Page 16 of 17
SU23.1-3,SU24.1-3 | Adrenal and Pancreatic Surgery — Assignment
CLINICAL SCENARIO
A 44-year-old man is referred to the surgical endocrine clinic with resistant hypertension despite three antihypertensive agents. Over the past six months he has had recurrent episodes of throbbing headache, profuse sweating, and pounding palpitations lasting 15-20 minutes, often triggered by exertion or straining. On examination his blood pressure is 178/108 mmHg with a resting tachycardia. A CT abdomen performed for non-specific abdominal pain has incidentally shown a 4.5 cm right adrenal mass with heterogeneous enhancement. He is anxious and asks you what is wrong and what will happen next.
Instructions
Work through this patient as the surgical team would, from suspicion to safe operation. Present a structured written response that demonstrates your reasoning at each step. Ground every recommendation in the underlying pathophysiology — explain WHY, not just WHAT. Write in clear clinical prose with headings.
Length: 900-1200 words
What to Submit
1. Clinical reasoning and differential
State your leading diagnosis for this adrenal mass and justify it from the history, examination and imaging. List two other functional adrenal lesions you must consider and the clinical clue that would point to each.
Guidance: Anchor your leading diagnosis in the episodic catecholamine triad (headache, sweating, palpitations) plus hypertension and an adrenal mass.
2. Confirming the diagnosis biochemically
Describe the first-line biochemical test you would order and explain the physiological reason it is more reliable than measuring catecholamines directly. State what result would confirm the diagnosis.
Guidance: Discuss plasma free metanephrines / urinary fractionated metanephrines and why continuous metanephrine production beats episodic catecholamine secretion.
3. Preoperative pharmacological preparation
Set out, in the correct sequence, the drug preparation required before surgery. Explain the danger of getting the sequence wrong and the role of volume re-expansion.
Guidance: Emphasise ALPHA-blockade FIRST, then beta-blockade, and the risk of unopposed alpha-mediated hypertensive crisis if beta-blockade is given first.
4. Definitive management and follow-up
Outline the definitive surgical treatment, the key intraoperative haemodynamic risks, and the principles of postoperative monitoring and long-term follow-up. Briefly state when an inherited syndrome should be suspected.
Guidance: Cover adrenalectomy, intraoperative catecholamine surge during tumour handling, post-resection hypotension, and screening for familial/syndromic disease.
Grading Rubric — Phaeochromocytoma Case Study — 40 points
| Criterion | Points | Full-marks descriptor |
|---|---|---|
| Diagnostic reasoning and differential | 10 pts | Correctly identifies phaeochromocytoma with full justification from the catecholamine triad, hypertension, and imaging; names appropriate alternatives (Conn's, Cushing's) with discriminating clues. |
| Biochemical confirmation and rationale | 10 pts | Selects metanephrines and clearly explains the physiological rationale (continuous vs episodic secretion); states confirmatory result. |
| Preoperative preparation sequence | 12 pts | Correct alpha-before-beta sequence with clear explanation of the hypertensive-crisis risk and the role of volume re-expansion. |
| Definitive management, intraoperative risk and follow-up | 8 pts | Describes adrenalectomy, intraoperative haemodynamic risks, postoperative monitoring, and syndromic screening accurately. |