What is the best course of management for an 83-year-old patient with a shin laceration, uncontrolled hypertension, and atrophic vaginitis?

Management of an 83-Year-Old with Shin Laceration, Uncontrolled Hypertension, and Atrophic Vaginitis

For this 83-year-old patient, increase amlodipine to 5mg daily to achieve blood pressure control below 140/90 mmHg, continue district nurse wound care with close monitoring for cellulitis progression, and initiate topical vaginal estrogen therapy for symptomatic atrophic vaginitis.

Hypertension Management

The current blood pressure of 153/77 mmHg remains above the target of <140/90 mmHg and requires medication adjustment. 1

• Increase amlodipine from 2.5mg to 5mg daily, as elderly patients often require dose titration and the current dose represents the lower end of the therapeutic range 2
• The patient is already on losartan 100mg daily (maximum dose), so intensification should focus on the calcium channel blocker 3
• Elderly patients have decreased clearance of amlodipine with 40-60% increase in drug exposure, but the current 2.5mg dose is well-tolerated and can be safely increased 2
• Recheck blood pressure in 2-4 weeks after dose adjustment 1
• The combination of an angiotensin receptor blocker (losartan) and calcium channel blocker (amlodipine) is appropriate for elderly patients with hypertension 1

Shin Laceration with Mild Cellulitis

Continue district nurse wound care with close monitoring, but address the incomplete antibiotic course immediately. 4, 5

• The dispensing error resulted in only 13 tablets instead of 15 for a 5-day course of cephalexin—prescribe the missing 2 tablets to complete the full course
• The wound being "sore and itchy around the area" suggests mild cellulitis that requires completion of antibiotics
• District nurse visits should continue with assessment for signs of worsening infection: increased erythema, warmth, spreading margins, purulent drainage, or systemic symptoms 4
• Ensure adequate pain management, as pain control is critical in elderly patients and improves wound healing 1, 5
• If cellulitis worsens despite completing antibiotics, consider wound culture and alternative antibiotic coverage
• This shin laceration may represent a fragility-related injury in an 83-year-old and warrants fall risk assessment and osteoporosis screening 4, 5

Atrophic Vaginitis

Initiate topical vaginal estrogen therapy as first-line treatment for symptomatic atrophic vaginitis causing significant genital itching and bleeding from scratching. 1, 6, 7

• Topical vaginal estrogen (cream, tablet, or ring) is the most effective treatment and reverses the mucosal changes causing symptoms 6, 7
• The normal genital swab excludes fungal infection, confirming the diagnosis of atrophic vaginitis 1
• Vaginal moisturizers and lubricants can be used as adjuncts for symptomatic relief of dryness 6, 7
• For postmenopausal women with recurrent UTI risk factors such as atrophic vaginitis, topical vaginal estrogen is specifically recommended 1
• The severity of symptoms (itching until bleeding) and impact on quality of life justify immediate treatment rather than conservative measures alone 8
• Systemic estrogen is not necessary given localized symptoms and can be avoided in this elderly patient 7

Common Pitfall to Avoid

Many clinicians under-treat atrophic vaginitis because patients are reluctant to report symptoms and providers fail to ask directly about vaginal discomfort 8. The normal swab results should not delay treatment, as atrophic vaginitis is a clinical diagnosis based on estrogen deficiency, not infection 6, 7.

Secondary Prevention Considerations

Given the patient's age and shin laceration, systematic evaluation for osteoporosis and fall risk is warranted. 4, 5

• Wrist and shin injuries in patients over 70 often represent fragility fractures requiring bone health assessment 4, 5
• Arrange DXA scan of spine and hip to evaluate bone mineral density 4
• Assess fall risk factors including home safety, gait stability, vision, and medication side effects 5
• Consider starting anti-osteoporotic therapy (alendronate or risedronate as first-line) if DXA confirms osteoporosis 4
• For patients with compliance concerns or gastrointestinal intolerance, zoledronic acid or denosumab are alternatives 4

Follow-Up Plan

• Blood pressure recheck in 2-4 weeks after amlodipine dose increase 1
• District nurse to continue wound assessments until complete healing 4
• Reassess atrophic vaginitis symptoms in 4-6 weeks after initiating topical estrogen 7
• Arrange DXA scan and comprehensive fall risk assessment 4, 5
• Ensure completion of cephalexin course with the 2 additional tablets