Orthostatic Hypotension Assessment
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Questions and Answers

What should be asked about the patient's medications during assessment?

  • If they have stopped taking medications prescribed in the past
  • Whether they are taking only over-the-counter medications
  • Whether they have discussed their medications with family members only
  • If they have started any new medications that correspond to the onset of symptoms (correct)

    • What investigation should be offered if it has not been done for a patient experiencing symptoms?

  • Ultrasound of the abdomen
  • X-ray of the chest
  • FBC, HBa1c, and ECG (correct)
  • MRI of the brain

    • What is a key part of managing a patient who has fallen and lives alone?

  • Providing a home exercise program
  • Offering a falls alarm through frailty practitioners (correct)
  • Suggesting a wellness retreat
  • Recommending a complete diet overhaul

    • Which of the following is part of the SOCRATES method for assessing pain?

    <p>Determining the site of the pain</p> Signup and view all the answers

    How often should a patient be followed up after management of symptoms?

    <p>In 1-2 weeks</p> Signup and view all the answers

    What lifestyle change can be recommended for managing intermittent claudication?

    <p>Smoking cessation and weight loss</p> Signup and view all the answers

    Which medication is commonly offered for managing intermittent claudication?

    <p>Clopidogrel 75mg daily</p> Signup and view all the answers

    Which symptom should work to rule out spinal claudication?

    <p>Back pain</p> Signup and view all the answers

    What is the best approach when discussing treatment options with a patient at a crossroads?

    <p>Provide full information and let the patient decide on the risks.</p> Signup and view all the answers

    What monitoring is suggested for a patient taking Apixaban to reduce bleeding risks?

    <p>Monitor creatinine clearance and FBC levels.</p> Signup and view all the answers

    When is stopping Aspirin under consideration?

    <p>If the patient has no contraindications for its use.</p> Signup and view all the answers

    What suggests the possibility of familial hypercholesterolaemia (FH)?

    <p>A total cholesterol level greater than 7.5 mmol/L.</p> Signup and view all the answers

    What is an indication to perform a blood test when assessing cholesterol?

    <p>The patient experiences chest pain or shortness of breath.</p> Signup and view all the answers

    Which of the following describes good cholesterol?

    <p>HDL.</p> Signup and view all the answers

    What symptom might indicate the need for further evaluation of cholesterol levels?

    <p>Tendon xanthomata or xanthelasma.</p> Signup and view all the answers

    When discussing cholesterol results with a patient, what is a recommended question to ask?

    <p>Was there anything you were expecting the results to show?</p> Signup and view all the answers

    What is considered a positive FeNO test result for adults aged 17 and over?

    <p>40 ppb or higher</p> Signup and view all the answers

    What FEV1/FVC ratio indicates a positive spirometry result?

    <p>Less than 70%</p> Signup and view all the answers

    What defines a positive bronchodilator reversibility test for adults?

    <p>Improvement in FEV1 of 12% or more, with an increase of 200 mL or more</p> Signup and view all the answers

    Which of the following is considered a positive result for peak expiratory flow (PEF) variability?

    <p>More than 20% variability</p> Signup and view all the answers

    What is the criteria for using inhaled SABA three times a week or more?

    <p>Waking up at night once a week</p> Signup and view all the answers

    For adults, what is considered a low dose of beclomethasone?

    <p>400 mcg</p> Signup and view all the answers

    Which medication is categorized as a Leukotriene Receptor Antagonist (LTRA)?

    <p>Montelukast</p> Signup and view all the answers

    Which combination therapy contains both an inhaled corticosteroid and a long-acting beta agonist?

    <p>Fostair</p> Signup and view all the answers

    What FEV1/FVC ratio confirms persistent airflow obstruction in COPD?

    <p>0.7</p> Signup and view all the answers

    Which of the following is a recommended first-step management for COPD?

    <p>SABA - Salamol or Salbutamol</p> Signup and view all the answers

    Which of the following features indicates asthmatic characteristics in COPD patients?

    <p>Personal history of atopy</p> Signup and view all the answers

    What should be assessed to determine the management step for a COPD patient?

    <p>Quality of life and exacerbations</p> Signup and view all the answers

    When should a patient progress to the next step in COPD management?

