Collapse / Syncope OSCE - Orthostatic Hypotension

Case Overview

• Age/Sex: 61-year-old female
• Occupation: Retired schoolteacher, lives alone
• Setting: Emergency Department after a brief collapse at home
• Chief complaint: "I collapsed / blacked out"

Patient Script

Who I Am

I'm 61, recently retired, I live on my own and tend my garden.

What Brings Me In

I stood up from the toilet this morning and suddenly felt very lightheaded and then I think I blacked out for a short time.

My Story

This morning, about 3 hours ago, I went to the bathroom and when I stood up I felt very dizzy and light‑headed and then I remember nothing for a minute or so — my neighbour says I was on the floor and I woke up after a minute conscious but dazed. Before I stood I had been sitting quietly reading. I had a bit of nausea but no vomiting. I felt a bit shaky as I walked to the door to call for help. There was no chest pain, but I felt slightly sweaty. I have felt a bit more dizzy sometimes when I stand up over the last few weeks but nothing like this. I cut my forehead slightly when I fell but I didn’t hit my head hard.

I take medicines every day and I started a new water tablet about two weeks ago because my doctor said my legs were swollen. I also sometimes get tingling in my feet. I haven’t been much more tired than usual and I haven’t fainted before like this.

My Medical Background

• Type 2 diabetes diagnosed 12 years ago
• Hypertension for many years
• Coronary artery disease with stable angina (diagnosed 5 years ago)
• Chronic peripheral neuropathy in my feet (diabetic)
• Medications:
  • Metformin 500 mg twice daily
  • Long‑acting insulin (basal) nightly
  • Lisinopril 10 mg daily
  • Amlodipine 5 mg daily
  • Furosemide 40 mg daily (started 2 weeks ago)
  • Sublingual GTN PRN for angina
  • Occasional sleeping tablet (zopiclone) taken some nights for the past month
• Allergies: none known
• Social: Lives alone, independent with ADLs, stopped driving after this event; drinks about 2–3 units alcohol per week
• Family: Mother had stroke in her 70s, father had heart disease

What I Think & Worry About

• I’m frightened I might have had a stroke or a heart attack.
• I worry I might faint again and hurt myself, or that I’ll lose my independence.
• I wonder if it’s because of the new water tablet I was given.

If You Ask Me About Other Symptoms...

• Chest pain: I had a bit of tightness once last month when gardening but nothing like an ongoing pain today.
• Palpitations: I noticed my heart racing once a few weeks ago after climbing stairs, not today though.
• Breathlessness: No, I’m not short of breath at rest.
• Headache/weakness/numbness: No new weakness or facial droop; some numbness/tingling in my toes for years.
• Loss of bladder/bowel control: No loss of control when I fell.
• Confusion after event: I was dazed for a minute but now I’m clearheaded.
• Recent illness/diarrhoea/vomiting: No recent vomiting or diarrhoea; I do sometimes skip lunch.
• Medication changes: I started the water tablet (furosemide) two weeks ago; my GP reduced my lisinopril dose recently because my BP was a bit low.

---

Clinical Summary

Examination

• General: Alert, oriented x3, no acute distress
• Vitals supine: BP 150/84 mmHg, HR 76 bpm, RR 14/min, SpO2 98% on air, temperature 36.7°C
• Vitals standing (1 minute): BP 112/66 mmHg, HR 86 bpm
• Vitals standing (3 minutes): BP 100/60 mmHg, HR 90 bpm
• Cardiac exam: Regular rhythm, no murmurs, no signs of heart failure
• Respiratory: Chest clear bilaterally
• Neurological: Cranial nerves intact, power 5/5 in all limbs, normal gait when assisted, no focal deficit
• Peripheral nervous system: Reduced vibration sense in both feet consistent with diabetic peripheral neuropathy
• Examination of head: Small forehead abrasion, no focal scalp haematoma

