Adrenal Disorders USMLE Step 1 Practice Question
A 38-year-old man presents to the emergency department with a 3-month history of episodic severe headaches, diaphoresis, and palpitations. His wife notes he has become increasingly irritable and anxious. He has a history of hypertension treated with lisinopril monotherapy. Vital signs today show blood pressure 182/115 mmHg, heart rate 118 bpm, and respiratory rate 16/min. Physical examination reveals mild tremor and pallor but is otherwise unremarkable. Laboratory studies show plasma free metanephrines 4.2 nmol/L (normal <0.9) and 24-hour urine metanephrines 420 µg (normal <90 µg). Abdominal CT demonstrates a 3.2-cm right adrenal mass with homogeneous enhancement. Genetic testing for hereditary syndromes is pending. Which of the following is the most appropriate next step in management?
Answer choices
- AInitiate selective beta-1 blocker (metoprolol) followed by addition of alpha-blocker (doxazosin) and then refer for surgical consultation
- BProceed directly to laparoscopic right adrenalectomy after patient consent, with intraoperative vasopressor support available
- CInitiate alpha-blockade (phenoxybenzamine) followed by addition of beta-blocker (propranolol) after blood pressure stabilization, then refer for surgical consultationCorrect answer
- DAdmit for continuous intravenous nitroprusside infusion and prepare patient for same-day adrenalectomy under general anesthesia
- EStart combination antihypertensive therapy with lisinopril, amlodipine, and hydrochlorothiazide; recheck catecholamines in 4 weeks
- FAdminister single-dose intravenous labetalol for acute blood pressure control and discharge home with close outpatient follow-up
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