Hypotension in Elderly Patient with Complex Medical History: Diagnostic Dilemma

Case at a Glance

An 86-year-old female with multiple comorbidities presented with severe hypotension (70-80 mmHg) following recent hospitalization for aspiration pneumonia. Initial concerns about cardiac vs. renal etiology led to anticoagulation therapy pending further diagnostic workup.

Patient's Story

The patient, weighing 170 pounds with no smoking or substance use history, has a complex medical background including pyloric valve disorders requiring multiple surgeries, extensive abdominal adhesions, peptic ulcer disease, mild chronic heart failure, and recurrent urinary tract infections. She had recently completed a 2-month hospitalization for chemical pneumonia secondary to aspiration during endoscopy. One day after discharge, her physical therapist documented severely low blood pressures (70-80 mmHg range) accompanied by weakness and dizziness.

Initial Assessment

The patient was initially evaluated at a rural emergency department where laboratory studies revealed abnormal cardiac and renal markers. Given the severity of findings and concern for acute cardiac event, she was transferred to a tertiary care facility for cardiology evaluation. Initial management included IV heparin anticoagulation despite her history of peptic ulcer disease.

The Diagnostic Journey

The working differential included acute coronary syndrome with demand ischemia secondary to hypotension, possible pulmonary embolism, and acute kidney injury. Cardiology consultation was obtained, and diagnostic workup included echocardiography and chemical stress testing. Initial concern focused on cardiac etiology given the patient's history of heart failure and presentation suggestive of cardiogenic shock.

Final Diagnosis

Further evaluation revealed that renal function remained stable compared to baseline over the previous year. Cardiac evaluation suggested the hypotension was not primarily cardiac in origin. The underlying cause of the hypotensive episode remained unclear, though demand ischemia was suspected given the severity of blood pressure reduction.

Treatment Plan

Continued anticoagulation with heparin under close monitoring given her peptic ulcer history. Supportive care with IV fluids and blood pressure monitoring. Awaiting results of outpatient cardiac studies for comparison with current cardiac function. Close monitoring for signs of gastrointestinal bleeding given anticoagulation in the setting of known ulcer disease.

Outcome and Follow-up

Blood pressure gradually improved toward normal ranges during hospitalization. Patient reported feeling subjectively better with stabilization. Continued inpatient monitoring was planned until blood pressure stabilized sufficiently for safe discharge. The multidisciplinary team maintained vigilance for potential complications of anticoagulation therapy.