A 25-year-old man is brought to the emergency department after a syncopal episode. The episode occurred during a power lifting competition. The patient suddenly collapsed after he straightened up from lowering the barbell from over his head to the floor. He was unconscious for about a minute. He reported feeling lightheaded prior to collapsing but states he frequently feels lightheaded after he stands or raises up during his competitive power lifting matches. The patient does not report similar symptoms at other times. He does not have any known medical conditions. Family history is significant for hypertension. Temperature is 36.7 C (98 F), blood pressure is 110/60 mm Hg, pulse is 72/min, and respirations are 16/min. He is awake, alert, and oriented with normal speech. Dry mucous membranes are noted on oropharyngeal examination. Heart and lung examinations are normal. Strength is 5/5 in the upper and lower extremities, and gait is normal. An ECG is normal. Laboratory results reveal the following: What is the best next step in management?
A)Inpatient ECG monitoring
B)Monitored carotid massage testing
C)Serum assay for anabolic steroids
D)Serum cortisol levels
E)Urine assay for diuretics

Question

A 25-year-old man is brought to the emergency department after a syncopal episode.  The episode occurred during a power lifting competition.  The patient suddenly collapsed after he straightened up from lowering the barbell from over his head to the floor.  He was unconscious for about a minute.  He reported feeling lightheaded prior to collapsing but states he frequently feels lightheaded after he stands or raises up during his competitive power lifting matches.  The patient does not report similar symptoms at other times.  He does not have any known medical conditions.  Family history is significant for hypertension.  Temperature is 36.7 C (98 F), blood pressure is 110/60 mm Hg, pulse is 72/min, and respirations are 16/min.  He is awake, alert, and oriented with normal speech.  Dry mucous membranes are noted on oropharyngeal examination.  Heart and lung examinations are normal.  Strength is 5/5 in the upper and lower extremities, and gait is normal.  An ECG is normal.  Laboratory results reveal the following:  What is the best next step in management?
A)Inpatient ECG monitoring 
B)Monitored carotid massage testing 
C)Serum assay for anabolic steroids 
D)Serum cortisol levels 
E)Urine assay for diuretics

Quizplus · Accepted Answer

Explanation: 11ec2b69_c11f_cd82_8f63_eb47b826a8c3_MD0005_00 This patient with a brief loss of consciousness after straightening up from lowering the barbell to the floor most likely experienced syncope due to orthostatic hypotension (ie, orthostatic syncope). Hypovolemia is a common cause of orthostatic syncope and can occur in athletes (including competitive weightlifters) who use fluid restriction and diuretics to achieve rapid weight loss and compete in a lighter weight category. Suggestive features in this patient include symptoms triggered by a postural change, premonitory lightheadedness, evidence of dehydration (eg, dry mucous membranes, hemoconcentration, elevated BUN/creatine ratio), and hypokalemia (from diuretic-induced potassium elimination). Evaluation of patients with orthostatic syncope focuses on identifying treatable causes. Causes of volume depletion (eg, fluid restriction, gastrointestinal losses) are investigated and a detailed medication list is obtained as medications commonly cause orthostatic syncope via a variety of mechanisms (eg, volume depletion from diuretics, impaired vasoconstriction from vasodilators). Diuretics can be detected via urine assay, which is often a routine component of drug testing in competitive athletes. Diuretic cessation and volume repletion should improve this patient's orthostasis. medications (Choice A) Inpatient ECG monitoring should be performed when syncope due to a cardiac arrhythmia is suspected. However, this patient does not have red flags for cardiac syncope (eg, lack of prodrome, family history of sudden death) but has many clinical features (eg, symptoms upon postural change, evidence of dehydration) consistent with orthostatic syncope. (Choice B) Monitored carotid massage testing can help diagnose syncope due to carotid hypersensitivity. However, carotid hypersensitivity predominantly occurs in elderly individuals with carotid atherosclerotic disease (vs young, healthy athletes). (Choice C) Some competitive weightlifters use anabolic steroids, which can cause erythrocytosis due to increased erythropoeisis. However, hypokalemia, hypovolemia, and syncope are not expected effects of steroid use. erythropoeisis (Choice D) Adrenal insufficiency (which serum cortisol levels can help diagnose) with associated aldosterone deficiency can cause volume depletion leading to orthostatic hypotension. However, hyperkalemia (vs hypokalemia) would be expected, symptoms would be unlikely to be limited to competitions, and other symptoms of adrenal insufficiency (eg, fatigue, gastrointestinal symptoms) would likely be present. Educational objective: Hypovolemia (eg, from fluid restriction) and medications (eg, diuretics) are common causes of orthostatic hypotension, which may lead to syncope (ie, orthostatic syncope). Evaluation of orthostatic syncope is directed at identifying and correcting treatable causes of orthostasis. References: The abuse of diuretics as performance-enhancing drugs and masking agents in sport doping: pharmacology, toxicology and analysis. (http://www.ncbi.nlm.nih.gov/pubmed/20718736) Preventing and treating orthostatic hypotension: as easy as A, B, C. (http://www.ncbi.nlm.nih.gov/pubmed/20439562)

A 25-Year-Old Man Is Brought to the Emergency Department After