PATHOPHYSIOLOGICAL MANIFESTATION

A Case Study Reflecting the Pathophysiological Manifestation Seen In One Patient in Nurse Practitioner

A Case Study Reflecting the Pathophysiological Manifestation Seen In One Patient in Nurse Practitioner

Case Study

Mr D was a 50-year-old man who visited a nursing care center for his annual checkup. He informed the nurse practitioner that until recently he had been in good health and did not have a family history of high blood pressure, heart disease, or diabetes. Mr D explained to the nurse that approximately two weeks before this visit, he began to experience episodic headaches, a pounding heart, profuse sweating, and panic attacks. These episodes sometimes were precipitated by heavy exertion (eg, lifting, bending). Mr D mentioned, as an aside, that he also had developed cold feet, which required him to wear socks to bed except on hot summer nights. (Thomas, 1993, 1494)

Mr D's physical examination revealed the following vital signs: BP = 196/115, pulse = 60 beats/min, temperature = 37.0 [degrees] C (98.6 [degrees] F). His skin was pale and moist without neurofibromatosis or cafe-au-lait spots, and his urine was 2 for glucose. Mr D weighed 100 kg (220 lb), and he was a nonsmoker. The nurse practitioner referred Mr D to a physician who saw him that afternoon.

The physician ordered the following laboratory tests: a complete blood count, liver enzyme studies, serum chemistries, a fasting serum glucose level, and a 24-hour urine collection for VMA analysis. Mr D's test results were normal, except for his serum glucose, which was 130 mg/dL (normal = 70 to 115 mg/dL) and his urine VMA, which was 40 mg/24 hr (normal = 2 to 7 mg/24 hr). The physician then ordered biochemical tests to measure Mr D's plasma catecholamines; and norepinephrine, epinephrine, and dopamine levels. The test results showed a total catecholamine concentration of 5,490 pg/mL (normal [is less than] 500 pg/mL), a norepinephrine level of 5,390 pg/mL (normal = 65 to 400 pg/mL), an epinephrine level of 15 pg/mL (normal = 15 to 55 pg/mL), and a dopamine level of 85 pg/mL (normal [is less than] 100 pg/mL). (Thomas, 1993, 1494)

A CT scan revealed a 6 x 3 cm tumor on Mr D's right adrenal gland. A subsequent MIBG scan revealed a similar finding but no evidence of an extra-adrenal tumor. Mr D's physician ordered serum parathormone, calcitonin, and thyroid function tests to rule out MEN syndrome and began Mr D on a daily regimen of 10 mg of oral phenoxybenzamine hydrochloride and 250 mg of oral metyrosine. He increased Mr D's phenoxybenzamine hydrochloride dosage 10 mg every other day and his metyrosine dosage every day until Mr D could tolerate a total daily dose of 50 mg of phenoxybenzamine hydrochloride and 2 g of metyrosine. The physician told Mr D that surgery for removal of the tumor was necessary and referred him to a surgeon.

The surgeon discussed the advantages and disadvantages of each surgical approach (ie, lateral, transabdominal, laparoscopic) in such a way that enhanced Mr D's ...