Adrenal Disorder

Adrenal DisorderCase-based Seminar

Win Yupar Lwin (Roll No. 407)Win Shwe Sin Oo (Roll No. 408)Win Lei Khine (Roll No. 409) 6th November, 2015Medical Unit (1), 3rd bloc posting

History Taking

Personal IdentificationName Daw Phyu NuAge 51 yearsRace & religion Burma, BuddhistMarital status widow with 2 sonsAddress YayOccupation making fishing netsDate of admission 2nd November, 2015

Chief ComplaintBreathlessness x 20 daysReduced level of consciousness x 7 days

History of Present IllnessBreathlessness at rest x 20 days Orthopnoea (+), she cannot even sleep Relieved by leaning forward positionAdmitted to Yay General Hospital due to loss of consciousness for 6 daysThen, she was referred to YGH on 2nd November, 2015Lower limb oedema x 6 yearsChest pain (-)Palpitation (-), reduced urine output (+)

HOPI continuedHypertension x 5 yearsAnti-hypertensives were taken only when she suffered from headacheNo history of stroke & TIA

Thickening of body hair, appearance of abdominal striae, significant weight gain & obesity x 2 yrs

On admission, O2, IV antibiotics & oral drugs are givenChest X-ray, USG abdomen & blood tests are done

Past Medical HistoryHypertension x 5 years Hospitalized to Yay General Hospital for 3 times due to hypertensionC/O - headache & loss of consciousness & diagnosed as hypertension, 5 yrs ago 2 times in 2014 with similar attackEach hospitalization lasted about 14 daysDiabetes mellitus is diagnosed at admission to YGH, no complicationsBronchial asthma x 2 years, took only compound drug () at each attack

Drug HistoryAnti-hypertensives, not regularly taken x 5 yrsCompound drugs for every asthmatic attack x 2 yrsNo history of taking traditional medicine & herbal medicine Allergic to Penicillin & Lovartin

Past surgical history not relevantMenstrual history menopause at 45 yrs

Personal HistorySmoking since 20 yrs of age, 2-3 cheroots per dayNo betel chewing & alcohol drinking Illiterate, cannot read & write

Family history 4 family membersNo similar attack in family No hypertension, heart disease, diabetes, TB contact in family

Social historyLives in wooden houseWater supply from well, used to boil water before drinkingFly-proof latrine

System ReviewRespiration breathlessness (+), cyanosis, cough, sputum, haemoptysis (-)GI - no constipation, diarrhoea, abdominal pain, jaundice Renal no frequency, urgency, haematuria, oliguria, loin painCNS no tingling or numbness of both upper and lower limb, headache, weakness of limb, fitsHaematological no pallor, tiredness, lasstiude, bleeding manifestations

Physical Examination

General examinationMiddle age lady of average height lying on the bedShe is obese for her age (centripetal obesity)Well conscious, well orientatedCushingoid facies (+)Dysponoiec & orthopnoeicOxygen is being given with nasal cannulaNo acne, facial plethora, pigmentation, vitiligo

General examinationAfebrileNo pallor, jaundice, xanthelasmaNo exophthalmosNo ala-nasi working Teeth are nicotine-stained, no active gum bleeding No central cyanosis, tonsillar enlargementNo visible neck gland enlargement, no goitre

On examination of upper limbCannula is inserted on left handNo clubbing, peripheral cyanosisNo excessive sweatingNo tremors, no palmar erythemaBody hair is thickened on upper limbs (hirsutism)No skin crease pigmentation No acanthosis nigricans in axilla

On examination of lower limb Severe pitting edema (+)Bruises (+)No ulcersDorsalis pedis pulsation is intactNo pretibial myxedemaNo muscle wasting

Cardiovascular examination Pulse rate - 80 beats/min, normal volume, regular rhythm, vessel wall is not thickened, no radio-femoral delay, equal on both sides, peripheral pulsations are intact.BP 110/70 mmHgApex beat is not palpable due to obesityNormal 1st and 2nd heart sound with normal intensity are heard with no added sounds in all 4 areas.

