Evaluation of hypotension

often older adults; may be a history of vomiting and diarrhea, prolonged period of illness, or diuretic use; burns; profound sweating; decreased oral intake; bronchorrhea or draining pleural effusion; history of or risk factors for diabetes insipidus; risk factors for diabetic ketoacidosis or hyperosmolar hyperglycemic state; may be fever; thirst; fatigue; dizziness on standing

hypotension may be profound if there is shock with decreasing level of consciousness; fever; tachycardia; weak pulse; dry mucous membranes; decreased skin turgor

history of nonsteroidal anti-inflammatory drugs use, often with concomitant corticosteroid use; may be history of peptic ulcer disease or chronic liver disease; upper abdominal pain (frequently absent in older adults); hematemesis; coffee ground emesis; fatigue, dizziness

hypotension may be profound if there is shock with decreasing level of consciousness; pallor, abdominal tenderness (usually upper abdomen); signs of chronic liver disease (e.g., palmar erythema, spider angiomata, petechiae, jaundice, hepatomegaly, ascites, muscle wasting, gynecomastia, pedal and ankle edema); rectal exam positive for melena

may be known history of inflammatory bowel disease or lower gastrointestinal tumor; melena; hematochezia; abdominal pain (left-sided in older adult suggests diverticular disease); fatigue; dizziness

hypotension may be profound if there is hemorrhagic shock with decreasing level of consciousness; may be blood on digital rectal exam; abdominal exam may be normal, or may be tenderness; patients with colonic tumor may have a palpable abdominal mass

presence of hypotension during dialysis session; previous history of dialysis-induced hypotension; presence of other condition that may predispose to hypotension (e.g., intercurrent infective illness leading to dehydration); diabetes, large interdialytic weight gain, female sex and low body weight are risk factors for dialysis-induced hypotension

tachycardia; weak pulse; increased skin turgor; dry mucous membranes; signs of chronic renal failure (e.g., increased skin pigmentation)

history of road traffic accident, fall, penetrating injury, blunt trauma

may be signs of external bleeding; open fracture; tender abdomen concealing intra-abdominal hemorrhage; decreased breath sounds and dullness to percussion on chest examination may indicate hemothorax; unstable pelvis if fractured; narrow pulse pressure

history of risk factors for coronary artery disease (CAD) (e.g., smoking, hyperlipidemia, diabetes, family history of CAD); chest pain (often described as heavy or tight) radiating to arms, back, neck, or jaw; chest pain may be absent in older adults and people with diabetes; dyspnea; nausea; diaphoresis

hypotension may be profound if there is cardiogenic shock + decreasing level of consciousness; diaphoretic appearance; pallor; tachycardia; bradycardia; new abnormal pulse rhythm; distended jugular veins; other signs of heart failure (e.g., dyspnea, crackles at lung bases); new heart murmur

acute onset shortness of breath; orthopnea; may be history of known heart failure or of risk factors (e.g., recent myocardial infarction, valvular heart disease, hypertrophic cardiomyopathy, known bacterial endocarditis, rheumatic fever, or Marfan syndrome)

hypotension may be profound if there is cardiogenic shock plus decreasing level of consciousness; distended jugular veins; crackles at lung bases; new murmur; additional heart sounds; fever in endocarditis; mitral facies (mild cyanosis of lips/cheeks without clubbing) may be present if mitral stenosis is a causative factor; may be signs of Marfan syndrome (e.g., tall stature, wide arm span, high arched palate, arachnodactyly with positive thumb sign)

more common in older patients; symptoms may be acute, chronic, or paroxysmal; palpitations; chest pain; syncope; dizziness; dyspnea; may be history of dysrhythmia, heart disease or heart failure

signs may be acute, chronic or paroxysmal; hypotension may be profound if there is cardiogenic shock + decreasing level of consciousness; tachycardia; bradycardia; irregular pulse; may have signs of heart failure (e.g., distended jugular veins, crackles at lung base, peripheral edema)

dyspnea; pleuritic chest pain (often absent in older adults); hemoptysis; palpitations; feeling of apprehension; may be history of recent immobilization (e.g., prolonged air flight, surgery), obesity, pregnancy/postpartum period, inherited thrombophilias, active malignancy, recent trauma/fracture, or history of deep vein thrombosis

hypotension may be profound if large pulmonary embolism (PE) but in other cases physical exam can be normal; may be tachypnea; pleural rub on chest auscultation; tachycardia; low oxygen saturations on pulse oximetry (may be transient); calf tenderness

previous history (including childhood) of faints; typical premonitory warning symptoms of feeling warm, nauseated, dizzy, distant from surroundings (may not be reported by older patients)

normal cardiac examination; features of witnessed event include transient loss of consciousness, may be myoclonic type jerks during the event, may appear flushed initially with pallor immediately preceding loss of consciousness

history of recently introduced medication known to produce hypotension; common responsible drug classes include beta-blockers, alpha-blockers, diuretics, nitrates, calcium channel blockers, ACE inhibitors, L-dopa, tricyclic antidepressants, phenothiazines, opioids (in high doses), intravenous acetaminophen in critically ill hospitalized patients; more common in older adults

