Department of Endocrinology and Metabolism R1 Jung Sang Wan MGR

정 O 자 (F/64) admission  Chief Complain 사지 위약감 recent onset) 10 일전  Present Illness 10 년 전 고혈압 진단받고 약물요법 시행 중인 64 세 여자 로 평소 간헐적으로 사지 위약감 있었으나 특별한 치료없 이 지내다가 한달 전 건강보조식품 복용 이후 내원 10 일 전부터 사지 위약감 증상이 악화되어 본원 한방병원 입원 함. 내원 후 시행한 혈액 검사에서 저칼륨혈증 (K 1.8 mmol/L) 소견과 복부 CT 에서 adrenal adenoma 발견되어 further evaluation 및 management 위해 내분비 대사내과 로 전원됨.

Past Medical History DM/HTN/Tb/hepatitis(-/+/-/-) :10 년 전 진단, 약물요법 시행 중 Op Hx : 24 년 전 Rt oophorectomy d/t PID Drug Hx : Isradipine 5mg qd Indapamide 2.5mg qd Carvediolol 25mg qd Herbal medication (-) 건강보조식품 (+)

Personal History Alcohol (-) Smoking (-) Family History HTN

Review of System General fever(-) chill(-) fatigue(+) weight loss(-) Skin rash(-) pigmentation(-) itching(-) Eyes & ENT headache(-) sore throat(-) Respiratory cough(-) sputum(-) dyspnea(-) Cardiovascular chest pain(-) palpitation(-) Gastrointestinal A/N/V/D/C(-/-/-/-/-) melena(-) hematochezia(-) abdominal discomfort(-) Renal & urinary polyuria(+) polydipsia(+) nocturia(-) dysuria(-) frequency(-) urgency(-) hematuria(-) Musculoskeletal backache(-) myalgia(-) weakness(+) Neurological dizziness(-) syncope(-) seizure(-) 평소 증상, 10 일전 악화 Both extremities 평소 증상, 10 일전 악화 Both extremities

Physical Examination V/S 140/90mmHg - 72/min - 20/min - 36°C Ht :164.3cm Wt : 63.6kg BMI : General Alert consciousness mentality Acutely ill looking appearance Head & Neck Cervical LN enlargement (-) Neck vein engorgement (-) Eye & ENT Isocoric pupil with PLR (++/++) Clear sclera, pinkish conjunctiva PTH (-/-) PI (-/-)

Physical Examination Chest Clear breathing sound without crackle, wheezing Regular heart beat without murmur Abdomen Soft & flat abdomen Normoactive bowel sound Abdominal tenderness (-) Rebound tenderness (-) Hepatosplenomegaly (-) Palpable mass (-) Back & extremities CVA tenderness (-/-) Pretibial pitting edema (-/-) Neurology Babinski (-) Motor Sensory VV VV 100

Initial Lab Findings CBC/DC 5340/mm² g/dl – 35.4% - 301K (Seg : 53.8%) aPTT 32.8sec PT(INR) 12.9sec (0.99) Chemistry TB /DB 0.55/0.23 mg/dL AST/ALT 26/40 U/L ALP 62 U/L Protein/alb 7.6/4.4 g/dL BUN/Cr 9/0.6 mg/dL Ca/P /Mg 8.6/3.1/2.0 mg/dL Na/K/Cl 145/2.5/97 mmol/L Uric acid 2.8 mg/dL UA SG RBC 0~1/HPF WBC 0~1/HPF ABGA – 41.9 mmHg – 63.9 mmHg – 30.3 mmol/L (SaO2 93.7%)

Initial Chest PA

Initial EKG

TFT ( ) 수치참고치 T3 (ng/dl) ~ 200 FT4 (ng/dl) ~ 1.94 TSH (μU/mL) ~ 4.00

Abdominal CT ( ) 1.3x1.7cm 0.7x1.1cm

Initial Problem List #1 Muscle weakness, Hypokalemia #2 Both adrenal gland adenoma #3 Known HTN #4 Incidental uterine mass, Lt ovarian cyst