Respiratory examinationShape of the chest wall is normalNo scars, no dilated veins, no aspiration marksRespiratory movement is equal on both sidesTrachea is in midline positionNormal vesicular breath sound is heard in all 3 zones of both lungsCrepitations are heard in middle & lower zones of both lungs

Abdominal ExaminationInspectionAbdomen is distended no scar, no dilated veins, move with respiration.Flanks are fullStriae (+) in lower abdomen

PalpationAbdomen is soft, not tender, no palpable massLiver & spleen are not palpable and kidneys are not ballotable PercussionBoth flanks are resonantNo free fluid in the abdomen

AuscultationBowel sound is present & normalNo hepatic and renal bruit

Investigations

Cortisol levelMorning = 1183 nmol/L (N=171-536)Evening = 306 nmol/L (N=64-327)

Full blood count (23/10/2015)WBC = 9.7 x 109/LNeutrophil= 5.55x 109/LLymphocyte= 2.2 x 109/L Monocyte= 1.26x 109/L Eosinophil= 0.57 x 109/L Basophil= 0.13 x 109/L Hb= 15.4 g/dlHCT= 47.6% MCV= 94.5fL MCH=30.6pgMCHC= 32.4 g/dl PLT= 272x 109/L

Full blood count (2/11/2015)WBC = 8x 109/LLymphocyte= 2.3 x 109/L Mid#=0.9 x 109/L Gran#= 4.8 x 109/L

Hb= 15.0 g/dlESR= 5 mm/1st hrRBC= 5.3x 1012/L HCT= 0.55L/L MCV= 103.8fL MCH=28.3pgMCHC= 27.2 g/dl

PLT=253 x 109/L

Blood testsUric acid= 1051 mol/L Urea= 9.1mmol/LCreatinine=129 mol/LNa=145mmol/LK=3.68mmol/LCl=95mmol/LBicarbonate= 15.8mmol/L ALT= 57U/L AST= 168U/L Total bilirubin=9mol/LTotal cholesterol=2.0mmol/LTSH=0.4ng/ml

Blood SugarRBS = 183 (on admission)Hb A1c = 6.9 % RBS = 192 (5/11/2015)

UrinalysisSpecific gravity = 1.005pH = 7Leucocyte= 10 25Nitrite = negativeProtein= 30 (1+)Glucose= normalKetone= negativeUrobilinogen=normalBilirubin= negativeBlood= 250 Ery/dl (4+)

Chest X-ray

Cardiothoracic ratio Upper lobe vein dilatations (+)

Dx: Heart failure & Cardiomegaly

Ultrasound AbdomenLiver enlarged, slightly increased echo, no SOLGall bladder, pancreas, spleen, both kidneys & urinary bladder are normalNo ascites, no mass, no lymph nodes

Inspection: Mild Fatty Liver

DiagnosisCongestive Cardiac Failure most probably due to uncontrolled hypertension,with underlying type 2 diabetes & bronchial asthma,complicated with steroid-induced Cushings syndrome

Current Management

Current medical treatmentIV Furosemide 40 mg 12hrlyPO Aspirin 1 od PO Amlodipine 5 mg odIV Augmentin 1.2 gPO Atorvastatin 10 mg 1 hsPO Omiprazole 20 mg odIV Cefotaxime 1 gIV Hydrocortisone 100 mg stat & 12hrly (to prevent steroid withdrawal)PO Flumox 500 mg tds

Literature ReviewAdrenal Disorder

Cushings SyndromeCushings syndrome is caused by excessive activation of glucocorticoid receptors. It is most commonly iatrogenic, due to prolonged administration of synthetic glucocorticoids such as prednisolone. Endogenous Cushings syndrome is uncommon but is due to chronic over-production of cortisol by the adrenal glands, as the result of an adrenal tumour or excessive production of ACTH by a pituitary tumour or ectopic ACTH production by other tumours.

In normal subjects, plasma cortisol levels are at their highest early in the morning and reach