E M E R G E N C Y   M E D I C I N E

HISTORY:

58 y.o. black M is BIBA with c/o disorientation and L sided weakness and a L eye gaze. He was living @ Barrier Free Living (a home for independent people who require a structured home life) when friends noted the sudden onset of mental status change and confusion. EMS was alerted; BLS found the patient to have HA on the scene with a BP 220/110 110P 20R GCS=15. EMS reports that as the patient was being brought in, he appeared to have had a clonic-tonic seizure; the episode lasted a few seconds and he stopped seizing on his own.

Currently, the patient is talking and has complaints of severe headache and is disorientated to time, but is conscious of place and name. Otherwise, the patient is unable to furnish any medical history, other than high blood pressure and that he was recently taken off of one of his HTN meds- cardizem.

Meds- cardizem & propranolol.
Allergy- NKDA
PMHx- HTN
PSHx- none
SoHx- No smoke, ETOH, drugs. Travel- none. Pets- none.
 

PHYSICAL:
 
240/120: BP equal in both arms 114P 18R T98.9
PulseO2-100% (non-rebreather). FS-120

WD/WN Black M lethargic
HEENT- NC/AT. Eyes are deviated to the left, but reactive to light and equal. Not cooperative with fundus exam.
Chest- CTA No W/C/R
Cor- RRR nl S1S2 No M/G/R
Abd- Soft, nontender, +BS, no masses
Rectal- guaiac neg, good tone.
Ext- 2+ pulses x 4 ext.
Neuro- A&O x 2. Lethargic. Spontaneously moving all extremities; sensory- non-cooperative. Reflexes- non-cooperative.

At this point, pt was started on a nitroprusside drip, given benzodiazepines for sedation and seizure prophylaxis, and intubated for control of airway in preparation for CT-scan of the head.
Dilantin bolus given for seizure control.

ANCILLARY TESTS:
 
EKG- marked LVH. NO ÆST, or dec. T wave.
CXR- post-intubation, good tube placement, no I/E

LABS-
ABG- 7.50/38/526/29.6 (HCO3)/BE 6.6/99.9%
CBC: WBC-6.7 HGB-15 HCT-43 PLT-175 G48 L39 M9.4
SMA-7: NA-139 K-3.1 CL-94 HCO3-33 BUN-15 CRE-1.3 GLC-129
PT/PTT/INR 11.8/29.5/1.0
UA- wnl.
CT-head- revealed an old L parietal lobe infarct, but no new masses or shifts.
MICU called and admitted for continued care.

HOSPITAL COURSE:
 
Pt was seizure free in MICU and dilantin serum levels were therapeutic; pt was transferred to neurology service the next day. His neurologic findings resolved with no apparent residual deficits.

LABS-
Na-139, K-2.7, Cl-98, HCO3-30, BUN-14, Cre-1.3, Glc-145
Ca-8.6, PO4-4.1, Mg-1.6, UricAcid-3.9, TP-6.8, Alb-3.5,
Glob-3.3, LDH-265, AST-36, ALT-22, ALP-78,
Tbili/direct-0.4/0.2, Chol-148,
CK-316, MB-3.9, CI-NK
Aldosterone-25 (nl supine < 8),
Renin-0.2 (nl supine < 2),
ACE-wnl,
cortisol-wnl.
24-Urine- All wnl.
Ucre-1.4,
Umeta-86,
Umeta tot-281,
Unormeta-195,
UVMA-2.4

Adrenal vein sampling performed to rule out
adrenal hyperplasia vs adenoma

Normal levels of aldosterone is less than 20 ugm/ml. Clearly, levels of both adrenals were elevated; and therefore, bilateral adrenal hyperplasia was diagnosed. Further management problems encountered were the titration of 6 antihypertensive medications to lower the patient's BP to 190/100. The patient was discharged on dilantin, monopril, atenolol, lasix, clonidine patch, cardizem, DSMO. At home, the patient washed off the clonidine patch by mistake; however, he did not realize that he had washed off the medications. The patient returned to the emergency room via EMS with cardiac chest pain, changes in his EKG, and a BP of 240/120. At this second presentation, the patient had elevated CPK-MB and cardiac enzyme index was elevated. A cardiac catheterization showed clean coronaries and a presumed rebound hypertensive crisis was given for his second admission. The patient was titrated on clonidine and discharged home with close Nephrology follow up. To date, the patient is doing well with control over his hypertension.