    <p>They have exacerbations despite using SABA alone</p> Signup and view all the answers

    Which question is crucial for understanding COPD exacerbations?

    <p>How many times have you had a flare requiring steroids in the last year?</p> Signup and view all the answers

    What does a chest X-ray help to exclude in the diagnosis of COPD?

    <p>Lung cancer</p> Signup and view all the answers

    Which medication combination is appropriate for a patient with asthmatic features in COPD?

    <p>LABA + ICS</p> Signup and view all the answers

    What are common causes of dizziness that may not be triggered by head movement?

    <p>Labyrinthitis</p> Signup and view all the answers

    What symptom associated with labyrinthitis can help differentiate it from vestibular neuronitis?

    <p>Hearing loss</p> Signup and view all the answers

    In the case of benign paroxysmal positional vertigo (BPPV), how long do episodes of dizziness typically last?

    <p>A few seconds</p> Signup and view all the answers

    Which of the following questions is important to clarify the type of dizziness?

    <p>Is the dizziness constant or intermittent?</p> Signup and view all the answers

    What symptom might indicate mastoiditis, requiring safety net advice?

    <p>Redness behind the ear</p> Signup and view all the answers

    Which of the following conditions typically presents with episodes of flu-like symptoms along with vertigo?

    <p>Vestibular neuronitis</p> Signup and view all the answers

    What is an important follow-up recommendation for patients experiencing dizziness?

    <p>Follow up in 3 days</p> Signup and view all the answers

    What differentiates central causes of vertigo from vestibular neuronitis and labyrinthitis?

    <p>Ability to walk with eyes open</p> Signup and view all the answers

    Study Notes

    Orthostatic Hypotension

    • Ask the patient about their alcohol consumption, and if anyone else in their household has noticed any unusual changes in their behavior or well-being.
    • Inquire about medication use, including over-the-counter medications. If they are taking any new medications, check if the onset of symptoms coincides with the medication initiation. Ensure you understand the indications of each medication to determine if they may be contributing to the orthostatic hypotension.
    • Offer investigations such as a full blood count (FBC), HbA1c, and electrocardiogram (ECG) if these have not already been performed.
    • Perform a physical examination, measuring blood pressure while the patient is lying down and standing up.
    • Consider deprescribing medications like bisoprolol and amlodipine if possible and if they are not currently essential for managing other conditions.
    • If the patient lives alone and has experienced a fall, consider offering them a falls alarm, which can be provided by frailty practitioners.
    • Advise the patient on how to avoid potential triggers, such as high temperatures or extreme temperature changes.
    • Encourage adequate hydration.
    • Instruct the patient to get up slowly from a sitting position to avoid sudden drops in blood pressure.
    • Schedule a follow-up appointment within 1-2 weeks to assess the patient's progress.
    • Emphasize the importance of seeking immediate medical attention for symptoms such as chest pain, palpitations, syncope (fainting), shortness of breath (SOB), or worsening symptoms.

    Intermittent Claudication/Peripheral Artery Disease (PAD)

    • Utilize the SOCRATES mnemonic to explore the nature and characteristics of the leg/calf pain.
    • Determine if the pain is located in one or both legs (unilateral or bilateral).
    • Ask if the pain is felt in the buttocks or thigh.
    • Inquire if the pain occurs at rest or only during activity.
    • Ask about the presence of back pain to rule out spinal claudication.
    • Assess the patient's presence of the “5 Ps” - Pallor, Paraesthesia (pins and needles), Paresis (weakness), Pain, Perishingly cold. Explore any swelling or redness in the legs to rule out deep vein thrombosis (DVT).
    • Assess for ulcers or skin changes, including hair loss on the legs or feet.
    • Inquire about erectile dysfunction.
    • Ask about chest pain, palpitations, and back pain to further rule out spinal claudication.
    • Obtain details regarding the patient's smoking habits, alcohol consumption, diet, and overall lifestyle.
    • Explore the patient's occupation to evaluate any potential occupational factors related to their symptoms.

