Tx of HTN - woodywoodpecker

[ArchivalUser]

A 20-year-old female is seen in the emergency department
with symptoms of severe periodic headaches,
sweating, and nausea with vomiting. She also complains
of feeling light-headed with standing. Her blood pressure
on presentation is 240/136, with a heart rate of 92. On
standing, the patient has a blood pressure of 204/98, with
a heart rate of 136. On ophthalmologic examination the
patient has mild blurring of the optic discs without hemorrhage.
The examination is otherwise normal. What is
the best medication for the management of this patient™s
hypertension?
A. Phentolamine
B. Fenoldopam
C. Esmolol
D. Nicardipine
E. Diazoxide

What test would best determine the patient™s diagnosis?
A. Plasma catecholamines
B. 24-h urine collection for 5-hydroxy-indoleacetic
acid
C. Abdominal CT scan
D. 24-h urine collection for metanephrines and vanillylmandelic
acid
E. Adrenal vein sampling for renin levels

[ArchivalUser]

A & D

[ArchivalUser]

A ,D

[ArchivalUser]

A
D

[ArchivalUser]

a&d pheochromocytoma

[ArchivalUser]

A and D

[ArchivalUser]

The answers are A and D. The scenario describes a young
patient with severe hypertension and should prompt consideration of secondary causes of
hypertension. The episodic symptoms and orthostasis despite marked hypertension are
suggestive of pheochromocytoma. Thus, the most appropriate management of this patient
should include an α-adrenergic receptor blocker. Phentolamine and nitroprusside are two
agents that can be used intravenously in the setting of hypertensive crises. This patient
should be managed as such as she has evidence of increased intracranial pressure on ophthalmologic
examination. An oral α-adrenergic blocker is available in the form of phenoxybenzamine.
The diagnosis of pheochromocytoma is best made by 24-h urine collection
for metanephrines and vanillylmandelic acid. Plasma catecholamines are elevated in patients
with pheochromocytoma, but the routine measurement of these levels for diagnosis
is confounded by the wide variation in levels associated with various stressors. If plasma
catecholamines are to be used, the levels must be drawn with the patient at rest for at least
30 minutes and drawn through an indwelling intravenous catheter. False-positive results
are common. Abdominal CT imaging can also be adjunctive to assess for an adrenal or periaortic
mass associated with pheochromocytoma but is not diagnostic without concurrent
demonstration of elevated catecholamines. Measurement of 5-HIAA and renin levels is
done for diagnosis of carcinoid syndrome and primary hyperaldosteronism, respectively.