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Old 06-01-2012
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Question A 62-year-old man is evaluated for a syncopal event

A 62-year-old man is evaluated for a syncopal event two nights ago. On his way to the bathroom during the night, he felt very dizzy and the next thing he remembered was waking up on the floor in the hallway to the bathroom. He went back to bed, and the symptoms did not recur the following morning. He notes that he often feels a little dizzy when he stands up. Medical history is remarkable for hypertension, benign prostatic hyperplasia, and hyperlipidemia. Two weeks ago, he started doxazosin, 2 mg before bedtime, for benign prostatic hyperplasia. Other current medications are lisinopril, atenolol, and atorvastatin. On physical examination, temperature is normal, blood pressure is 142/78 mm Hg (supine) and 106/64 mm Hg (standing), pulse rate is 74/min (supine) and 80/min (standing), and respiration rate is 16/min. He experiences lightheadedness when he stands up. BMI is 31. Cardiac and neurologic examinations are normal. An electrocardiogram is normal. Which of the following is the most appropriate management option for this patient?

A Admit to hospital for cardiovascular evaluation
B Brain MRI
C Discontinue doxazosin
D 24-Hour ambulatory electrocardiographic monitoring
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D 24-Hour ambulatory electrocardiographic monitoring

not sure......
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C Discontinue doxazosin
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.osin...drugs ...first dose syncope...stop the drug.
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Quote:
Originally Posted by tyagee View Post
.osin...drugs ...first dose syncope...stop the drug.
he started doxazocin 2 weeks ago while sycopal episode is 2 nights ago......how it can be first dose hypotension.....?????
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Im also thinking of discontinuing the Doxa, because all the things point to ortho hypotension, and he's already on 2 drugs that could cause a serious drop in bp aswell.


The other choices don't make particular sense either, particularly B & D.
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if he had to suffer from orthostatic hypotension , why did he not suffer it 2 weeks ago when doxazocin was started.....why suffering now ???
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Originally Posted by K06100 View Post
if he had to suffer from orthostatic hypotension , why did he not suffer it 2 weeks ago when doxazocin was started.....why suffering now ???
I dunno.. Maybe this was the first time he got out of the bed to urinate in past 2 weeks...
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Quote:
Originally Posted by patelMD View Post
I dunno.. Maybe this was the first time he got out of the bed to urinate in past 2 weeks...
haha......
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Originally Posted by patelMD View Post
I dunno.. Maybe this was the first time he got out of the bed to urinate in past 2 weeks...
wow...haha...what a thought...
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The patient’s history and examination findings are consistent with orthostatic hypotension. A drop in systolic blood pressure of 20 mm Hg or more or diastolic blood pressure of 10 mm Hg or more after standing for 3 minutes is diagnostic of orthostatic hypotension. Medications are a common cause of orthostatic hypotension, and α-adrenergic blockers, such as doxazosin, are a class of medications that may precipitate this condition. As the episode of syncope was temporally related to initiation of the doxazosin, a prudent strategy would be to discontinue the medication.

Structural heart disease is common in this patient’s age group, but nothing in his clinical history or physical examination suggests a cardiac abnormality. In the presence of a likely explanation for his syncope, there is no indication for admitting him for inpatient cardiovascular evaluation.

Cerebrovascular causes of syncope are invariably associated with neurologic signs and symptoms, such as ataxia, vertigo, and diplopia. Since the patient has no neurologic signs, a cerebrovascular cause is unlikely and a brain MRI would be of limited use.

24-Hour ambulatory electrocardiographic monitoring has poor yield in the evaluation of syncope unless the patient has frequent episodes of syncope or lightheadedness that could be captured during testing. For patients with infrequent symptoms, continuous-loop recorders are recommended. However, in a patient with historical and clinical findings strongly suggesting orthostatic hypotension, additional diagnostic evaluation for arrhythmia is not indicated.
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Quote:
Originally Posted by Novobiocin View Post
The patient’s history and examination findings are consistent with orthostatic hypotension. A drop in systolic blood pressure of 20 mm Hg or more or diastolic blood pressure of 10 mm Hg or more after standing for 3 minutes is diagnostic of orthostatic hypotension. Medications are a common cause of orthostatic hypotension, and α-adrenergic blockers, such as doxazosin, are a class of medications that may precipitate this condition. As the episode of syncope was temporally related to initiation of the doxazosin, a prudent strategy would be to discontinue the medication.
just explain me one thing why he's having syncopal episode after 2 weeks of starting medication....?????we have all read -osin drugs cause first dose hypotension .......
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just explain me one thing why he's having syncopal episode after 2 weeks of starting medication....?????we have all read -osin drugs cause first dose hypotension .......
I don't know......maybe there is a typo in the question (he started two days ago and not two weeks ago)............or maybe it took 2 weeks for it to get absorbed......or maybe his pharmacy only delivered it two days ago..............maybe his dog hid it..........maybe his teenage grandson took it thinking they are codeine or something..................maybe he forgot to actually take them till 2 days ago...........maybe he couldn't open the bottle and to wait for his daughter/son to come visit him so that he can ask them to open the bottle for him...........maybe the pill bottle rolled under the bed/table and he could not reach it and didn't want to call 911 for help.............maybe he was watching Superbowl(or wardrobe dysfunction)....................
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Quote:
Originally Posted by Novobiocin View Post
I don't know......maybe there is a typo in the question (he started two days ago and not two weeks ago)............or maybe it took 2 weeks for it to get absorbed......or maybe his pharmacy only delivered it two days ago..............maybe his dog hid it..........maybe his teenage grandson took it thinking they are codeine or something..................maybe he forgot to actually take them till 2 days ago...........maybe he couldn't open the bottle and to wait for his daughter/son to come visit him so that he can ask them to open the bottle for him...........maybe the pill bottle rolled under the bed/table and he could not reach it and didn't want to call 911 for help.............maybe he was watching Superbowl(or wardrobe dysfunction)....................

lol..........C was my original answer but when 2 weeks did not correlated with 2 days I chose D......
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Old 02-13-2013
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C Discontinue doxazosin
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Discontinuing the doxazosin is the only one which makes sense of the given answers.

But wouldn't his BPH then go untreated? I think the fact that he's taking a B-blocker as well also contributes to the orthostatic hypotension so I would consider changing the combination of medications he's taking as well...
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Originally Posted by spacecadet View Post
Discontinuing the doxazosin is the only one which makes sense of the given answers.

But wouldn't his BPH then go untreated? I think the fact that he's taking a B-blocker as well also contributes to the orthostatic hypotension so I would consider changing the combination of medications he's taking as well...
The priority is to treat his orthostatic hypotension since it endangers his life.

There are other drugs to treat BPH which are more selective alpha blockers like Tamsulosin (alpha 1 a blocker) with cosiderably less chances of causing orthostatic hypotension AND 5 alpha-reductase inhibitors such as dutasteride and finasteride
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Default c

prazocin>>>>alpha blocker>>>orthostatic hypotension
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Default c

doxaxocin/prazocin>>>>alpha blocker>>>orthostatic hypotension
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To the person asking why it did not occur during the two weeks, I believe the Side effect of zosins is ORTHOSTATIC hypotension which is indicated by the difference in blood pressure when standing/supine.
In the two weeks meanwhile, the person's compensatory mechanisms could have maintained the blood pressure without excess stressors that cause hypotension.
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Quote:
Originally Posted by patelMD View Post
I dunno.. Maybe this was the first time he got out of the bed to urinate in past 2 weeks...
so fun.......
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