Transcript Title should be: Medical Grand Rounds Clinical Vignette

NYU Medical Grand Rounds
Clinical Vignette
Michael Chu MD, PGY-2
5/20/09
Chief Complaint
71 year old male with difficult to control
hypertension for approximately 15 years
History of Present Illness
The patient was noted by his primary care
physician to have difficult to control
hypertension despite being treated with
five antihypertensive medications
The patient was largely asymptomatic
Noted to require potassium
supplementation to maintain normal
potassium levels
Additional History
Past Medical History:
– Hypertension
– Type II Diabetes Mellitus
– Glaucoma
– Diverticulosis
Past Surgical History:
– none
Additional History
Social History:
– Previous tobacco use, quit 10-15 years prior
– 1-2 drinks of alcohol 3-4 times per week
– Works as a plumber and owns business
Family History:
– No history of heart disease or diabetes in the
family
– Sister died of a brain tumor in her 70s
Medications
Allergies:
– Lisinopril (lip swelling)
Medications:
– Aspirin 325mg PO daily
– Atenolol 50mg PO daily
– Chlorthalidone 25mg PO daily
– Hydralazine 50mg PO BID
– Losartan 50mg PO BID
– Nifedipine 90mg PO daily
– Potassium Chloride 40 meq PO BID
– Simvistatin 20mg PO daily
– Metformin 1000mg PO BID
– Timolol eye drops
Physical Exam
General: Well appearing male in no acute
distress
Vital Signs: T:98.7 BP:139/88 HR:62
RR:16
Trace pedal edema was noted in his lower
extremities bilaterally
Otherwise the remainder of his physical
exam was normal
Laboratory Findings
CBC: Hemoglobin 12.7 g/dL Hematocrit 37.1%
– Remainder of the CBC was within normal limits
Basic Metabolic panel: Potassium 3.4 mEq/L,
previously had been as low as 3.0 mEq/L
– Remainder of the BMP was within normal limits
Hepatic panel: within normal limits
Aldosterone level 10.9 ng/dL (Ref. range 1.0-16)
Plasma Renin Activity 0.2 ng/mL/hr (Ref. range 0.33)
Aldosterone/Renin ratio elevated > 50
– Ratio > 20 suggestive of primary hyperaldosteronism
Imaging
Magnetic Resonance Imaging of the
Abdomen revealed an 8 millimeter
adenoma of the left adrenal gland and no
evidence of renal artery stenosis
Differential Diagnosis
Hyperfunctioning adenoma, such as a
pheochromocytoma or aldosterone
secreting tumor
Non-functioning adenoma
Bilateral adrenal hyperplasia
Adrenal cancer
Metastatic cancer
Myelolipoma
Clinic Course
The patient was referred to the endocrinology clinic for
further management and repeat lab testing was
performed
Aldosterone level 28.3 ng/dL
Plasma Renin Activity level 0.48 ng/mL/hr
Aldosterone/Renin ratio elevated > 50
24 hour urine catecholamine and metanephrines was
within normal limits
Salt loading testing was performed and serum
aldosterone level was noted to be non-suppressed
Clinic Course
It was recommended for the patient to undergo
adrenal vein sampling to differentiate between an
aldosterone secreting adenoma and bilateral
adrenal hyperplasia, however the patient opted for
medical management
The patient was started on spironolactone therapy
Since beginning spironolactone, the was able to
come off of Chlorthalidone, Hydralazine and
potassium supplementation
Final Diagnosis
Primary Hyperaldosteronism