change in BP readings date from after introduction of new medication, and improvement noted after discontinuation of drug; no specific physical exam findings to suggest other cause

woman of childbearing age; delayed menstruation; history of unprotected sexual intercourse; may be known pregnancy or history may indicate the patient is unaware she is pregnant

gravid uterus on abdominal or pelvic exam; fetal heart on auscultation

symptoms of localized infection, nonspecific symptoms include fever or shivering, dizziness, nausea and vomiting, muscle pain, feeling confused or disoriented; may be history of risk factors (e.g., immunosuppression, pregnancy or postpartum period, frailty, recent surgery or invasive procedures, intravenous drug use, or breach of skin integrity)

tachycardia, tachypnea, hypotension, fever >101°F (>38°C) or hypothermia >97°F (<36°C), prolonged capillary refill, mottled or ashen skin, cyanosis, low oxygen saturation, newly altered mental state, reduced urine output

known history of chronic liver disease; pruritus; abdominal swelling; confusion; lethargy; weight loss; weakness; bruising; may be worsening light-headedness and unsteadiness in presence of concurrent hematemesis, melena or other symptoms of gastrointestinal bleed; history of sepsis (fever, anorexia, focal symptoms depending on site of infection)

may be jaundice; muscle wasting; gynecomastia; palmar erythema; spider angiomata; petechiae; ascites; distended abdominal veins; hepatosplenomegaly; signs of encephalopathy (e.g., memory, attention, and concentration deficits, confusion, asterixis, nystagmus, clonus, rigidity, coma)

more common in older adults; usually long-standing history of Parkinson disease; may be recent initiation or change in anti-Parkinsonian medication, or symptoms of concurrent general medical illness (e.g., dysuria and urinary frequency with urosepsis, or cough with purulent sputum with pneumonia)

bradykinesia; tremor; increased tone; postural instability; stooped shuffling gait with reduced arm-swing, mask-like face; signs of intercurrent infection (e.g., fever, crackles on chest auscultation)

abdominal pain radiating to back; abdominal distension; bilateral flank pain; light-headedness; may be a history of risk factors (e.g., smoking, peripheral vascular disease, known history of aneurysm)

hypotension may be profound with decreasing level of consciousness; abdominal tenderness; pulsatile mass; weak peripheral pulses

women of childbearing age; amenorrhea; may be known pregnancy; abdominal pain; vaginal bleeding; may be history of previous ectopic pregnancy, prior tubal surgery, pelvic inflammatory disease, or intrauterine contraception use

tachycardia; abdominal tenderness and guarding; decreased bowel sounds; cervical motion tenderness; vaginal bleeding

symptoms may be vague; groin, lower abdominal, or back pain; history of risk factors (e.g., recent anticoagulation use, recent history of cardiac or femoral angiography, recent obstetric procedure in women of childbearing age)

unexplained tachycardia; tenderness in lower abdomen on side of bleed; may be bruising of flank; diaphoresis if severe; profound hypotension with decreasing levels of consciousness if shock present

Sudden-onset continuous upper abdominal pain, typically radiating to the back; nausea and vomiting, malaise; history of alcohol use or gallstones, may be history of azathioprine, mercaptopurine or didanosine use

Epigastric or left upper quadrant tenderness with voluntary guarding, abdominal distension, may be reduced bowel sounds; hypotension, dry mucous membranes, reduced skin turgor, oliguria, sweating, tachycardia, tachypnea; signs of pleural effusion (more commonly left side); jaundice

history of recurrent or unexplained falls, drop attacks or collapse episodes occurring in an older adult (usually >70 years); patient may not report classical precipitant of neck extension or turning

usually unremarkable clinical findings; on clinical exam there are no differentiating features from the vasodepressor subtype of carotid sinus syndrome and differential findings are almost always at time of tilt table testing with carotid sinus massage

weight gain; weakness; lethargy; slow speech; cold sensation; forgetfulness; constipation; neck swelling

evidence of severe hypothyroidism (e.g., coma, hypothermia, signs of heart failure); coarse hair; facial edema; bradycardia; eyelid edema; thick tongue

sudden onset pleuritic chest pain; severe and worsening dyspnea; rapid deterioration; may be risk factors (e.g., recent placement of central venous pressure line, history of emphysema or chest trauma)

acute distress; cyanosis; profuse diaphoresis; tachycardia; absent unilateral breath sounds; hyperresonance to percussion on affected side; tracheal shift from midline; hypotension develops rapidly with subsequent loss of consciousness

chest pain reduced by sitting forward; shortness of breath; may be risk factors present (e.g., recent myocardial infarction, pericarditis, coronary angiogram, or cardiac surgery)

hypotension may be profound with decreasing level of consciousness; increased respiratory rate; distended jugular veins, reduced heart sounds and hypotension (Beck triad); tachycardia; pulsus paradoxus (high positive predictive value and sensitivity, though lower specificity)

previous history of faints precipitated by similar event, recognized precipitants include micturition, defecation, exercise, brass instrument playing, weightlifting, and eye exam

