G90.3: Multi-system degeneration of the autonomic nervous system
I95.1: Orthostatic hypotension
R55: Syncope and collapse (when etiology undetermined)
Underlying cause codes
G20: Parkinson disease
G90.3: Multiple system atrophy
E11.40: Diabetic autonomic neuropathy
G62.9: Peripheral neuropathy (unspecified)
Patient Discharge Instructions
copy discharge instructions
What happened today
You fainted or nearly fainted due to a drop in blood pressure when you stood up
This is called orthostatic hypotension or postural hypotension
It is caused by blood pooling in your legs when you stand, reducing blood flow to your brain
Steps to prevent fainting episodes
Rise slowly from lying or sitting
Sit at the edge of the bed or chair for 1-2 minutes before standing
Stand up gradually, holding onto furniture for support
Stay well hydrated
Drink at least 2-3 litres of fluid per day
Drink a large glass of water (500 mL) before getting up in the morning
Increase your salt intake as directed by your doctor
Add extra salt to food unless you have heart failure or are on a low-salt diet
Salt tablets may be prescribed
Avoid triggers
Prolonged standing (>5-10 minutes)
Hot showers, baths, or environments
Large heavy meals (especially carbohydrate-heavy)
Alcohol
Counterpressure techniques if you feel dizzy
Cross your legs and tighten the muscles
Squat down to the ground if you feel a faint coming on
Clench fists and tense arms
Wear compression stockings if prescribed
Put them on before getting out of bed in the morning
Your medications
Some of your medications may be making this worse
Do not stop prescribed medications without calling your doctor first
Your doctor may adjust or hold certain blood pressure or water pills
New medications prescribed (if applicable)
Take as directed
Last dose of midodrine at least 5 hours before bedtime
Activity and driving
Do not drive until you have had no fainting or near-fainting for at least 1-2 weeks
Check local regulations for syncope and driving
Avoid heights or operating heavy machinery until cleared
Return to the emergency department immediately if
You faint again without positional trigger (while seated or lying down)
Chest pain, chest pressure, or palpitations occur
You feel short of breath or have difficulty breathing
You have weakness, numbness, speech difficulty, or vision loss
You have a fall with injury to the head
You notice black or bloody stools
Dizziness persists despite drinking fluids
Follow-up plan
See your family doctor within 1-2 weeks
Repeat blood pressure measurements lying and standing
Medication review
Neurology or cardiology referral if arranged — keep the appointment
References
Guidelines and key sources
2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope
Shen WK, Sheldon RS, Benditt DG, et al.
Journal of the American College of Cardiology, 2017
Class I recommendation: 500 mL water bolus for OH management
Class IIa recommendation: counterpressure maneuvers
Class I: medication review and offending agent removal
Management of Orthostatic Hypotension — JAMA Internal Medicine 2026
Moloney D, Youssef A, Okamoto LE
Comprehensive management algorithm for OH
Fluid, salt, and pharmacologic treatment hierarchy
Syncope: Evaluation and Differential Diagnosis — American Family Physician 2023
Bayard M, Gerayli F, Holt J
Midodrine dosing: 2.5-10 mg PO 1-3 times daily
Fludrocortisone: 0.05-0.2 mg daily; avoid in HF
Discharge and admission criteria
Diagnosis and Treatment of Orthostatic Hypotension — Lancet Neurology 2022
Wieling W, Kaufmann H, Claydon VE, et al.
Coat hanger pain specificity for neurogenic OH
Non-pharmacologic and pharmacologic management review
Timing and triggers of OH episodes
Orthostatic Hypotension in Adults With Hypertension — AHA Scientific Statement 2024
Juraschek SP, Cortez MM, Flack JM, et al.
Hypertension journal, 2024
Management of coexisting hypertension and OH
Pyridostigmine preferred when supine HTN present
ACR Appropriateness Criteria — Syncope 2021
Kligerman SJ, Bykowski J, Hurwitz Koweek LM, et al.
JACR 2021
CT head usually not appropriate in uncomplicated syncope
MRI brain not routinely indicated for typical OH
Canadian Syncope Risk Score — American Family Physician 2021
Meisenheimer ES, Rogers TS, Saguil A
Validated risk stratification tool for ED syncope
Score <0: very low risk (~0.4%) 30-day serious adverse events
Orthostatic Hypotension: A Practical Approach — AFP 2022
Kim MJ, Farrell J
Droxidopa dosing: 100-600 mg PO 2-3 times daily
Last dose 3 hours before bedtime
Baroreflex Dysfunction — NEJM 2020
Kaufmann H, Norcliffe-Kaufmann L, Palma JA
Pathophysiology of neurogenic OH
Plasma NE thresholds for distinguishing pre- vs postganglionic failure
Diabetes Care Standards 2026 — ADA Professional Practice Committee
12. Retinopathy, Neuropathy, and Foot Care: Standards of Care in Diabetes 2026
Autonomic neuropathy in diabetes: prevalence and management
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.