Orthostatic Hypotension

Patient Presentation:
L.W. a 78 year old male was brought to the ED after a syncopal episode at his nursing facility. Health history includes prostate cancer, BPH, and bilateral knee replacements 2 years ago. Assessment includes a hematoma above the left eye and the patient reports decreased urine output and blurry vision at times. VS: BP 113/68, HR 118, RR 18, Temp 36.9, and SpO2 96% on room air.

Differential Diagnosis:
syncope, orthostatic hypotension, malnutrition

Diagnosis:
Labs collected included BMP, CBC, coags, serum and urine osmolality, and urine analysis. A 12 lead EKG showed sinus tachycardia.
Lab results included: Na+ 150, Cl- 112, serum osmolality 303 urine osmolality 1280, all other labs were within normal limits.

Orthostatic testing was as follows: supine BP 116/71 HR 97, sitting BP 102/64 HR 104, standing BP 82/48 HR 121 showing patient has positive orthostatics.

Stress test and echocardiogram were completed to evaluate heart function with unremarkable findings. The patient was diagnosed with orthostatic hypotension second to dehydration.

Treatment/Outcome:
IV fluids were given to the patient. Strict intake and output records logged to monitor fluid balance. Labs were followed and sodium returned to normal level after dehydration was corrected. Midodrine was started to help increase blood pressure. The patient was educated on increasing oral fluid intake and using salt freely in his diet.