jmj11 Posted November 20, 2011 Share Posted November 20, 2011 Okay here is a case I want to throw out and see who can solve it. It is not one of my headache patients (because to you they all sound a like . . . thus boring) but this is a real case, but a close friend of ours. I'm presenting it because it baffled her PCP (family doc) then when she was in the hospital, not getting better, they got a second opinion from the internist. She was eventually discharged with an unknown diagnoses, but no better. She was re-admitted a few days later at another hospital . . . where the definitive diagnoses was made. I only know some of the test results because I was not following her myself. But I have a feeling that you will get it rather quickly. 48 year old white female was admitted for acute right flank pain (direct admit from her PCP's office). It was assumed that it was a renal calculi (the pain was a 8-9/10). Her UA came back completely normal, yet her PCP figured it must be pyelonephritis (with a normal UA) and he was waiting on a culture while she was on IV antibiotics. The culture eventually came back without pathogens. Other symptoms were a bad headache and some nausea. She has no history of headache. Other signs were her blood pressure was 184/100 in her PCP's office. It was assumed to be elevated because of her acute pain. She had no history of hypertension. On the floor (and with PCA morphine) and the pain level at about a 3/10, her blood pressure was about the same. Consults included surgery. They didn't find a surgical cause, although an exploratory lap crossed their minds. Okay, you might guess it at this point. I do know a few labs and other information . . . if you want to "buy a vowel" you can ask about any tests and I will tell you if I know. I will say that due to my recent study for the PANRE I was guessing this was what she had, even when she was in her first admission and her PCP was baffled. Link to comment Share on other sites More sharing options...
medic25 Posted November 20, 2011 Share Posted November 20, 2011 Did the surgery consult request an abdominal CT? I'd be very interested to see what her adrenal glands look like, especially with her hypertension. I'd be surprised if they didn't scan her, since that seems to be the first answer for many surgical consults these days :) Anybody run a metanephrine level? Link to comment Share on other sites More sharing options...
jmj11 Posted November 20, 2011 Author Share Posted November 20, 2011 Did the surgery consult request an abdominal CT? I'd be very interested to see what her adrenal glands look like, especially with her hypertension. I'd be surprised if they didn't scan her, since that seems to be the first answer for many surgical consults these days :) Anybody run a metanephrine level? I was told by her family that the CT of the abdomen was done at the first hospital and read it as normal. I will not access her official report because she is not my patient. I don't know about a metanephrine level, but I will say you are on the right path. Link to comment Share on other sites More sharing options...
ToppDog Posted November 20, 2011 Share Posted November 20, 2011 Well, I'm only pre=PA, but I am curious how they jumped to renal calculi or pyelonephritis with a normal U/A unless they ran other tests that would indicate that. Any MRI or CT scan, or IVP or retrograde ureterogram? U/A was normal, so no hematuria, Leukocytes or nitrates. Link to comment Share on other sites More sharing options...
Just Steve Posted November 20, 2011 Share Posted November 20, 2011 Shooting from the hip and blurting out the first thing that came to mind....renal infarct. Just a PA-S1 who is still trying to figure out my elbow from my ear...I should be studying rheumatic arthritis for the pathology paper that is due Monday morning but am distracting myself....It'll be interesting to watch where your case presentation goes. Link to comment Share on other sites More sharing options...
jmj11 Posted November 20, 2011 Author Share Posted November 20, 2011 Well, I'm only pre=PA, but I am curious how they jumped to renal calculi or pyelonephritis with a normal U/A unless they ran other tests that would indicate that. Any MRI or CT scan, or IVP or retrograde ureterogram? U/A was normal, so no hematuria or nitrates. I'm as baffled as you. At this point we strongly suggested that they get a second opinion. The family asked for a second opinion (at the first hospital). The Internist disagreed with the PCP because of the fact of having a normal UA. No IVP, ureterogram. no hematuria or nitrates. I think the PCP was taking a stab in the dark thinking "flank pain = stone or pyleo." She was discharged still with hypertension, still with flank pain (although it was less that at first) an on antibiotics (for reasons that I can only guess). Link to comment Share on other sites More sharing options...
ToppDog Posted November 20, 2011 Share Posted November 20, 2011 Okay, cool. I might have bought a renal calculi dx with a normal U/A if there was a complete blockage of the ureter, which could have prevented anything from getting past it that would have shown up in the urine, but not without further tests to back it up. I'd be interested in the adrenal glands as well, but this is where I go back to lurking :) Link to comment Share on other sites More sharing options...
jmj11 Posted November 20, 2011 Author Share Posted November 20, 2011 Okay, cool. I might have bought a renal calculi dx with a normal U/A if there was a complete blockage of the ureter, which could have prevented anything from getting past it that would have shown up in the urine, but not without further tests to back it up. I'd be interested in the adrenal glands as well, but this is where I go back to lurking :) Good call. Keep lurking. Link to comment Share on other sites More sharing options...