    Raised Cholesterol and Statin Initiation

    • Ascertain the reason for the blood test that revealed raised cholesterol levels.
    • Inquire about symptoms like chest pain, shortness of breath (SOB), palpitations, and weakness in a single limb.
    • Assess for the presence of lumps or bumps around the knuckles or ankles (tendon xanthomata) and a yellowish lump around the corner of the eye (xanthelasma).
    • Explore the patient's diet and level of physical activity.
    • Obtain information regarding their smoking and alcohol consumption.
    • Ask about family history of heart disease, stroke, etc. Consider the possibility of familial hypercholesterolaemia (FH) in adults with:
      • A total cholesterol level greater than 7.5 mmol/L
      • A personal or family history of premature coronary heart disease (CHD, an event before 60 years in an index person or first-degree relative - parents, siblings, children).
    • Inquire about any over-the-counter medications the patient may be taking.

    Asthma

    • Diagnosis

      • Fractional exhaled nitric oxide (FeNO) testing: A positive result in adults (aged 17 and over) is 40 ppb or higher; 35 ppb or higher is a positive result in children aged 5-16 years.
      • Spirometry: A FEV1/FVC ratio lower than 70% is indicative of asthma.
      • Bronchodilator reversibility: An improvement in FEV1 of 12% or more, together with an increase in volume of at least 200 mL in response to beta-2 agonists or corticosteroids suggests a positive result in adults. In children, an improvement in FEV1 of 12% or more is considered a positive result.
      • Variable peak expiratory flow (PEF) readings: A value of more than 20% variability after monitoring at least twice daily for 2-4 weeks indicates a positive finding in both adults and children.

    • Management

      • Inhaled Short-acting Beta-2 Agonist (SABA): Prescribe salbutamol or salamol to all patients suspected of having asthma.
      • Inhaled Corticosteroids (ICS): Criteria for initiation or change in medication:
        • Use an inhaled SABA 3 times a week or more.
        • Experience asthma symptoms 3 times a week or more.
        • Wake up at night once a week or more.
        • Have had an asthma attack requiring oral steroid treatment.
      • Examples of ICS: Clenil (beclomethasone)
      • Dosage of ICS (Beclomethasone example) - Adults:
        • Low dose: 400mcg (100mcg 2 puffs BD)
        • Moderate dose: 800mcg (200mcg 2 puffs BD)
        • High dose: More than 800mcg
      • Dosage of ICS (Beclomethasone example) - Children:
        • NICE paediatric Low dose (BTS/SIGN very low dose): 200mcg (50mcg 2 puffs BD)
        • NICE paediatric Moderate dose (BTS/SIGN Low dose): 400mcg (100mcg 2 puffs BD)
        • NICE paediatric High dose (BTS/SIGN Moderate dose): 800mcg (200mcg 2 puffs BD)
      • Steps after SABA and ICS:
        • Leukotriene Receptor Antagonist (LTRA): Montelukast tablets.
        • Long-acting Beta-2 Agonist (LABA) in combination with ICS: For example, Fostair (Beclometasone with Formoterol), Symbicort (budesonide and formoterol).
        • Maintenance and Reliever Therapy (MART): containing both ICS and fast-acting LABA. Examples include Seretide (fluticasone with salmeterol), Fostair, Symbicort.

    Chronic Obstructive Pulmonary Disease (COPD)

    • Diagnosis

      • Post bronchodilator FEV1/FVC less than 0.7 confirms persistent airflow obstruction.
      • Other investigations include:
        • Chest X-ray: to help exclude other causes (such as lung cancer, bronchiectasis, tuberculosis, and heart failure).
        • Full blood count (FBC): To identify anemia or polycythemia.

    • Management

    • Step 1: Offer SABA (salamol or salbutamol)

    • Step 2:

      • Long-acting Muscarinic Antagonist (LAMA) + LABA: For example, Anoro Ellipta (umeclidinium + vilanterol)
      • LABA + ICS: If asthmatic features are present, such as Fostair or Symbicort.

    • Step 3:

      • LAMA + LABA + ICS: For example, Trimbow (beclemetasone +formoterol + glycopyrronium bromide) or Trelegy Ellipta (fluticasone +umeclidinum and vilanterol).
      • If no improvement after a 3-month trial, revert to Step 2.

