CASE
A 25-year-old male presented to the emergency department after an alleged assault. The patient was hit in the head several times but never lost consciousness. He complained of headache but no nausea. His injuries were isolated to the head and face and limited to lacerations and contusions. The patient was intoxicated; he had consumed as many as 12 cans of beer throughout the evening. A review of systems was otherwise negative for neck or back pain, chest pain, visual changes, shortness of breath, or syncope. Initial vital signs included pulse, 150 beats per minute, and BP, 210/130 mm Hg. Baseline laboratory studies and an ECG were ordered. Potassium level was 2.2 mmol/L, but all other values and CBC results were within normal limits; the blood alcohol level was 0.14 g/dL. CT of the brain was negative. ECG indicated a normal sinus rhythm. Coagulation and cardiac enzyme study results were within normal limits.
History The patient denied any medical problems and family history was negative. He had a one-pack-per-day smoking habit and a remote history of cocaine use. He was employed as a construction worker. During the past 4 months, the patient had lost 30 lb through an effort to stay in shape. He had no contributory night sweats or foreign travel.
Diagnostic studies The patient was admitted to the hospital for evaluation of his hypertensive urgency and hypokalemia. BP remained high; however, he had no sympathomimetic symptoms of anxiety or sweating. Renal ultrasonography was unremarkable. Low plasma renin levels and elevated aldosterone levels were appreciated as part of his admission evaluation. A high resolution CT of the abdomen revealed a 15-mm nodule on the right adrenal gland (Figure 1). Given his transient tachycardia and heavy alcohol use, magnesium and phosphorus levels were obtained; results were 2.5 mg/dL and 3.6 mg/dL, respectively (both within normal ranges).
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