Conn's diasease-presentation diagnosis.pptx

Conn's diasease-presentation diagnosis

1. Case Discussion 報告者： R3 韓逸宏 臨床老師： 張仲豪醫師 報告日期： 2024/06/18

2. General data ID:958491 Age: 51 Gender: Female Marriage: Married Height: 162cm Weight:80->68kg (over 6months)

3. Chief complaint General weakness for 1 month

4. Present Illness Bilateral lower limbs weakness for weeks and the symptoms worsen after taking a long walk Associated with significant weight loss (10+kg over past 6 months), muscle soreness (Lower limbs > upper limbs), poor appetite , constipation and shortness of breath . Denied fever, chills, trauma, nausea, vomiting, diarrhea, thyroid disease, focal weakness, headache or chest pain

5. Medical history Hypertension for +10 years at LMD Home BP: SBP:150-160 mmHg Under 4 classes of medications control - Bisoprolol 5mg 1# QD - Hydrochlorothiazide 0.5# QD - Valsartan/Amlodipine 80mg/5mg 1# QD

6. Q1: 頑 固 性 高 血 壓 (Resistant hypertension) 定義？

7. 高 血 壓 的 病 人，在服用了 至少三種降血壓藥物 包含其中一種為 利尿劑 的降血壓藥物之後，血壓仍大於 140/90 mmHg 或者在 糖尿病、慢性腎臟疾病 的病人身上，血壓仍大於 130/80 mmHg Q1: 頑 固 性 高 血 壓 (Resistant hypertension) 定義？ Moser M, Setaro JF: Resistant or difficult-to-control hypertension. N Engl J Med. 2006;355:385-92.

8. 診斷頑固性高血壓 (Resistant hypertension) 診斷的流程包括 正確的測量血壓 (2) 排除白袍性高血壓 (3) 仔細的評估病人對藥物的順應性 (4) 觀察病人不良的生活形態 (5) 合併藥物的影響 (6) 排除續發性高血壓

9. Q2: 續發性高血壓 (Secondary hypertension) 的成因 ？

10. 續發性高血壓的成因 - 腎臟 (Renal artery disease )

11. 續發性高血壓的成因 - 內分泌 ( 康氏症 Conn's syndrome) (pheochromocytoma ) (Cushing’s syndrome ) (Thyroid )

12. 續發性高血壓的成因 - 心肺

13. Family history Denied HTN, Type 2 DM, CAD, CKD or cancers

14. Personal history Allergy: denied Smoking: denied Alcohol: denied Betel nut: denied Occupation: Grandma ( 騙孫 x2)

15. Chest: symmetric movement Breath sound: clear Abdomen: hypoactive bowel sound no tenderness no rebound pain Skin: Bilateral lower leg pitting edema: 1+ Heart sound: regular, no murmur Conjunctiva: pale Sclera: anicteric Pupil: (+/+) No knocking pain Vital signs : BT:  36.1℃ HR: 69 bpm BP: 156/107 mmHg RR: 14/min Consciousness: E4V5M6 Physical examination Muscle power: 3 2 3 2

16. CXR 2024/5/21 Cardiomegaly. Pulmonary congestion.

17. EKG 5 /21

18. Brain CT 5/21 No strong evidence of intracranial abnormality

19. Microcytic anemia

20. AKI or CKD ? Severe hypokalemia: K:1.6 Elevated TnI , cause? Elevate CK, mild rhabdomyolysis ?

21. Q3: How does hypokalemia present?

22. Q3: How does hypokalemia present?

23. Tentative diagnosis Severe hypokalemia, (K:1.6 meq /L), cause to be determined Elevated cardiac enzyme and CPK, suspect hypokalemia/CAD related AKI or CKD ? Unintentional body weight loss (10kg in 6 months), cause? Hypertension, suspect secondary hypertension Microcytic anemia, Hb: 10.3 g/dL, MCV: 58.1 fL

24. Hospital course S: - Poor appetite - Weakness 5/21 (ICU) O: MP: 2 (Lower limbs)

25. Mild hypomagnesemia No significant TnI increase (1553 ->1666) Persist severe HYPOkalemia

26. Hospital course S: - Poor appetite - Weakness 5/21 (ICU) A/P: HypoK , HypoMg : KCL: IV + PO, Mg: IV + PO Cardiac echo: EF: 67%, no significant valvular disease HTN: - Sevikar 1# - Stop thiazide O: MP: 2 (Lower), K:1.6, Mg:1.8

