Analysis

Ms Lord’s had a combination of many factors likely contributing to her diagnosis of postural hypotension.

Her health history featured:
-Complete heart block - dual chamber pacemaker.
-Cardiomyopathy - severe left ventricular systolic dysfunction, mild right ventricular dysfunction and an increase in filling pressures.
-Atrial Fibrillation - irregular and rapid heart rates as atria and ventricles were no longer in sync.
-Cerebrovascular Accident/Stroke - right anterior communicating artery infarction.
-Pitting oedema - swelling of feet due to accumulation of fluids.
-Dyslipidaemia - an increased level of cholesterol or fats in the blood
-Splenectomy - removal of spleen

And her regular medication included:
-Aspirin to treat cardiovascular disease and dyslipidaemia through reducing platelet aggregation and preventing thrombus formation by irreversibly inhibiting cyclo-oxygenase-1 in platelets, preventing their production of thromboxane A2.
-Isosorbide Mononitrate to treat coronary heart disease and dyslipidaemia through relaxation of vascular smooth muscles promoting vasodilation but also has an adverse effect of postural hypotension.
-Simvastatin to treat dyslipidaemia by reducing total cholesterol and triglycerides by inhibiting HMG CoA.
-Furosemide to treat oedema by inhibiting reabsorption of sodium to promote excretion of water.
-Metoprolol to treat cardiac arrhythmias by blocking beta1-adrenergic receptors but not blocking beta2-receptors. It decreases blood pressure and provides a regulating effect on the heart rate due to prolongation of atrioventricular conduction.
-Omeprazole to raise gastric pH and gastro-oesophageal reflux disease. Take in conjunction with aspirin to treat NSAID-associated duodenal or gastric ulcer and gastro-duodenal erosions.
-Cilazapril to treat asymptomatic left ventricular systolic dysfunction but may also have an adverse effect of postural hypotension as it is primarily used to treat hypertension by inhibiting the conversion of angiotensin I to angiotensin II which increases vasodilation.

I was unable to make time to ask a nurse or health officer about postural hypotension but with my own knowledge, I believe that Ms Lord may have developed postural hypotension as a combination of her oedema,her medication used to treat her oedema, cardiomyopathy and atrial fibrillation and her diet/fluid balance.

The amount of urine she was passing was recorded as she had an indwelling catheter was upwards of one litre per eight hours. Likely as a result from the furosemide she had been taking. Her fluid intake was not on par with her output as she would only drink the tea that was served with her meals and the water she needed to swallow pills. This meant an overall net loss of fluids and therefore blood volume. I could not measure any absolute improvement in terms of her oedema during my time in Ms Lord’s room but her fluid balance chart showed a definite net loss. This in conjunction with the aspirin, isosorbide mononitrate and cilazapril she was taking, I hypothesise to be the contributing factors to the development of postural hypotension.