOTENSION OUT OF 5
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Case Report Format
ABSTRACT- PC’s SCORE
OUT OF 5

This case related to 50 years old man, came to us in Salabiakhat health care center
complaining of having general weakness, lethargic, headaches and occasional
dizziness for the past 2 months. He had also had occasional abdominal discomfort,
moderate anorexia, and minimal intermittent weight loss due to nausea. He tired
more frequently. Detailed history and examination and investigations were done and
he was diagnosed with orthostatic hypotension and was mainly treated by advice.

PC’s SCORE
HISTORY OUT OF 15

Chief Complain A 50 years old male patient presented with general weakness,
headaches and occasional dizziness for the past 2 months

He had also had occasional abdominal discomfort, moderate anorexia, and minimal
intermittent weight loss due to nausea. He tired more frequently than before and
had also anhedonia.

He was normally well, had a balanced diet and was not on regular medication. He
seemed frustrated, anxious and concerned, and had done some research into
possible causes for his symptoms. He thinks he was having anemia or hypothyroidism
and there was no family history of thyroid problems.

EXAMINATION PC’s SCORE OUT

OF 15
The patient's examination seemed unremarkable, with a sitting BP of 124/74 mmHg,
a regular pulse rate of 66, a BMI of 22 kg/m 2, no apparent goiter, normal looking skin,
and a normal abdominal examination.

There was no focal weakness in his limbs and the Romberg test was negative. An ear,
nose, and throat examination and a brief check of the cranial nerves were all normal.
A urine dipstick was clear.

The challenge with such presentations is that the symptoms are vague and could be a
feature of common temporary and self-resolving phases in patients with no clear
 Texila American University
Case Report Format

underlying medical condition.

However, a sitting-standing BP re-check confirmed a significant drop from 120/72

mmHg to 92/60 mmHg, although there were no acute symptoms, such as dizziness.

DIAGNOSIS :
ORTHOSTATIC HYPOTENTION
The BP finding determined postural hypotension, which is defined as a positional
difference of at least 20 mmHg.

DIFFERENTIAL DIAGNOSIS
PC’s SCORE
1: VASO-VAGAL syncope
OUT OF 5

2: Vertigo

3: Idiopathic

4: Psychogenic syncope

5: Neurogenic

INVESTIGATIONS / INTERVENTIONS PC’s SCORE

OUT OF 10
CBC
ferritin
liver function
renal function
blood sugar
thyroid function
CRP and ESR
Serum Electrolyte

The blood results were all normal, apart from minimally out of range LFTs and slightly
low sodium (130 mmol/l), as well as mildly raised potassium levels of 5.5 mmol/l.
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Case Report Format

TREATMENT
Advices

1: Advice to avoid standing micturition.

2: Avoid getting up too quickly from a lying or sitting position.

3: Drink plenty of water before long periods of standing, or any activities that tend to
trigger symptoms.

4: Avoid alcohol. Alcohol can worsen orthostatic hypotension, so limit or avoid it

PC’s SCORE OUT
completely.
OF 10
5: Compression stockings.

6: Avoid bending at the waist.

7: In cases of regular vasovagal syncope there could be a need for medication

(prescribed by a specialist), including fludrocortisones (100-200 microgram at night),
pyridostigmine or, in some cases, paroxetine, which has been shown to be
occasionally helpful. Frequent syncope can have significant implications for a
patient's life, including for work and driving.

DICUSSION PC’s SCORE OUT

OF 15
Orthostatic hypotension, which is a physical finding, not a disease, may be
symptomatic or asymptomatic. The American Autonomic Society (AAS) and the
American Academy of Neurology (AAN) define orthostatic hypotension as a systolic
blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease
of at least 10 mm Hg within three minutes of standing up [Evidence level C,
consensus/expert guidelines] The AAS and AAN also provide a tilt-table definition.
This determination has limited usefulness for the approach outlined in this article and
appears to have a high rate of false-positive results.
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Orthostatic hypotension has been observed in all age groups, but it occurs more
frequently in the elderly, especially in persons who are sick and frail. It is associated
with several diagnoses, conditions, and symptoms, including lightheadedness soon
after standing, an increased rate of falls, and a history of myocardial infarction or
transient ischemic attack. It also may be predictive of ischemic stroke.

LEARNING POINTS PC’sSCORE OUT

OF 5
Normally, when a person moves to an upright position, blood pressure and heart rate
change so quickly that continuous electronic monitoring is required to detect the
differences, and ordinary clinical observations lag behind the physiologic changes.
The line between normal and pathologic changes in blood pressure and heart rate is
not easy to define clinically. Although heart rate measurement is not included in the
AAS/AAN definition of orthostatic hypotension, it can be determined easily and may
be helpful, especially in patients who do not meet the blood pressure criteria of
orthostatic hypotension. An elevation in heart rate that occurs when a patient moves
from decumbency to standing may indicate compensation for decreased stroke
volume. However, clinical decisions should be guided more by symptoms of
decreased cerebral perfusion than by absolute blood pressure or heart rate
measurements.

REFERENCES PC’sSCORE OUT

OF 5

1: Consensus statement on the definition of orthostatic hypotension, pure autonomic

failure, and multiple system atrophy. The Consensus Committee of the American
Autonomic Society and the American Academy of Neurology. Neurology.
1996;46:1470

2: Petersen ME, Williams TR, Gordon C, Chamberlain-Webber R, Sutton R. The normal

response to prolonged passive head up tilt testing. Heart. 2000;84:509–14
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3: Harrison TR, Brunwald E. Harrison's Principles of internal medicine. 15th ed. New
York: McGraw-Hill, 2001

4: Low PA. Prevalence of orthostatic hypotension. Clin Auton Res. 2008;18(Suppl 1):8-
13

5: Weiss A, Grossman E, Beloosesky Y, et al. Orthostatic hypotension in acute

geriatric ward: is it a consistent finding? Arch Intern Med. 2002;162:2369-2374

COMMUNIC ATION AND PRESENTATION PC’s SCORE

OUT OF 5
The first steps in treatment of orthostatic hypotension are diagnosis and management
of the underlying cause. A patient with symptomatic orthostatic hypotension who has
a disease with no complete or specific cure may benefit from no pharmacologic
interventions. Increasing salt and fluid intake often is an initial step, although it may
be difficult to undertake in some patients, such as those with severe congestive heart
failure. Non steroidal anti-inflammatory drugs can be used to increase intravascular
volume.

When an adult rises to the standing position, 300 to 800 mL of blood pools in the
lower extremities. Maintenance of blood pressure during position change is quite
complex; many sensitive cardiac, vascular, neurologic, muscular, and neurohumoral
responses must occur quickly. If any of these responses are abnormal, blood pressure
and organ perfusion can be reduced. As a result, symptoms of central nervous system
hypo perfusion may occur, including feelings of weakness, nausea, headache, neck
ache, lightheadedness, dizziness, blurred vision, fatigue, tremulousness, palpitations,
and impaired cognition. Vertigo also has been reported.