Abstract
A patient with a known pheochromocytoma was admitted to the emergency department with hypertension and headache. Because of the disease rarity, the potential medication-disease interactions were not recognized. The patient received a dose of prochlorperazine to treat their headache. Prochlorperazine is a potential trigger of pheochromocytoma crisis. The patient developed worsening hypertension, pulmonary edema, and demand non-ST segment elevation myocardial infarction. In response, our health system has created a best-practice advisory within our electronic medical records that can alert a provider to interactions between medications and pheochromocytoma. We are looking to expand this practice to include other pathologies with dangerous medication interactions, and we recommend other health systems create similar initiatives.