medic25 Posted November 20, 2011 Share Posted November 20, 2011 I was told by her family that the CT of the abdomen was done at the first hospital and read it as normal. I will not access her official report because she is not my patient. I don't know about a metanephrine level, but I will say you are on the right path. Got it. I'll leave it for a hard-working PA student to complete the diagnosis :) Link to comment Share on other sites More sharing options...
jmj11 Posted November 20, 2011 Author Share Posted November 20, 2011 I will add that I know a few labs . . . which sealed it for me. Link to comment Share on other sites More sharing options...
mdebord Posted November 20, 2011 Share Posted November 20, 2011 Alright so essentially we've got two symptoms: acute unilateral flank pain and elevated BP (with HA/nausea). Clean UA makes pyelo and stone very unlikely. I too considered renal infarct, but if this lady is 48 I don't know if she has the risk factors for it (hard to exclude with no history). I'm also considering ruptured renal cyst (although I don't know about the BP with that), pheochromocytoma (which I would have expected to show up on CT, but the metanephrine hint helps :;;D:), or maybe some other obstructive cause like RCC. Anything I'm missing? I'm trying to work on creating differentials instead of just going for the gold, so feedback is appreciated! Link to comment Share on other sites More sharing options...
jmj11 Posted November 20, 2011 Author Share Posted November 20, 2011 This may help, I think her K was 2.9 and her Na was 148-9. Link to comment Share on other sites More sharing options...
bobuddy Posted November 20, 2011 Share Posted November 20, 2011 I would be thinking hyperaldosterone syndrome and looking at the adrenal glands - especially with no history of hypertension in the past. possibly renal stenosis too? Link to comment Share on other sites More sharing options...
chiaroscuro27 Posted November 20, 2011 Share Posted November 20, 2011 When I first read the case my DDx consisted of pheochromocytoma and AAA (although I couldn't think of a reason that AAA would cause nausea). Now that I see the lab work my thoughts turn to a possible adrenal adenoma: it would increase the level of aldosterone which would increase the pressure, dump K+, and cause the symptoms. I can't think of anything other possibilities. I assume her CBC was normal? I'm surprised the PCP didn't do a better work up on a young woman with a new onset of HTN. Link to comment Share on other sites More sharing options...
Moderator ventana Posted November 20, 2011 Moderator Share Posted November 20, 2011 opposite of addison's ds - - - -?????? Link to comment Share on other sites More sharing options...
jmj11 Posted November 20, 2011 Author Share Posted November 20, 2011 I will add that the abdominal pain was a bit of a zebra and was what threw so many (including myself ) off the track. The pain is unusual (but not unheard of ) in this condition. Link to comment Share on other sites More sharing options...
d2305 Posted November 20, 2011 Share Posted November 20, 2011 Cushings' adrenal tumor should have been seen on the abdominal CT. Link to comment Share on other sites More sharing options...
adjk1229 Posted November 20, 2011 Share Posted November 20, 2011 Ou this is fun! I'm a pre-PA student and don't know what half the stuff you're talking about means but I'm keeping up (which I guess is a good thing). To be honest, I was thinking adrenal gland tumor as well but like you said, that wouldn't really cause the pain, right? I saw this mystery diagnosis on TV one time and this woman had symptoms that sounded similar to this and went undiagnosed for about 10 years until they found that she had a tumor on her adrenal glands. High blood pressure, headaches, nausea, profuse sweating, etc. I am excited to see! Link to comment Share on other sites More sharing options...
jmj11 Posted November 20, 2011 Author Share Posted November 20, 2011 I will give the conclusion. I'm sorry that there are many unanswered questions because I wasn't her care giver, but a family friend. She was readmitted to another hospital and left with a definitive dx as primary aldosteronism. She had elevated aldosterome during the second hospitalization and was told they found a right adrenal adenoma (thus appears to be so). She is scheduled to have the adenoma removed. I don't know why her original CT was read as normal. I could access her radiology report and films, but that would be unethical as she is not my patient. The caveats, for me at least, is that hypertension + elevated Na and decreased K suggest aldosteromism. I've since read that acute abdominal pain can be a presenting symptoms and it is believed that it is when the adenoma bleeds. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 20, 2011 Moderator Share Posted November 20, 2011 Nice teaching case, thanks Mike-e Link to comment Share on other sites More sharing options...
ToppDog Posted November 20, 2011 Share Posted November 20, 2011 Awesome! Can't wait until I know enough to get some of these :) Link to comment Share on other sites More sharing options...
chiaroscuro27 Posted November 22, 2011 Share Posted November 22, 2011 Awesome...finally I get one of these cases correct. Link to comment Share on other sites More sharing options...
HopefulPA Posted November 22, 2011 Share Posted November 22, 2011 Okay here is a case I want to throw out and see who can solve it. It is not one of my headache patients (because to you they all sound a like . . . thus boring). LOL JMJ Glad you friend has the mystery solved! Link to comment Share on other sites More sharing options...
cecilia Posted November 23, 2011 Share Posted November 23, 2011 maybe they did the CT scan without contrast? Link to comment Share on other sites More sharing options...
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