Presentation on theme: "CC Pt is a 48 yo AA male who presents with SOB.. HPI SOB has been progressive over the last couple of weeks. Patient has had orthopnea, no dyspnea on."— Presentation transcript:
CC Pt is a 48 yo AA male who presents with SOB.
HPI SOB has been progressive over the last couple of weeks. Patient has had orthopnea, no dyspnea on exertion, cough productive of white sputum. Patient denies fever,admits wheezing, denies pedal edema, denies palpitations, denies chest pain or pressure.
PMHx Pt has had 16 year Hx of HTN, refractory to multiple medications including, Ace-I, HCTZ, BB and CCB. BPH
FHx Diabetes in Father Father died of MI
SHx Patient has a Hx of cocaine use that ended 2 years ago. Patient currently smokes 1 ppd
ROS Claims weight loss of 10 lbs over 1 month Constipation for 2 weeks, only broken miralax, several days ago
Medications and Allergies Clonidine Metoprolol HCTZ Amlodipine PCN-allergy of rash
PE Afebrile, HR 111, BP 203/139, RR 18, SAO2 99% on RA A large non-obese AA man AAOX3 Coughing, speaking complete sentences, in NAD, mild dyspnea on minimal exertion No visible JVD, no pedal edema, Taccycardic s1s2, with s4 gallop, no murmur, no rub Good inspiratory effort with reduced breath sounds on posterior lung fields, no crackles
Labs Na-134 K-3.9 Cl-95 CO2-23 BUN-13 Cr-1.1 Glu-103 BNP-4054 WBC-12.4 Hg-11.7 Hct-33.8 Plat-287 Troponin=0.06, CKMB=9.0, CK=522 CT chest- no PE, b/l pleural effusions, L heterogenous mass w/ internal calcification from adrenal gland
24 hour collection for metanephrines: 100% sensitive Patient’s: Normetanephrine 20,154 (649) Metanephrine 105 (203) Total Metanephrine 20,259 (739) Plasma [normetanephrine>2.5 pmol/ml] or [metanephrine>1.4 pmol/ml] 100% specific We decided to wait for biopsy, also 100% specific
Scintigraphy w/ 131 I-MIBG (NE analog) targets to adrenergic tissue Clonidine suppression test- clonidine should no suppress the plasma levels of NE
Treatment requires phenoxybenzamine, B blocker, metyrosine and IV rehydration 14 days prior to surgery Surgical Resection
Cardiac Reflections Echo 3/2: LV diastolic dysfunction, EF45- 49%, LV relaxation abnormality. Techitium 99 M Stress test 3/4: LVEF estimated at 29%, global hypokinesis, and inhomogenous trace uptake, compatible with dilated cardiomyopathy. Cardiac Catheterization: moderately severe RCA 70%, LV 30%