2 HPISOB 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.
3 PMHxPt has had 16 year Hx of HTN, refractory to multiple medications including, Ace-I, HCTZ, BB and CCB.BPH
5 SHx Patient has a Hx of cocaine use that ended 2 years ago. Patient currently smokes 1 ppd
6 ROS Claims weight loss of 10 lbs over 1 month Constipation for 2 weeks, only broken miralax, several days ago
7 Medications and Allergies ClonidineMetoprololHCTZAmlodipinePCN-allergy of rash
8 PE Afebrile, HR 111, BP 203/139, RR 18, SAO2 99% on RA A large non-obese AA man AAOX3Coughing, speaking complete sentences, in NAD, mild dyspnea on minimal exertionNo visible JVD, no pedal edema,Taccycardic s1s2, with s4 gallop, no murmur, no rubGood inspiratory effort with reduced breath sounds on posterior lung fields, no crackles
9 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-287Troponin=0.06, CKMB=9.0, CK=522CT chest- no PE, b/l pleural effusions, L heterogenous mass w/ internal calcification from adrenal gland
13 PheochromocytomaDefinition: a catecholamine secreting tumor derived from chromaffin cells in adrenal medulla.
14 Epidemiology: no gender difference, 0 Epidemiology: no gender difference, 0.05% of population, incidence at is highest at yo.Associated with MEN II: Medullary carcinoma, 1 Hyperparathroidism, Pheochromocytoma, (RET gene)Associated with Von Hippel Lindau-hemangioblastomas (CNS), retinal angiomas, renal cysts, clear cell renal carcinoma, pancreatic cysts, papillary cystadenoma of epididymus, endolymphatic sac tumors (Von Hippel Lindau gene)
16 24 hour collection for metanephrines: 100% sensitivePatient’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% specificWe decided to wait for biopsy, also 100% specific
17 Scintigraphy w/ 131 I-MIBG (NE analog) targets to adrenergic tissue Clonidine suppression test- clonidine should no suppress the plasma levels of NE
18 Treatment requires phenoxybenzamine, B blocker, metyrosine and IV rehydration 14 days prior to surgerySurgical Resection
19 Cardiac ReflectionsEcho 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%