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

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.