    Known COPD History and Management

    • Inquire about shortness of breath (SOB).

    • Ask if SOB occurs at rest or only during activity.

    • Determine how far the patient can walk before experiencing SOB.

    • Assess for orthopnea (SOB when lying flat) or paroxysmal nocturnal dyspnea (PND, SOB waking the patient at night).

    • Inquire about any ankle swelling.

    • Ascertain details about cough, including the presence of sputum production or hemoptysis (coughing up blood).

    • Ask about chest pain, palpitations, fever, and visible neck veins.

    • Assess for asthmatic features, which include personal or family history of atopy (eczema) or asthma, and nighttime wheezing.

    • Ask about weight loss, night sweats, fatigue, changes in appetite, and the presence of any lumps or bumps.

    • Inquire about inhaler use.

      • If the are using an inhaler, ask about any challenges they may have.
      • Determine if they were taught proper inhaler technique and if anyone checks their technique.

    • Two Essential Questions

      • In the last year, how many times have you had a COPD flare requiring steroid treatment?
      • In the last year, how many times have you been hospitalized due to your COPD?

    • Ask about home conditions and inquire about their ability to manage.

    • Assess the patient's mood, particularly if they have chronic health conditions or have been hospitalized for more than two weeks.

    • Inquire about vaccination status.

    • Difference Between an Acute Exacerbation of COPD and Poorly Controlled COPD:

      • Acute Exacerbation: A sudden worsening of COPD symptoms.
      • Poorly Controlled COPD: Ongoing, persistent difficulty managing COPD symptoms, even with medication.

    • Management:

      • Advise on maintaining adequate fluid intake.
      • Encourage the use of paracetamol or ibuprofen to manage symptoms.
      • Provide safety-netting advice for worsening symptoms. Watch for signs like swelling or redness behind the ear (mastoiditis), neck stiffness, lethargy, difficulty making urine, or wetting diapers.
      • Schedule a follow-up appointment within 3 days.

    Dizziness (Vertigo)

    • Clarify exactly what the patient means by "dizziness." Do they experience lightheadedness or a spinning sensation (true vertigo)?
    • Determine when the dizziness started.
    • Assess if the dizziness is constant or intermittent.
    • If it is intermittent, ask how long each episode lasts before resolution.
    • Benign Paroxysmal Positional Vertigo (BPPV): Generally episodic, with each episode lasting only a few seconds.
    • Vestibular Neuronitis and Labyrinthitis: Constant vertigo, possibly mimicking a central cause of vertigo.
    • Explore if the dizziness is triggered by head movement.
    • BPPV: Episodes of dizziness are triggered by head movement.
    • Vestibular Neuronitis and Labyrinthitis: Not triggered by head movement but may be exacerbated during movement.
    • Determine if there is any hearing loss:
    • Labyrinthitis: Hearing loss is present.
    • Vestibular Neuronitis: There is NO hearing loss.
    • Ask about a feeling of pressure or fullness in the ear (Meniere's disease can cause these symptoms).
    • Ask if the patient has any tinnitus, headaches, blurry vision, slurred speech, weakness in one part of the body, recent flu symptoms or a sore throat (vestibular neuronitis and labyrinthitis are often preceded by flu-like symptoms).
    • Inquire about any falls due to the dizziness.
    • Determine if the patient drives and operates machinery.
    • Evaluate the patient's ability to manage their daily activities. Ask about their coping strategies.
    • Gather information about smoking, alcohol use, and their occupation.
    • Key Points to Remember:
      • Both vestibular neuronitis and labyrinthitis are often preceded by flu-like symptoms and cause true vertigo. Hearing loss can distinguish these two conditions.
      • The dizziness in BPPV is episodic, lasting seconds, and triggered by head movement.
      • Central causes of true vertigo present with constant vertigo, similar to vestibular neuronitis and labyrinthitis. The main difference is the inability to stand or walk even with open eyes. In contrast, vestibular neuronitis and labyrinthitis usually allow for walking, even if the patient feels unstable.

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    Description

    This quiz covers the assessment and management of orthostatic hypotension. It includes questions on patient history, medication usage, and suggested investigations. Test your knowledge on how to effectively evaluate and support patients experiencing this condition.

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