Investigations

• ECG: Sinus rhythm 88 bpm, no acute ischemic changes (no ST elevation or new Q waves)
• Random capillary glucose: 6.4 mmol/L (normal for patient on insulin/metformin)
• FBC: Hb 120 g/L (slightly low-normal), WCC 7.2 x10^9/L, platelets 260 x10^9/L
• U&E: Na 138 mmol/L, K 3.4 mmol/L (low‑normal), creatinine 120 µmol/L (eGFR moderately reduced for age)
• HbA1c (recent clinic 2 months ago): 8.2% (poor glycaemic control)
• Troponin: initial 14 ng/L (within local normal range), repeat planned in 3–6 hours
• Orthostatic BP documented: drop of 50 mmHg systolic from supine to 3 minutes standing (150 → 100 mmHg)

Diagnosis

• Primary diagnosis: Orthostatic hypotension

  • Evidence: symptomatic presyncope/syncope on standing with documented orthostatic fall in BP (supine 150/84 → standing 100/60 mmHg at 3 minutes); prodromal lightheadedness on standing; multiple risk factors (recent diuretic initiation, antihypertensives, long‑standing diabetes with probable autonomic neuropathy).

• Important differentials and reasoning:

  • Cardiac syncope (arrhythmia or ischemia): less likely given normal initial ECG, no ongoing chest pain or exertional syncope, but still needs consideration if recurrent or abnormal troponin/ECG.
  • Vasovagal syncope: typically prodrome (nausea, sweating) and often triggered by pain or emotional stress — patient’s event occurred on standing without classic vagal trigger, and orthostatic BP drop supports orthostatic cause.
  • Seizure: unlikely — no tonic‑clonic activity, no tongue bite, no incontinence, brief duration and quick recovery.
  • Hypoglycaemia: capillary glucose normal at presentation.
  • Neurological event (TIA/stroke): unlikely given no focal neurology and rapid recovery, but should be considered if focal signs develop.

Management

• Immediate

  • Place patient supine with legs raised; monitor ABCs and continuous sats/ECG
  • Ensure head wound cleaned and dressed; assess for head CT only if clinical concern for significant head injury or reduced consciousness
  • Recheck orthostatic BP and heart rate; check bedside glucose and ECG (done)
  • Hold probable offending medications (withhold furosemide and consider holding lisinopril/amlodipine pending review)
  • Give oral fluids if tolerated; consider IV crystalloid bolus if clinically dehydrated or hypotensive

• Short term / inpatient measures

  • Review and correct reversible factors: review diuretic dose, check and correct electrolytes (K is low‑normal), review other sedating medications (zopiclone)
  • Falls risk assessment and physiotherapy review; assess home supports
  • Cardiology review if recurrent syncope, arrhythmia suspected, or abnormal troponins/ECG
  • Consider autonomic testing or referral to geriatrics/neurology if orthostatic hypotension persists despite medication review

• Longer term / preventive

  • Educate patient about slow positional changes: sit up for a minute before standing, rise slowly, avoid sudden standing from sitting/lying
  • Advise adequate oral fluid and salt intake unless contraindicated
  • Consider compression stockings and physical counter‑maneuvers (e.g., leg crossing) if symptoms continue
  • If symptoms persist despite conservative measures, consider pharmacologic therapy (fludrocortisone or midodrine) after specialist review
  • Arrange GP follow‑up within a week to review medications and home safety; consider home health support if recurrent falls

Key Learning Points

• Always measure supine and standing BPs in a patient who reports syncope or presyncope; a drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes indicates orthostatic hypotension.

• In older patients, orthostatic hypotension is often multifactorial: medications (diuretics, antihypertensives), volume depletion, and autonomic dysfunction (eg, diabetic autonomic neuropathy) are common contributors.

• Immediate management includes supporting blood pressure (supine position with leg elevation), stopping offending medications, correcting reversible causes, and arranging appropriate follow‑up to prevent recurrent falls.