Hypotension: A Case Study

S.P. is admitted to the orthopedic ward. She has fallen at home and she has sustained an intracapsular fracture of the hip at the femoral neck. The following history is obtained from her: She is a 75-year-old widow with three children living nearby. Her father died of cancer at age 62; mother died of heart failure at age 79. Her height is 5’3 and weighs 118 pounds. She has a 50 pack year smoking history and denies alcohol use. She has severe Rheumatoid Arthritis (RA) and had an upper GI bleed in 1993 and had Coronary Artery Disease with CABG 9 months ago. Since that time, she has engaged in “very mild exercise at home.” Vital signs are 128/60, 98, 14, 99 degree farenheight (32.7 degrees C) SAO2 94%

1. Postural vital signs. It is important to test for orthostatic hypotension especially given the patient's recent change in medications

She converses appropriately. Blood pressure 92/60 supine. Blood pressure decreased to 72/50 standing. Pulse is 90 and regular. Weight 113 pounds. She has a normal appearance of her face and does not have a masked appearance of her face. She has good strength throughout her face. She has good strength of her extremities. She has only minimal cogwheel rigidity at the left wrist, but no cogwheel rigidity at the right wrist. She has no tremor of her hands. She moves her extremities freely and with normal speed. She is able to rise on her own from a sitting to a standing position, only minimal bradykinesia of standing. She walks fairly freely and there is a normal cadence of her gait. She did not have dyskinetic movements of her extremities. She is able to walk, including turning without losing her balance. She does not shuffle her feet when walking. She does not have en bloc turning. She has good posture stability

She has a medical history of severe RA, had an upper gastrointestinal bleed in 1993, and had coronary artery disease with a coronary artery bypass graft (CABG) 9 months ago. She lives alone but has three children whom live close to her. She is a widow and her father died of cancer at 62 years old and mother died from heart failure at 79 years old. She has a 50-pack-year smoking history but denies alcohol use. Ever since her CABG she has engaged in “very mild exercises at home.” Her medications are Rabeprazole (Aciphex) 20mg/day, Prednisone (Deltasone) 5 mg/day PO and Methotrexate (Amethopterin) 2.5 mg/week.

A review of her medical record indicates that she has a history of functional decline, dementia, weakness, MRSA, cognitive communication deficit, presence of right artificial hip joint and HTN.

MEDICAL UPDATE: Client continues to report arthritis in her left leg and hand, high blood pressure. She also reports she will need surgery but she is waiting to be housed.

Mrs. Wilson is seen in her room at Glenbridge Nursing Home on 02/28/2018. She had an episode last night of chest pain. She is so ebullient and distracted that it is hard to get a straight history, it came on when she was asleep but she may been sitting up. She was seen by a nurse, a sat was taken. I am not sure if there were other orders taken, but there is none on the chart. She says that she spent most of this morning in the bed and still feels tired, but she does not think she broke out in a sweat. She was more short of breath. She is calling it is a "stroke." I had tried to begin tapering her diazepam by discontinuing the morning dose and apparently all daytime clorazepate was discontinued by error and she gets it only at night.

A review of her medical records indicates that she has not had any significant health events, such as falls or hospitalization since her last visit. She suffers from chronic stable hypothyroid, chronic DM which is mange with medication and chronic neuropathy.

Pt lived on her own until 4-27-12 when her family found her lying on the floor in her home. Pts family brought her to live with them but pt continued to have episodes of falling and hitting her head. Pt was taken to the ER and given a Ct of the brain where all results turned up normal. After at least 5 more falls the pts family took her back to the hospital with complaints of chest pain and palpitations. Pt was more confused than usual & and was having increased difficulty in

At today’s visit she is accompanied by her husband and private aide. Her husband reports that she is doing much better. He states that her pain has improved and she has not taken her pain medication since last visit. He states that her anxiety had improved extremely with the recent change in her Xanax. He states that he has hired 24 help for the patient and since she has not fallen. She reports that she is feeling well. The caregiver reports that the patient continue to suffers from hypotension and hypertension with variation in blood pressure. The patient also continues to suffer from chronic tremors as a result of her Parkinson.

Childhood illnesses include measles, mumps, rubella, and chickenpox. She has fallen many times however, has never broken any bones. Serious traumas include three concussions. Has had many surgeries including tonsils removed, gastric bypass, right hip replacement, 2 bilateral knee surgeries, cataracts removed, back surgery and is waiting for shoulders to be replaced. Reports sinus infections in the spring and fall due to pollen and mold. These symptoms are similar to the ones she is experiencing now. Several years ago, she traveled around the world for 7 months and was in England for the Mad Cow Disease outbreak.

At todays visit she is accompanied by her husband. She is awake, alert and oriented. She complains of chronic pain in her hips and legs that radiate down to her feet. She describes her pain as as shooting, dull, ache. “she states, sometimes its like

At today's visit she is found in her room sitting in her recliner. She reports chronic, intermittent, dull, achy, lower back pain. Her current pain regimen is effective for her pain according to the facility staff. The staff reports that the patient is sleeping more hours during the day. She has increased generalized weakness. No acute distress noted this visit.

At today’s visit she is found sitting in her room in her wheelchair. She is awake, alert and oriented. She reports that she has had multiple falls over the weekend. She denies pain, shortness of breath and chest pain. The facility staff reports that she has had multiple falls and seems to be falling more lately. The patient uses a wheelchair;

Daily weights: Performed on the same scale, the same time of day, and in clothing of the same/similar weight