Case history
Case history #1
A 75-year-old man presents to the hospital emergency department after a syncopal episode when he got up at night to urinate. He has recently been started on the alpha-blocker tamsulosin at bedtime after complaining of urinary frequency and a weak urinary stream, and physical examination had revealed an enlarged prostate. On questioning, he says that he has previously had occasional episodes of light-headedness when standing for prolonged periods in church or when gardening on a hot day.
Case history #2
A 56-year-old obese woman with a 12-year history of poorly controlled diabetes mellitus presents with light-headedness on standing, relieved by sitting down. She has not had syncopal spells, but these episodes of light-headedness are worse after meals and are impairing her quality of life. She also admits to burning pain in her feet and lower legs that is more severe at night and associated with numbness and inappropriate pain and discomfort to touch (allodynia).
Other presentations
Other symptoms include dizziness, weakness, faintness, fatigue on exertion, and dimming of the vision (tunnel vision or visual blackouts). Symptoms do not occur while supine, generally get worse on standing, and are relieved by sitting or lying down. Aggravating factors can often be identified, and the symptoms are often worse early in the morning, in hot weather, after meals, after long periods of standing still, or when the arms are raised above heart level. However, some patients may have difficulty recognising or describing symptoms of orthostatic hypotension and may present with recurrent unexplained falls.
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