Adrenal Mass Causing Secondary Hypertension.

BACKGROUND: Most hypertensive patients have essential (primary) hypertension; only 5% to 10% have a secondary cause. Two clinical characteristics suggestive of secondary hypertension are early onset (< 30 years of age) and severe hypertension (>180/110 mm Hg). When faced with these findings, clinicians should consider a secondary cause of hypertension. CASE REPORT: A 22-year-old woman being evaluated for asthma exacerbation in the emergency department was noted to have severe persistent hypertension. Additional evaluation revealed severe hypokalemia, metabolic alkalosis, and hypernatremia. The patient was admitted to the hospital for blood pressure management, electrolyte replacement, and further evaluation of presumed hyperaldosteronism. Diagnostic imaging revealed a large adrenal mass. Surgical resection was performed, leading to a diagnosis of hyperaldosteronism caused by adrenal carcinoma. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Secondary hypertension is far less common than essential hypertension; however, considering the large volume of patients seen in emergency departments, it is likely that some will have secondary hypertension. Emergency physicians should be aware of the clinical characteristics that suggest secondary hypertension so that the appropriate diagnostic and treatment pathways can be pursued.

Insurance Eligibility of Adult Emergency Department Patients.

ACKNOWLEDGMENTS: This study was supported by a grant from the Maryland Emergency Medicine Network. The manuscript was copyedited by Linda J. Kesselring, M.S., ELS, the technical editor/writer in the Department of Emergency Medicine at the University of Maryland School of Medicine. PURPOSE: To determine if uninsured patients seeking care in an inner-city emergency department (ED) were eligible for any of the three government-sponsored insurance programs that were available to them at the time this study was conducted. METHODS: In June and July 2012 (before implementation of the Affordable Care Act), a medical student and two social work students trained in insurance eligibility approached a convenience sample of uninsured adult ED patients (age ≥19years) whose conditions warranted discharge after treatment. The students administered a survey that collected information (age, marital status, income, family size, number of dependents, and pregnancy status) that was used to determine if the patient was eligible for medical insurance. Patients who were acutely ill, confused, under the influence of substances, acutely psychotic, non-English speaking, unable to give consent, under arrest, or being admitted or transferred were deemed ineligible for this study. RESULTS: Of the 132 patients who participated in the study, 114 (86.4%) were eligible for insurance. The difference between the median incomes for those who were eligible for insurance and those who were not ($2,300 vs $17,388) was statistically significant (p<0.0001). CONCLUSION: EDs have a valuable opportunity to identify patients who are eligible for government-backed medical insurance programs. Identifying these individuals, and assisting them with the application process, has the potential to enhance the indigent population's access to medical care and to give hospitals a means of billing for reimbursement for services provided.