WBR0229

Author	[[PageAuthor::Mugilan Poongkunran M.B.B.S [1]]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Emergency Room
Sub Category	SubCategory::Endocrine
Prompt	[[Prompt::A 23 yr old male came to the emergency department with complaints of headache and palpitations. By time you attended the patient, he is asymptomatic. He reveals three similar episodes in the past that resolved spontaneously. He is currently on no medications and requests some pills to stop the episode because it is disturbing his preparation for exams. On examniation, you see a anxious and diaphorectic person in no acute distress. His temperature is 36.7 C, blood pressure is 130/70 mmHg, pulse is 102/min and respiartions are 16/min. Her oxygen saturation is 97% on room air. The neck is supple without any jugular venous distension or thyroid enlargement. The oropharynx is dry. Pupillary reflexes are intact. There is no obvious pallor or icterus. Lungs are clear to auscultation. Cardiovascular and gastrointestinal systems are unremarkable. During the prior visit in the ED for the similar episode his BP was 158/90mmHg. What is the most appropriate next step in the patient management?]]
Answer A	AnswerA::Refer him to psychiatrist
Answer A Explanation	AnswerAExp::'''Incorrect''' : Panic attacks can present in a similar way. However high blood pressure in one of the previous attack favors the diagnosis of pheochromocytoma.
Answer B	AnswerB::Measure the blood pressure in a week’s time
Answer B Explanation	AnswerBExp::'''Incorrect''' : Screening for pheochromocytoma should be the next step in the management of this patient.
Answer C	AnswerC::MRI of the abdomen
Answer C Explanation	AnswerCExp::'''Incorrect''' : MRI/CT is done only after biochemical confirmation is made for localizing the tumour.
Answer D	AnswerD::Measure 24-hour urine metanephrines and catecholamines
Answer D Explanation	AnswerDExp::'''Correct''' : Screening with plasma-free metanephrines (metanephrine and normetanephrine) or 24-hour urine metanephrines and catecholamines for confirming pheochromcytoma.
Answer E	AnswerE::Start anti-hypertensive’s
Answer E Explanation	AnswerEExp::'''Incorrect''' : Treatment is started after biochemical confirmation is made, because the drugs may interfere with interpretation of results.
Right Answer	RightAnswer::D
Explanation	[[Explanation::Pheochromocytoma is a tumor of chromaffin tissue found either in the adrenal medulla or in extra-adrenal sites that secrete catecholamines. It can also be associated with Von Hippel–Lindau disease, neurofibromatosis, or MEN 2 syndromes. It usually presents with intermittent tachycardia, palpitations, chest pain, diaphoresis, hypertension, headache, tremor, and anxiety. Crises may be precipitated by anesthesia. Screen with plasma-free metanephrines (metanephrine and normetanephrine) or 24-hour urine metanephrines and catecholamines. A 24 hour urine test is superior to spot urine testing, however urine tests could be altered by number of foods and drugs and hence plasma levels are done in certain centres. Urinary VMA is another screening test that can be used. Educational Objective: References: ]]
Approved	Approved::Yes
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