Anonymised patient case with elder female, multiple metabolic comorbidities, no definitive diagnosis made at time of presentation. Slides mainly focus on differentials and appropriate management in absence final Dx. By Robert Ferris and Philip Aigner, as part of medical school studies. Sources for all imagery and sources listed in references section where possible. I do not claim ownership of any images or graphics. Slides for educational purposes only, and should not replace clinical judgement. No monetary gain was made for this work.

1. 11. April 2018
Patient presentation
Robert Ferris & Philip Aigner

2. Patient History
✤ H.K. , female, 64 years old admitted due to suspicion of Cushing syndrome.
✤ Left sided mastectomy and associated lymph node resection in XXXX.
✤ CT-Scan conducted in XXXX showed an abnormality in the left adrenal gland, 4 cm in size.
✤ Had a recent skin resection on the back, suspicion of melanoma with suspected
metastasis.
✤ Has been suffering from Hypertension for 30 years.
✤ Has Diabetes Mellitus Type II, controlled by Insulin.
✤ Ischemic Heart Disease.
✤ Has had glaucoma for ~ 10 years

3. Patient history cont’d
✤ Has had glaucoma for ~ 10 years
✤ No weight gain or loss
✤ No osteoporotic problems
✤ No recent infections
✤ Normal urination frequency with normal appearing colour
✤ No tingling sensation in extremities
✤ No diarrhoea/ constipation
✤ Does have episodes of diaphoresis but no associated tachycardia
✤ Lab values not available at time of examination
✤ No hirsutism or other signs of virilization.

4. Physical Examination
✤ HR: 104 bpm
✤ BP: 146/92 mmHg
✤ No buffalo hump, moon-face or striae
✤ Patient complained of left arm weakness after mastectomy
✤ Central obesity
✤ No muscle wasting
✤ Lung and Heart sounds unsuspicious
✤ Bowl sounds present in all four quadrants
✤ Liver and spleen not palpable, soft abdomen
✤ Varicose veins present on posterior aspect of the left thigh

5. Current Medication
✤ Lorsartan
✤ Levothyroxine
✤ Insulin
✤ Molsidamine
✤ Metoclopramide
✤ Morphine
✤ Venoruton forte

6. Further work-up
✤ Lab values
✤ Aldosterone-Renin Quotient (ARQ) to rule out Conn
Syndrome
✤ Screenin for pheochromocytoma by means of urinary
metanephrines and vanillylmandelic acid
✤ Assessment of Cortisol Levels

7. Therapy
✤ At the time of examination the final diagnosis was not
established yet.
✤ Still the patient should be encouraged to loss weight
and a tighter hypertensive control is required.