normal cardiac exam; features of witnessed event include transient loss of consciousness, may be myoclonic type jerks during the event, pallor

history of recent ingestion/exposure to known allergen (e.g., bee sting); acute onset of symptoms with rapid deterioration; wheeze; rash; swollen lips or tongue; swollen eyelids; pruritus; agitation; anxiety; impending sense of doom (angor animi); nausea; vomiting; diarrhea; light-headedness

rapidly progressive signs; signs of bronchospasm (e.g., audible wheeze, use of accessory muscles); erythematous confluent rash or itchy urticarial wheals; angioedema of tongue, lips or eyelids; flushing; rhinitis; inspiratory stridor; syncope; delirium; coma

history of recurrent or unexplained falls, drop attacks or collapse episodes occurring in an older adult (usually >70 years); patient may not report classical precipitant of neck extension or turning

usually unremarkable clinical findings; typically there are no definite differentiating features on clinical exam from the cardio-inhibitory subtype of carotid sinus syndrome and tilt table test with carotid sinus massage is required

known history of diabetes mellitus; may be known peripheral neuropathy; loss of sensation in feet and hands; painless injuries; dysesthesia

impaired peripheral (glove and stocking distribution) sensation; evidence of painless injuries particularly of feet; absent ankle reflexes; orthostatic hypotension

more commonly older adult; parkinsonism symptoms recently noted; may be history of falls or unexplained injuries

bradykinesia; tremor; increased tone; upward gaze palsy; commonly orthostatic hypotension detected; parkinsonism, cerebellar, autonomic and urological dysfunction in any combination

recent stroke, typically in preceding days; most commonly right cerebral hemisphere stroke; reduction in patient's level of consciousness or deterioration in his/her mobility and ability to sit upright over time; history of recent introduction of BP lowering medication

signs of stroke (neurological deficit dependent on cerebral region affected); BP measurements may appear normal at first glance but have shown a drop since initial admission (hypertensive) BP readings

may be a known history of autonomic failure and orthostatic hypotension; dizziness on standing; may be erectile dysfunction, constipation, decreased sweating; history of regular (daily) symptoms occurring within a short period (minutes) after posture change

no specific physical findings other than orthostatic hypotension; posture test positive (systolic BP falls >20 mmHg and diastolic BP falls >10 mmHg within 3 minutes orthostatic stress with lack of an adequate compensatory heart rate increase [>20 bpm]); if posture test normal should not deter from further investigation in the presence of suggestive history

history of unexplained weight loss; parasthesia; shortness of breath; fatigue; dizziness on standing; may be a known history of amyloidosis, or of a chronic inflammatory condition known to predispose to amyloidosis development (e.g., rheumatoid arthritis)

macroglossia (specific for amyloidosis); periorbital purpura; lower limb edema which is resistant to diuretic therapy; elevated jugular venous pressure; orthostatic hypotension; signs of a chronic inflammatory condition (e.g., rheumatoid deformities of joints, erythematous, tender joints, rheumatoid nodules, skin lesions)

More common in patients with chronic inflammatory disorders such as rheumatoid arthritis, polymyalgia rheumatica, or inflammatory bowel disease. May be associated with intercurrent illness or abrupt withdrawal of chronic steroids

Hypotension may be mild; lethargy and decreased level of consciousness; stigmata indicative of underlying chronic inflammatory disorder such as rheumatoid hands; cushingoid appearance

weight loss; anorexia; increased pigmentation; fatigue; nausea and vomiting; salt craving; dizziness

hyperpigmentation (commonly mucous membranes and sun-exposed areas, more pronounced in palmar creases, areas of friction, and scars)

failure to thrive in childhood; short stature; failure of secondary characteristics; oligomenorrhea; infertility; headache; visual field defects; blurred vision

dry skin; breast atrophy; increased body mass index; loss of axillary and pubic hair; ophthalmoplegia

presence of suggestive risk factors (e.g., alcohol abuse, recurrent vomiting, chronic diarrhea, postgastrointestinal surgery, AIDS, total parenteral nutrition, diet of polished rice); fatigue; weakness; muscle aches; reduced peripheral sensation; swollen legs; poor balance; confusion; paresthesia

peripheral edema; reduced knee jerks and other tendon reflexes; severe muscle weakness; muscle wasting; tachycardia; signs of Wernicke encephalopathy (e.g., mental state changes such as acute confusion, ataxia, and ocular abnormalities such as nystagmus and strabismus)

may be known vitamin B12 deficiency; may be risk factors present (e.g., elderly people, patients with chronic malabsorption, history of gastric resection or bypass, and those taking certain medications such as metformin, proton pump inhibitors); lower limb numbness; other parasthesia; depressed mood

decreased vibration sense; gait abnormalities; decreased peripheral sensation; absent ankle jerks; signs of depression or dementia; exam may be normal; late signs: angular cheilitis, glossitis, pallor and bruising

associated symptoms of flushing, diarrhea, abdominal pain, palpitations and wheeze

peripheral edema secondary to right heart failure, tachycardia, telangiectasia, cardiac murmur, hepatomegaly, wheeze, abdominal mass