Dr Mohammad Nabi Sanaei Resident of internal medicine Shahid Beheshti university of medical sciences Taleghani hospital Chief complaint Flank pain with dizziness palpitation sweating and headache ID: 1047245
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1. in the name of god
2. 36 years old male with headache, dizziness, palpitation, tremor and sweatingDr. Mohammad Nabi SanaeiResident of internal medicine Shahid Beheshti university of medical sciencesTaleghani hospital
3. Chief complaint:Flank pain with dizziness, palpitation, sweating and headachePresent illness:Patient is a 35 years old male, farmer, from Rasht, who developed with sudden onset episodes of dizziness, headache, palpitation, flushing, tremor and sweating since 2.5 months ago, he also had a left side flank pain since then, his pain is constant, compressive, without any response to any condition, without refer to anywhere, due to the pain he went to a nephrologist.
4. A SBP of 170 was detected and sonography, BUN, Cr, and U/A was checked for him. Losartan 25 mg BD was started. After that his condition get worse, recurrence of attacks elevated and episodes of orthostatic changes added to his problems, his attacks repeated 1 to 3 times/week, and he disabled due to orthostatic changes, in sonography an adrenal mass was detected, so further evaluation was done and he referred here for better evaluation.Neg. history of chest pain or syncopal attackNeg. history of weight gainNeg. history of weight loss, anxiety, normal apetide
5. Drug history:Losartan 25 mg PO BD sice 3 monthes agoPast medical history:Decreased visual acuity since 5-6 years agoSurgical history:Appendectomy 17 years agoHabitual history:Negative smoking, opium addiction or alcohol abuseFamily history:His father had some skin lesion same as himHis mother, three brothers and one sister are healthy
6. Physical exam:General appearance: A young male, not ill nor toxic, awake and orient without any distressVital sign: BP: 120/70, Neg. tilt, PR: 78, RR:16, OT: 36.8 Wt: 85 Kg, Ht: 183 cm, BMI: 25.38 kg/m2HEENT: NL mucosa, Neg. pigmentation, NL Conj., Flat JVP, Neg. LAP, NL Thyroid, Neg. moon face, Neg. fat pad, Pigmented nodules in iris (lisch nodule), Rt. Eye visual acuity without correction: 8/10, left eye visual acuity without correction: hand motion, left eye exotropia
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8. Lung: Clear without rale or wheezeHeart: NL. S1 S2 without murmurAbdomen: soft without organomegaly or tenderness Ext.: NL without edema, Neg. skeletal deformity Neurologic exam: MP 5/5, DTR 2/2, Neg. focal neurologic deficitskin: axillary brown patches (axillary freckle), Neg. inguinal freckles, some brown patches with different size in chest, abdominal wall and back (café au lait) with maximum size of 2.5 * 1.5 cm in back, >6 >1*1 cm , small skin papules (neurofibroma) with maximum size of 0.8 * 0.5 cm in anterior and posterior part of trunk and upper limbs, Neg. striae
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13. Lab data:Unit96.8.1396.7.18RashtMicro L13000WBCg/dl16.4HbFL87.1MCVMicro L367000PLTMg/dl1421BUNMg/dl1.31.5CrMg/dl179TGMg/dl265CHOLIU/L46ASTIU/L48ALTIU/L2.6TSHMg/dl105FBS
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15. RangeUnit96.8.22Rasht135-145Meq/L143Na3.5-5.5Meq/L4.8k24 hr urin800-1800ML/24hrs900volume1000-2000Mg/24hrs1404Cr10-100Micro gr/24hrs217CortisolUp to 350Micro gr/24hrs1503MetanephrinUp to 13.6Mg/24hrs44VMA2.8-30Micro gr/24hrs18.4Aldosterone30-400Pg/ml151Aldosterone up.4.5-24Micro gr/dl16.78Cortisol (8AM)
16. CT Scan
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23. Here in Taleghani hospital
24. Losartan holdPhenoxybenzamine started and elevated till 80 mg daily (Poor controlled blood pressure but minimal orthostatic changes) then changed to prazocin due to unavailability (Good controlled blood pressure but recurrent orthostatic hypotension)Surgeon consult was doneOphthalmologist consult was doneB-blocker and calcium channel blocker added laterRe work up
25. Range Unit 96/9/2Taleghani4000-11000Micro L10400WBC13-16g/dl16.3Hb80-100FL85.9MCV150-400Micro L354000PLT7-20Mg/dl17BUN0.7-1.4Mg/dl1.1Cr135-145Meq/L141Na3.5-5Meq/L4K8.5-10Mg/dl8.8Ca2.5-5Mg/dl3.6Ph3.5-5.2Gr/dl4.9Alb
26. Range Unit 96/9/2Taleghani -Mg/dl286TG-Mg/dl209Chol-Mg/dl42LDL-Mg/dl123HDL3-64.6Hb A1C0-20Mm/h6ESR0-6Mg/L4CRP
27. Range Unit 96/9/1996/9/1396/9/11Gholhak171-536Nmol/L405BaseCortisol 8 AM171-536Nmol/L13.5Low doseCortisol 8 AM1.6-13.9Pmol/L0.7ACTHRange Unit 96/9/1996/9/1396/9/996/9/296/9/1Markazi 6.2-19.4Micro gr/dl10.38Cortisol 8 AM7.2-63.3Pgr/ml34.6ACTH5>Micro gr/dl10.17Cortisol Dexa.50-190Micro gr/24 hrs165UFC (Base)Ml/24 hrs1400Volume 0.8-2Gr/24 hrs1.8Cr 50-190Micro gr/24 hrs15.4UFC (Low dose)Ml/24 hrs1200Volume 0.8-2Gr/24 hrs1.8Cr 50-190Micro gr/24 hrs22.4UFC (High dose)Ml/24 hrs2200Volume 0.8-2Gr/24 hrs1.4Cr
28. Ophthalmologist consult:Visual acuity: right: 8/10, left: hand motionLisch nodules in irisLeft eye exotropiaLeft eye exudative RD and possibility of choroidal metastatic leisonRight eye macular pigmentary lesion possibility of nevusPlan: Orbit CT-Scan, refer to eye oncologistOncologist:Left eye vasoproliferative tumor, need surgery after blood pressure control and discharge from endocrinology service
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34. Summary:A 35 years old male with flank pain and episodes of dizziness, tremor, palpitation and sweating, high blood pressure and orthostatic hypotention attacksLisch nodules, axillary freckles and café au laits in examAn adrenal mass in sonography and CT-ScanHigh levels of 24hrs urine metanephrine and cortisolRetinal leisons
35. Thanks for your attention