Initial Assessment & Plan #1,2,3 Muscle weakness, hypokalemia, adrenal gland adenoma, and known HTN A) Primary aldosteronism r/o drug induced hypokalemia r/o cushing’s syndrome r/o pheochromocytoma P) Serum aldosterone, PRA Lasix upright stimulation test 24hr urine collection (electrolytes, cortisol, VMA, Epinephrine,Norepinephrine Metanephrine) Urine and Serum osmolarity K+ supplement and serum K+ f/u Stop antihypertensive drug, 건강 보조 식품 성분 파악

Initial Assessment & Plan #4 Incidental uterine mass, Lt ovarian cyst A) Uterine polyp r/o submucosal myoma r/o endometrial cancer Benign ovarian tumor r/o functional cyst P) Consult to OBGY DCB, if needed

24 hr Urine Collection 24hr urine creatinine 981 mg/day CrCL hr urine K 159 mmol/day 24hr urine Na 705 mmol/day

Screening Test 수치참고치 Aldosterone (ng/dl) PRA (ng/ml/hr) PAC/PRA ratio (ng/dl per ng/ml/hr) 150.9>30

Confirmatory Test Lasix Upright Stimulation Test 0 hrs2hrs Aldosterone (ng/dl) PRA (ng/ml/hr) 0.2 PAC/PRA ratio (ng/dl per ng/ml/hr)

24 hrs Urine Collection 수치참고치 Cortisol( ㎍ /day) ~270 VMA (mg/day)3.41 ~ 5 Epinephrine( ㎍ /day) ~ 20 Norepinephrine( ㎍ /day) ~ 80 Metanephrine(mg/day) ~ 1.2

Clinical Course #1. Primary aldosteronism S) fatigue(+), muscle weakness(+)  improved O) K+ 2.5  3.9 (aldactone, K + supply 후 ) BP 120/80 (Amlodipine 5mg qd) A) Primary aldosteronism d/t adrenal adenoma P) Adrenal venous sampling Unilateral PA  larparoscopic adrenalectomy bilateral PA  mineralocorticoid R antagonists

Adrenal Venous Sampling( )

Adrenal Venous Sampling ACTH (50 ㎍ /hr) infusion BP : 150/90 mmHg IVC Lt adrenal v. Rt adrenal v. Aldosterone(ng/dl)92.9> Cortisol( ㎍ /dl) 55.6> Cortisol corrected adosterone Ratio (ng/dl per ㎍ /dl)

Clinical Course #5. Uterine polyp, Lt ovarian cyst S&O) Consult to OBGY DCB( ) A) Endometrial polyp, Lt ovarian cyst P) Pelviscopic Lt salpingoophorectomy

Operation( ) Laparoscopic Lt adrenalectomy Pelviscopic Lt salpingoophorectomy with adhesiolysis

F/U Abdominal CT ( )

PAC 45.2 PRA 0.3 PAC/PRA ratio PAC 45.2 PRA 0.3 PAC/PRA ratio Laparoscopic Lt adrenalectomy Muscle weakness Adrenal adenoma Muscle weakness Adrenal adenoma AVS PA 140/90 150/90 120/80 PAC 6.5 PRA 0.2 PAC/PRA ratio 32.9 PAC 6.5 PRA 0.2 PAC/PRA ratio 32.9 KCL i.v. KCL p.o. Isradipine Indapamide Carvediolol Amlodipine 5mg qd Aldactone25/25 25/50 Stop all antihypertensive drugs

Final Diagnosis #1 Primary aldosteronism d/t adrenal cortical adenoma s/p Laparoscopic adrenalectomy, Lt #2 Endometrial polyp s/p DCB Lt ovarian serous cystadenoma s/p Pelviscopic Lt salpingoophorectomy