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I haven't posted one in a while. Nothing tricky, just a rare condition, fun case.
43 year old male with no prior medical or surgical history admitted for chest pain and headache after collapsing during exercise. He described about a year of exertional angina and palpitations. BP on admission was 200/110. Labs of note were Cr 2.4, Hb 19.5, glucose 366. Peak troponin of 7.50, BNP 306. Negative drug screen. Prior to transfer to our institution he was diagnosed with polycythemia vera and was phlebotomized 300 mL. Reportedly they felt his MI might have been related to hyperviscosity. Family history of early cardiac events.
Admitted to our ICU for hypertensive crisis, NSTEMI, ARF, still with the working diagnosis of polycythemia vera. BP controlled with hydralazine and clonidine. Renal ultrasound was done (presumably looking for renal artery stenosis) which showed a right adrenal mass, and followup CT showed a 4x4x5 cm adrenal mass. Eventually the word pheochromocytoma shows up in the chart. Confirmatory labs sent out.
Around hospital day 5 we get consulted re: scheduling the adrenalectomy. BPs have been controlled for several days now, and they say he's optimized.
Questions for students and residents.
1) How do you optimize a pheo patient for surgery?
2) How do you know when they're optimized?
3) How long does it take to optimize them?
4) What if you don't optimize them?
5) This patient had an MI. What cardiac workup does he need, if any?
6) How long after his MI should the tumor resection be delayed? Should it be delayed at all?
These can be fun cases intraop, but most of the important work is preop preparation, so I'll leave it there.
43 year old male with no prior medical or surgical history admitted for chest pain and headache after collapsing during exercise. He described about a year of exertional angina and palpitations. BP on admission was 200/110. Labs of note were Cr 2.4, Hb 19.5, glucose 366. Peak troponin of 7.50, BNP 306. Negative drug screen. Prior to transfer to our institution he was diagnosed with polycythemia vera and was phlebotomized 300 mL. Reportedly they felt his MI might have been related to hyperviscosity. Family history of early cardiac events.
Admitted to our ICU for hypertensive crisis, NSTEMI, ARF, still with the working diagnosis of polycythemia vera. BP controlled with hydralazine and clonidine. Renal ultrasound was done (presumably looking for renal artery stenosis) which showed a right adrenal mass, and followup CT showed a 4x4x5 cm adrenal mass. Eventually the word pheochromocytoma shows up in the chart. Confirmatory labs sent out.
Around hospital day 5 we get consulted re: scheduling the adrenalectomy. BPs have been controlled for several days now, and they say he's optimized.
Questions for students and residents.
1) How do you optimize a pheo patient for surgery?
2) How do you know when they're optimized?
3) How long does it take to optimize them?
4) What if you don't optimize them?
5) This patient had an MI. What cardiac workup does he need, if any?
6) How long after his MI should the tumor resection be delayed? Should it be delayed at all?
These can be fun cases intraop, but most of the important work is preop preparation, so I'll leave it there.