What management approach is recommended for a patient with dizziness, motion sickness, chronic shoulder pain, and numbness in the fingertips, with a history of hypertension and current medications including Felodipine, Carvedilol, and Losartan/Hydrochlorothiazide?

Management of Dizziness, Motion Sickness, and Chronic Shoulder Pain in a Hypertensive Patient

Initial Assessment and Diagnosis

For this patient with dizziness, motion sickness, and chronic shoulder pain, the most appropriate management approach is to first address the orthostatic hypotension likely caused by the current antihypertensive regimen, while simultaneously investigating the vestibular cause of dizziness and implementing targeted treatment for the shoulder pain. 1

The patient presents with multiple issues requiring attention:

1. Dizziness and motion sickness - Features suggest a possible peripheral vestibular disorder with:

   • Brief, seconds-long episodes occurring spontaneously
   • Humming sound in the ears
   • Occasional imbalance when walking
   • Motion sickness, particularly in cars
   • Slight dizziness on standing (orthostatic component)

2. Orthostatic hypotension - Evidence includes:

   • BP drop from 140/85 sitting to 133/85 standing
   • Patient reporting feeling slightly dizzy on standing
   • Current medications include three antihypertensive agents (Felodipine, Carvedilol, and Losartan/HCTZ)

3. Chronic right shoulder pain - Characteristics include:

   • Present for over a year and gradually worsening
   • Aching pain, worse at night
   • Soreness on lifting the arm
   • No history of injury

Management Plan

1. Address Orthostatic Hypotension and Medication Adjustment

The patient is currently on triple therapy for hypertension with:

• Felodipine 5mg daily (dihydropyridine CCB)
• Carvedilol 6.25mg twice daily (beta-blocker)
• Losartan/Hydrochlorothiazide (ARB/diuretic combination)

This regimen may be contributing to orthostatic symptoms and dizziness 1, 2.

Recommended medication adjustments:

• Consider discontinuing Carvedilol as it may be contributing to dizziness and is not a first-line agent for hypertension without specific indications (e.g., heart failure, post-MI) 1
• Maintain Losartan/HCTZ and Felodipine as these are preferred first-line agents 1
• Monitor BP closely after medication adjustment, both sitting and standing
• Consider timing of medication to improve adherence and minimize side effects; no specific time of day is superior for outcomes 1

2. Vestibular Assessment and Management

For the dizziness and motion sickness symptoms:

• Perform targeted vestibular examination:

  • Check for nystagmus
  • Perform Dix-Hallpike maneuver to assess for BPPV
  • Consider HINTS examination (Head-Impulse, Nystagmus, Test of Skew) if acute vestibular syndrome is suspected 3, 4

• Management based on findings:

  • If BPPV is diagnosed: Perform canalith repositioning procedure (Epley maneuver)
  • For peripheral vestibular dysfunction: Refer for vestibular rehabilitation therapy
  • Consider short-term symptomatic treatment with antivertigo medications (e.g., meclizine) for motion sickness, but avoid long-term use as it may impede central compensation 3

3. Shoulder Pain Management

For chronic right shoulder pain:

• Physical examination to assess range of motion, strength, and specific pain triggers
• Conservative management:
  • Continue topical Voltaren (diclofenac) as currently using
  • Consider acetaminophen for pain relief, especially at night
  • Avoid Norflex (orphenadrine) due to previous adverse effects
  • Refer for physical therapy focused on shoulder strengthening and mobility exercises
• Consider imaging (X-ray or ultrasound) if pain persists despite conservative management to rule out rotator cuff pathology or osteoarthritis

Follow-up Plan

1. Short-term follow-up (1-2 weeks):

   • Reassess BP control after medication adjustment
   • Evaluate response to vestibular and shoulder pain interventions
   • Check for any new or worsening symptoms

2. Medium-term follow-up (4-6 weeks):

   • Comprehensive BP assessment including home BP monitoring
   • Consider ambulatory BP monitoring if white coat or masked hypertension is suspected 1
   • Adjust medications as needed based on BP control

3. Long-term management:

   • Regular BP monitoring
   • Continued assessment of vestibular symptoms
   • Progressive management of shoulder pain

Important Considerations and Pitfalls

• Avoid common pitfalls:

  • Don't attribute all dizziness to hypertension or medications; vestibular causes require specific diagnosis and treatment 5, 3
  • Avoid excessive BP lowering which can worsen orthostatic symptoms 1
  • Don't continue beta-blockers without specific indications in patients with dizziness 1

• Special considerations:

  • The patient's work as a healthcare partner in a dementia facility requires adequate mobility and balance
  • Sleep disturbance may be contributing to symptoms and should be addressed
  • Numbness in left fingertips warrants further neurological assessment if it persists

By systematically addressing the orthostatic component, vestibular symptoms, and shoulder pain with targeted interventions, this patient's quality of life and functional status can be significantly improved while maintaining adequate BP control.