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Adrenal Case: 25-year-old Man with Severe Pulsatile Headache

by Michael Lazarus, MD

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    00:00 Let's go on to another case.

    00:03 A25-year-old male presents to the emergency department with a severe pulsatile headache for one hour.

    00:09 He says that he's having palpitations and sweating.

    00:12 He adds that he has had several similar episodes in the past which resolved without seeking medical attention.

    00:20 He is a nonsmoker and does not drink alcohol.

    00:23 He denies the use of any illicit drugs.

    00:26 He looks anxious and diaphoretic.

    00:29 His temperature is 37 degrees Celsius.

    00:31 His respirations are 25 breaths per minute.

    00:34 Pulse rate is 107 and blood pressure is 228/160.

    00:40 A CT scan of the abdomen reveals an adrenal mass.

    00:44 What is the next step in the management of this patient? Based on the clinical suspicion formulated by the presentation of this patient, a pheochromocytoma or an adrenaline-secreting tumor of the adrenal gland is very high on the differential.

    01:04 Usually, this manifests as the classic triad of diaphoresis, headache, and tachycardia.

    01:11 CT scan findings also suggest that there is an adrenal mass which would go along with the diagnosis.

    01:18 The next best step in the management of this patient would be to order a 24-hour urine metanephrine and catecholamine level to confirm the diagnosis.

    01:28 Phenoxybenzamine is a non-competitive alpha blocker and is given 7-10 days prior to surgery for patients needing resection for their pheochromocytoma.

    01:38 This medication blocks alpha receptors in blood vessels.

    01:42 This is then followed by beta blockade using a non-selective beta blocker like propranolol which acts on the beta receptors in the heart and kidney to lower blood pressure further.

    01:54 Beta blockade should be done when all the alpha-1 receptors are already blocked or else the circulating catecholamines may stimulate alpha-1 receptors precipitating a hypertensive crisis.


    About the Lecture

    The lecture Adrenal Case: 25-year-old Man with Severe Pulsatile Headache by Michael Lazarus, MD is from the course Adrenal Gland Disorders.


    Included Quiz Questions

    1. Evaluation of 24-hour urine metanephrine and catecholamine levels
    2. Surgical excision
    3. Administration of an alpha-blocker
    4. Administration of a beta-blocker
    5. Reevaluation in 7–10 days

    Author of lecture Adrenal Case: 25-year-old Man with Severe Pulsatile Headache

     Michael Lazarus, MD

    Michael Lazarus, MD


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