27. Hospital course S: - Poor appetite - Weakness 5/21 (ICU) A/P: HypoK , HypoMg : KCL: IV + PO, Mg: IV + PO Cardiac echo: EF: 67%, no significant valvular disease HTN: - Sevikar 1# - Stop thiazide O: MP: 2 (Lower), K:1.6, Mg:1.8 S: - Poor appetite - Weakness 5/22 (ICU) A/P: Consult Endocrine: O: MP: 2 (Lower), K:1.6 TnI : 1828

28. Q4: Which secondary hypertension are we suspecting?

29. Q4: Which secondary hypertension are we suspecting? Resistant Hypertension + Hypokalemia -> Suspect Conn’s disease (Primary aldosteronism) DDx: - Pheochromocytoma (Intermittent HTN) - Cushing’s disease (Elevated sugar) - Thyroid disease (abnormal thyroid function test)

30. Hospital course S: - Poor appetite - Weakness 5/21 (ICU) A/P: HypoK , HypoMg : KCL: IV + PO, Mg: IV + PO Cardiac echo: EF: 67%, no significant valvular disease HTN: - Sevikar 1# - Stop thiazide O: MP: 2 (Lower), K:1.6, Mg:1.8 S: - Poor appetite - Weakness 5/22 (ICU) A/P: Consult Endocrine: - Check PRA (Plasma Renin activity) and aldosterone - Add Aldactone 1# tid O: MP: 2 (Lower), K:1.6 TnI : 1828

31. K level KCL 100mEq Aldactin 25mg 1# TID

32. Hospital course S: - Poor appetite - Weakness 5/21 (ICU) A/P: HypoK , HypoMg : KCL: IV + PO, Mg: IV + PO Cardiac echo: EF: 67%, no significant valvular disease HTN: - Sevikar 1# - Stop thiazide O: MP: 2 (Lower), K:1.6, Mg:1.8 S: - Poor appetite - Weakness 5/22 (ICU) A/P: Consult Endocrine: Conn’s screen test: Aldosterone/PRA - Add Aldactone 1# tid O: MP: 2 (Lower), K:1.6 TnI : 1828 S: - Improved appetite - Weakness subsided 5/24 (Ward) A/P: - Aldosterone/PRA ratio: 462 (>20) - Aldosterone 32.4 (>15) - Abdominal CT (C+) O: MP: 5 (Lower), K:2.7 PRA: <0.07 ng/mL/ hr Aldosterone: 32.4 ng/dL Recovered RFT

33. 5/29 Abd CT: - Suspicious right adrenal myelolipoma (10% Functional) - Suspicious left adrenal adenoma

34. Hospital course S: - Improved appetite - Weakness subsided 5/24 (Ward) A/P: - Aldosterone/PRA ratio: 462 (>20) - Aldosterone 32.4 (>15) - Abdominal CT O: MP: 5 (Lower), K:2.7 PRA: <0.07 ng/mL/ hr Aldosterone: 32.4 ng/dL Recovered RFT S: - Good appetite - Weakness subsided 5/29 (Ward) A/P: - Abdominal CT R: A drenal myelolipoma L: A drenal adenoma - GS consultation: Adrenalectomy side? -> A drenal vein sampling (AVS) O: MP: 5 (Full), K:3.2

35. A drenal vein sampling (AVS) AVS A/C Ratio result: > 4 is indicative of a unilateral source of aldosterone (15.6/2.4=6.5) < 4 is indicative of bilateral disease. 

36. Hospital course S: - Improved appetite - Weakness subsided 5/24 (Ward) A/P: - Aldosterone/PRA ratio: 462 (>20) - Aldosterone 32.4 (>15) - Abdominal CT O: MP: 5 (Lower), K:2.7 PRA: <0.07 ng/mL/ hr Aldosterone: 32.4 ng/dL Recovered RFT S: - Good appetite - Weakness subsided 5/29 (Ward) A/P: - Abdominal CT R: A drenal myelolipoma L: A drenal adenoma - GS consultation: Adrenalectomy side? -> (AVS) O: MP: 5 (Full), K:3.2 S: - Good appetite - Weakness subsided 5/29 (Ward) A/P: - Refer to CGMH for (AVS) O: MP: 5 (Full), K:3.4

37. Final diagnosis Hypokalemia, suspect primary hyperaldosteronism, right adrenal myelolipoma and left adrenal adenoma Resistant hypertension, suspect primary hyperaldosteronism related Acute kidney injury, in recovery state Elevated cardiac enzyme, suspect CAD or hypokalemia related Unintentional weight loss, cause to be determined

38. Thank you~~

39. K: 1.7