after surgical removal the catecholamines elaborated by the tumor also take time to be washed out of the circulation thus the blood pressure will need careful monitoring . conventional alpha blockage first and beta blockage later was the algorithm followed but choice of agent was also discussed with nesthethesiologist . though classically taught phenoxy benzamine is used , in this case it was not used and a combination of prazosin and propranolol a 32 year old african male presented with history of weight loss , pain in the abdomen and episodes of sweating and palpitations . he had hypertension which was being treated by multiple drugs over a course of three years . as a consequence of the episodes of the aforesaid symptoms he had been forced to take extended leave of absence and as a result lost his job as an accounting clerk . he was evaluated in our hospital as a case of young hypertension and found to have a large palpable mass in the epigastrium that magnetic resonance imaging ( mri ) showed as a large tumor adherent to the great vessels . he recovered completely and eight months later on follow up had regained some of his weight , was off anti hypertensives and had also been successfully reemployed . a 32 year old african male an accounting clerk by profession presented with history of weight loss of around 6 kilograms over a period of two years and episodes of palpitations accompanied by headaches . on several occasions he had been admitted in a local hospital with the above symptoms . he however had no loss of vision at any time and there was no relief by the intake of sugar . a few times there was pain in the abdomen during such episodes which though he says was severe but short lasting . he was taking multiple anti hypertensives and also tab morphine for pain during these episodes . on initial presentation the patient was a thinly built , anxious looking individual and his palms were moist to touch . his thyroid was not enlarged and there were no unusual skin findings . the blood pressure recorded both in the ward and by us averaged 150/96mmhg . on examining his abdomen a vague , ill defined , mildly tender mass was felt in right hypochondrium and extending up to the epigastric region . based on the symptomatology and general physical examination of this patient ; a battery of investigations were ordered for establishing the cause of the hypertension . the ecg showed a left ventricular hypertrophy pattern and the echocardiogram revealed a concentric left ventricular hypertrophy consistent with long standing hypertension . a 24hrs urinary metanephrines and normetanephrines study was ordered and an mri abdomen scheduled . a large mass found indenting the great vessels . mri scan abdomen coronal view mri scan transverse section abdomen clinically correlating with the symptomatology a catecholamine producing lesion was suspected and the urinary normetanephrines-55217 nmol / l ( normal 72 - 505 ) were grossly elevated . the urinary metanephrines 698 nmol / l ( normal 9.3 - 122 ) too were very high . to finally confirm that the mass in abdomen was indeed responsible , an meta iodo benzyl guanidine ( mibg ) the mibg scan uses meta - iodobenzylguanidine scintigraphy that has a specificity of almost 100%in localising a pheochromocytoma . as shown above alpha receptor blockade initiated first with prazosin ( minipres ) a short acting alpha - one blocker . the patient was given four pints of normal saline per day to prevent volume depletion and minimise the postural hypotension that usually accompanying alpha blockade . an effective alpha blockade is signalled by > 20 mm fall in bp on upright posture . beta blockade was then initiated with non - selective agent propranolol to control tachycardia due to catecholamines . the patient was operated successfully by the oncosurgeon and intra operative pressure managed by the anesthesiologist . post operatively patient was monitored closely and propranolol restarted to cater for still circulating catecholamines . the patient made a full and complete recovery and was eventually taken off anti hypertensives on discharge . on initial presentation the patient was a thinly built , anxious looking individual and his palms were moist to touch . his thyroid was not enlarged and there were no unusual skin findings . the blood pressure recorded both in the ward and by us averaged 150/96mmhg . other than that the lungs , central and peripheral nervous system examinations were normal . on examining his abdomen a vague , ill defined , mildly tender mass was felt in right hypochondrium and extending up to the epigastric region . based on the symptomatology and general physical examination of this patient ; a battery of investigations were ordered for establishing the cause of the hypertension . blood sugars serum electrolytes , calcium , phosphorous etc . , all were normal . the liver , kidney parameters were also normal . the ecg showed a left ventricular hypertrophy pattern and the echocardiogram revealed a concentric left ventricular hypertrophy consistent with long standing hypertension . mri scan abdomen coronal view mri scan transverse section abdomen clinically correlating with the symptomatology a catecholamine producing lesion was suspected and the urinary normetanephrines-55217 nmol / l ( normal 72 - 505 ) were grossly elevated . the urinary metanephrines 698 nmol / l ( normal 9.3 - 122 ) too were very high . to finally confirm that the mass in abdomen was indeed responsible , an meta iodo benzyl guanidine ( mibg ) scan the mibg scan uses meta - iodobenzylguanidine scintigraphy that has a specificity of almost 100%in localising a pheochromocytoma . as shown above the tumor alpha receptor blockade initiated first with prazosin ( minipres ) a short acting alpha - one blocker . the patient was given four pints of normal saline per day to prevent volume depletion and minimise the postural hypotension that usually accompanying alpha blockade . an effective alpha blockade is signalled by > 20 mm fall in bp on upright posture . beta blockade was then initiated with non - selective agent propranolol to control tachycardia due to catecholamines . the patient was operated successfully by the oncosurgeon and intra operative pressure managed by the anesthesiologist . post operatively patient was monitored closely and propranolol restarted to cater for still circulating catecholamines . the patient made a full and complete recovery and was eventually taken off anti hypertensives on discharge . a pheochromocytoma classically has the five p 's pressure ( htn ) 90% of cases pain ( headache ) 80%  paroxysms ( the sixth p ! ) of the above pain ( headache ) , perspiration , palpitations are quite important and lack of all three virtually excluded diagnosis . all young hypertensives must be evaluated fully keeping the above facts in mind . as far as the pre - operative preparation of a pheo is concerned ; the anesthesiologist view point was that prazosin and propranolol was better than using phenoxybenzamine as phenoxybenzamine destroys the beta receptor permanently . in case the patient goes into shock the resuscitation becomes much more difficult if the inotropic receptors are compromised . consent  written informed consent was obtained from the patient for publication of this case report and accompanying images . a copy of the written consent is available for review by the editor - in - chief of this journal .