Quiz Week 3

A 52 year old Caucasian male presents to your clinic for a complaint of headache. His wife feels sorry that they could not come to see you earlier because they did not have insurance.

You examined him thoroughly and find that he is slightly cachectic, heart rate of 103, has an unremarkable examination of Head, neck, chest, heart, abdomen and extremities. Neurologically , he is fine. His blood pressure is normal and so is his EKG.

A few minutes later, he complains about headache. He seems anxious and his blood pressure and pulse have sky-rocketed.

Q1. Which of the following features in this person is not usual for the suspected disease?

Rise in blood pressure after manipulating the abdomen

Feeling of doom associated with the headache

Normal initial blood pressure

Headache

None of the above is unusual

The answer is Normal initial blood pressure.
Majority of patients with Pheochromocytoma (60%) have a persistently elevated blood pressure.
The paroxysms of hypertension can be produced in a patient by manipulating the abdomen therefore one should avoid repeated examination of the abdomen in them. The headache is common in patients and is associated in a large percentage of patients with a feeling of doom. In the description of the case, cachexia too is described - remember that it too is expected as catecholamines are catabolic hormones and cause an increase in metabolic rate. On the other hand, a patient with an insulinoma actually continues to put on weight as Insulin is an anabolic hormone.

Q2.  Of the following choices, what test should you order to help with the diagnosis of the patient?

Urinary VMA (Vannilyl mandelic acid)

Serum VMA

24 hour urinary catecholamines

Serum catecholamines

Serum metanephrines

The answer is 24 hour urinary catecholamines.
Explanation:
Diurnal variations of catecholamine production and excretion are significant. This calls for more reliability in 24 hour tests. Spot checks may be falsely elevated or falsely normal in those tested. Just the thought of a needle can make a person start to produce more catecholamines.
24 hour VMA would be a viable choice but VMA can be increased by many foodstuffs and in this quiz it was deliberately not included as an option.
One should know the meaning of the word usual when used in medical discussions. A finding is "usual" if it is seen in more than 50% of patients. Another way of saying this would be "in the majority of patients"
If in doubt please read "Harrissons" for this answer.