Hi. It’s Dr Louella. I had an awesome time dancing in church today. I promised to tell you about a sweet elderly gentleman in “Caring for others more than they care for themselves part II.” Well this is it, but with a different title.
The new title reflects how they bombarded me that day, as soon as I dropped my bags in my office. When I walked into the screening room last Wednesday, I was accosted by nurses.
They were sorry to disturb me so early but they wanted advice on an elderly man with a very low pressure. Now we hardly ever get patients with low blood pressure as a problem; unless they are in heart failure or it is from blood or fluid loss or a severe allergy.
This old timer was a regular, they said. He had been seen for low blood pressure before and had already been referred to hospital. I looked at the BP. It was for real, 59/35. That’s quite low. I looked at the man. He looked terrible, really sunken in temples and cheeks. He looked like a homeless person.
He was not out cold so he could speak. He complained of dizziness and some weakness. Said he was 72 years old. First thing that came to mind is if he had had breakfast. Yes he did, was the reply, after I had identified myself. He had had a coconut water. (Ok, so now I knew he did not have breakfast).The nurses had started giving him water to drink. I said, “Let’s get this man something to eat”. All we had were his crackers and my slice of chocolate cake (my lovely cake that I had baked from scratch and brought to have as a snack).
We moved him to the treatment room and gave him these things to eat. I proceeded to find out what his normal diet was like. Turns out he was married, his wife died and he lived with three subsequent women after that, all of whom had died. He has eleven children, who visit him from time to time but he lives alone. He drives his own vehicle.
He often neglected his meals now that there was no one to care for him and did not go through the trouble of preparing anything. He drank about quarter of a 1.5 litre water bottle a day. He sometimes felt weak when going to his garden.
So I was wrong about one thing. Here was no homeless person but a gentleman with the means to take care of himself but not the will to do so. I stressed the importance of regular meals and lots of water and asked if he wouldn’t mind a visit with our dietitian to advise him on meal planning.
Water is needed for blood. It makes up about 50% of it. When we are dehydrated the blood volume decreases and there is less blood for the heart to pump so blood pressure drops. Eating helps the water to remain in the circulation by providing salt.
I explained that he found difficulty going to the garden because his muscles were weakened by old age and without eating and drinking he would feel much weaker. He was interested in avoiding that.
As soon as he had eaten the snacks he wanted to leave. I had to say “Slow down pappy. That food is not digested so it cannot benefit you as yet”. He himself admitted to still feeling somewhat ill.
I realised that with all this talk I did not do a physical exam on this man. When I did, I found him to have a bradycardia, an unusually slow heart rate. His was 48 while the normal heart beats between 60 and 100 beats per min.
Here was another cause of a low blood pressure. I ordered an electrocardiogram (ECG or EKG), or heart tracing. It was normal except for a heart rate of 54. He was not on any medication.
I was now able to explain to him that his slow heart rate was most likely responsible for his low blood pressure. But this becomes exacerbated when he is dehydrated. Also when he does not eat, there is less salt to keep liquid in the circulation.
I explained that if his heart rate decreased further to the point where he could not support a decent blood pressure he would need a pacemaker inserted in his heart. He reacted strongly to that because in no way did he wish to go to hospital.
After a couple hours I felt pleased to see our elderly gentleman walking out of the centre, looking and feeling much improved, and with a blood pressure of 105/65. I’m sure that he would now be more empowered to manage such episodes. I’m also sure we’ll be seeing him again, if even for an update.
My next case will be what the doctor does when threatened by someone else’s body fluids. Does she save herself or play the brave doctor? My next post will tell. Bye for now! Dr Louella.