In the second of a new monthly series, we are asking readers to help solve this case involving a 67-year-old man who has dizziness and an ‘odd thing he has noticed today’. Find the answers below!
You are the duty doctor on an interminable-feeling shift full of all the usual coughs, sore throats and febrile children. You notice that the next patient on your list is a 67-year-old man whose complaint, according to the note made by the receptionist, is ‘Dizziness’. This strikes you as slightly odd given that all these cases are supposed to be ‘urgent’.
Your best guess prior to ushering him in is that he will be suffering acute vertigo – assuming this is a genuinely acute case. He rises fairly slowly from the chair in the waiting area but walks without trouble to your consulting room.
The story is that he is usually fit and well but today, for the last few hours, has felt very dizzy. By this he means light headed, particularly on standing – but there is no illusion of movement and no nausea or vomiting. He has never experienced this before.
Prior to this, he has been perfectly fit and well, apart from some minor aches and pains from work he has been doing in his garden and for which he’s just take over the counter painkillers. ‘I really don’t like to bother you doctors,’ he says, a statement borne out by his records, which reveal that he has nothing of relevance in his past history, is on no repeat medication and has attended a total of two times in the last ten years. ‘I only came because my wife insisted’.
He volunteers no other symptoms today and in particular, on questioning has had no chest or abdominal pain, nor any neurological symptoms.
On examination he looks well enough. The findings are:
- HR 112 regular
- BP 110/70 with a minimal drop on standing (and no old readings to compare)
- P02 98%
- Heart sounds normal
Perplexed, and going by your gut instinct, you ask the HCA to do an urgent ECG while you see another patient. When he comes back in he says the light headedness is still there. The ECG is completely normal, apart from the previously noted tachycardia and, as you ponder what to do next, he says, ‘I doubt it can be of any relevance, but there is one odd thing I’ve noticed today, if that helps?’
Answer
He is about to tell you that he has noticed his stool has been black today. This is because he has had an acute upper gastrointestinal bleed – which is the cause of his dizziness.
There are some clues in the case:
- Non-vertigo dizziness may be a bit of a heartsink symptom when seen in routine surgery as it is often longstanding and often difficult to pin down. But it is very unusual if of genuinely acute onset and should therefore ring some alarm bells.
- He has been taking some ‘over-the-counter painkillers’ for gardening-related aches and pains. These turn out to be NSAIDs, which are associated with upper GI bleeds – which can be painless.
- His tachycardia and lowish blood pressure certainly suggest something is going on, and a bleed would be one of those ‘somethings’ – another potential cause would be a silent myocardial infarct. The normal ECG does not rule this out, of course, but makes it less likely.
- Wives know their husbands. Take wifely concern seriously.
He was admitted to hospital, made a full recovery, and was left wondering what all the fuss was about.
I have no doubt the ABCDS score which I created about 5 years ago (available on http://www.ABCDS.co.uk) would have been significantly raised. A recent study established that postural changes in both systolic BP and HR were a more sensitive indicator of a problem when taken quickly rather than waiting several minutes between readings so lack of time is no excuse. I believe it is ridiculous that NEWS2 scores can be calculated with recumbent SBP and HR readings with no consideration of postural changes. I’ve been using postural changes in SBP and HR for over 20 years to detect A) Autonomic dysfunction/ early Anaphylaxis in patients having an allergic reaction B) Bleeding C) Cardiac dysfunction eg.severe viral myocarditis D) Dehydration and S) Sepsis. In an audit of over 70 patients I’d seen out of hours in whom I’d take SBP and HR readings in different postures all the patients with sepsis had high scores, two even with a minor change in posture from lying flat in bed to sitting up with legs still horizontal in bed. Of course lying to standing comparisons provide readings with the greatest sensitivity for detecting a significant problem and it is always wise to repeat and confirm an abnormal result and interpret with caution in the presence of AF perhaps dismissing HR changes altogether. Whilst studies are desperately needed to confirm how to best use postural changes in SBP and HR in clinical practice, particularly in patients undergoing chemotherapy who could track their own scores, Changes in HR alone offer a useful alternative in younger patients particularly as the younger a patient is the more able they are to change their HR to maintain their BP – the main reason I believe PoTS is primarily seen as a disorder affecting the young on OH Orthostatic Hypotension mainly affecting older patients when really I believe they are both the same condition except one measures primary HR and the other BP. I see little harm in clinicians and indeed patients taking a few additional SBP and HR readings in different postures. I believe everyone should know what is normal for them. It only takes detecting one patient with sepsis who you might otherwise have diagnosed with flu to become a lifelong convert.