Okay, let's tackle this question. The patient is a 25-year-old man with sudden onset of headache, confusion, sweating, and eye rolling. He has a history of similar episodes that resolved spontaneously. His BP is very high at 210/108, and he's hypertensive. The key here is to figure out the underlying cause of his hypertension and the episodes.

First, the symptoms like headache, sweating, and eye rolling could point to a hypertensive emergency. But the fact that these events have happened before and resolved on their own might suggest an episodic cause. Hypertension that's episodic and associated with sweating and headaches is classic for pheochromocytoma. Pheochromocytoma is a tumor of the adrenal medulla that secretes catecholamines, leading to paroxysmal hypertension. The episodes can cause the symptoms described.

Now, the lab results: BUN is elevated (30 mg/dL), which might indicate prerenal azotemia due to high blood pressure. The potassium is normal, so hyperkalemia isn't a concern here. The other electrolytes are within normal limits. The patient's age is 25, which is a bit younger, but pheochromocytoma can occur at any age, though more common in adults.

The question asks what medication should be started before surgery. The standard treatment for pheochromocytoma is surgical removal of the tumor. However, before surgery, the patient needs to be stabilized. The main issue is managing the hypertension and preventing intraoperative complications. The key here is to use alpha-adrenergic blockers to prevent the vasoconstriction caused by excess catecholamines. Phenoxybenzamine is a non-selective alpha-blocker that is typically used preoperatively. It works by blocking both alpha-1 and alpha-2 receptors, which helps to control the episodic surges of catecholamines.

Looking at the options, even though they aren't listed here, the correct medication would be an alpha-blocker. Beta-blockers alone could be dangerous because they might unopposed alpha-adrenergic stimulation, leading to severe vasoconstriction. So, the answer is likely phenoxybenzamine. The other options might include medications like nitrates, ACE inhibitors, or beta-blockers, which are incorrect in this context.

The clinical pearl here is to remember that in pheochromocytoma, alpha-blockers must be used preoperatively to avoid intraoperative hypertensive crises. Beta-blockers should only be used if there's a tachycardia, but after alpha-blockade is established.

**Core Concept**
This scenario presents a classic case of **pheochromocytoma**, a catecholamine-secreting tumor of the adrenal medulla. The episodic hypertension, headache, sweating, and tachycardia are hallmark features. Preoperative management requires **alpha-adrenergic blockade** to prevent intraoperative hypertensive crises.

**Why the Correct Answer is Right**
The patient’s paroxysmal hypertension with symptoms like headache, diaphoresis, and tachycardia strongly suggests pheochromocytoma. **Phenoxybenzamine**, a non-selective alpha-adrenergic antagonist, is the

✓ Correct Answer: D. Phenoxybenzamine and propranolol