Adrenal Gland OSCE

OSCE
Supervised by: Dr. Maitham Al-Khateeb
Presented by: Dr. Ahmad Jassim
1
Case 1 : A patient is referred from nephrology with headache and uncontrolled
BP not responding to medications (despite being on two antihypertensives).
- What is the differential diagnosis?
- What’s your approach to the definitive diagnosis?
- Treatment?
▷ The differential diagnosis in such case scenario is either Conn’s or
Pheochromocytoma
 
▷ The approach to reach definitive diagnosis is:
Check her electrolytes → if her serum Na and K are normal it’s unlikely
to be conn.
If imaging reveals a mass → pheochromocytoma .
 
▷ Treatment: Surgical removal of the tumor is the treatment of choice.
 
● The patient should come to operation with blood pressure and
pulse rate controlled to reduce the risk of adrenal crisis!!
3
Case 2 : A 46-year-old man presented with a 3-month history of generalized weakness and 15-
pound unintentional weight loss. He also reported mild dyspnea on exertion and decreased
appetite. His past medical history was significant for hypertriglyceridemia, primary hypothyroidism,
and vitamin D deficiency. He had emigrated from the Philippines 6 years prior and had been
working as a nurse at a skilled nursing facility.
Laboratory evaluation was significant for hyponatremia, hyperkalemia, and mild hypercalcemia. A
random cortisol was 2.5 mcg/dL with an ACTH of 531.2 pcg/mL.
- What is the diagnosis?

▷ The diagnosis is primary adrenal insufficiency most
likely due to tuberculosis.
▷ Mycobacterium tuberculosis complex spreads to the

adrenal glands hematogenously. Clinical manifestations
may take years to become apparent, and asymptomatic
infection is not uncommon.
5
Case 3 : The patient is a 41-year-old Caucasian female who was admitted to the
hospital for evaluation of high blood cortisol level. Her complaints were fatigue,
weakness, lethargy, decreased concentration and decreased memory over the last
18 months. She also gained 40 lbs over the last two months with central
distribution of weight gain and neck obesity.
- Investigations?
- Management?
▷ The diagnosis is Cushing’s syndrome.
▷ Investigations: (the test must be repeated at least twice to confirm the

diagnosis)
 
✓ Exclude exogenous steroid use then order: 24 hr urinary free cortisol and/or
dexamethasone suppression test. Imaging can be done → MRI (pituitary
adenoma) or CT (adrenal adenoma).
▷ Management: Most of the time you just treat the symptoms but if it failed
and adrenal lesion was found then you go for surgery.
➡ Adrenal adenoma: are rarely bilateral → unilateral adrenalectomy is most

commonly indicated.
➡ Adrenal carcinoma: should be completely removed whenever possible +/-

chemotherapy.

➡ Pituitary disease: → bilateral adrenalectomy, with lifelong steroid therapy.

Pituitary irradiation or surgery avoids the side-effects of adrenalectomy, and
microsurgical removal of the adenoma is now the treatment of choice.
7
Case 4 : This is a 46-year-old male patient referred for the management of a left adrenal
corticoid secreting mass. He presented with a 3 months’ duration of painless and
progressing abdominal distension, discomfort, insomnia, anorexia, nocturia and rapid
weight gain. He took anti-hypertensives and hypoglycemic agents for type 2 diabetes. He was
a well-developed, well-nourished male with a blood pressure of 150/90 mmHg, A CT scan
revealed a left adrenal tumor measuring 23.2 × 31.3 mm strongly enhanced with contrast
- Management?
8
▷ The diagnosis is adrenal adenoma.
▷ Management: he would be benefited from a left subcostal

adrenalectomy and postoperative corticoid supplementation.
Left adrenalectomy postoperative specimen
A: en bloc B: opened
9
Case 5 :
A 52-year-old man presented to the Emergency department

because of 1-week history of nausea and abdominal pain. The
patient referred generalized muscle pain, fatigue, hyporexia
and 13 kg weight loss since 18 months ago. He also noticed a
brown-colored pigmentation in his skin during the last year.
Laboratory data showed an elevated white blood cell count
(11,300/μL, 7900 neutrophils), hemoglobin 14.5 mg/dL,
potassium 5.37 mmol/L, sodium 135.7 mmol/L, magnesium
2.71 mg/dL, phosphorus 4.7 mg/dL, calcium 9.4 mg/dL,
glucose 70 mg/dL, BUN 21 mg/dL, VIH negative. On a physical
examination blood pressure was 90/50 mm Hg,
hyperpigmentation of the skin mostly in palmar creases,
flexural areas, nipples, vermilion border of the lips and the
buccal periodontal was noticed
- Investigations?
10
▷ The diagnosis is Addison’s disease
▷ Investigations:
✓ Serum cortisol is low
✓ Serum glucose is low
✓ Serum K is high
✓ Serum Na is low
11
Case 6 : The 15-year-old female patient was born with genital ambiguity. She was
brought up as a boy. She is short (146cm) with pubic hair, a vagina, and bilateral
unpalpable testes. Karyotype test result was 46,XX, and laboratory examination showed
a high value for 17-hydroxyprogesterone (115.9ng/mL). A uterus with endometrial lining
was found on USG examination.
- Treatment?
12
▷ The diagnosis is ambiguous genitalia (congenital adrenal hyperplasia).
▷ Treatment of all forms of CAH may include any of:
1. Supplying enough glucocorticoid to reduce hyperplasia and

overproduction of androgens or mineralocorticoids.
2. Providing replacement mineralocorticoid and extra salt if the person is

de cient.
fi

3. Providing replacement testosterone or estrogens at puberty if the

person is de cient
fi

4. Additional treatments to optimize growth by delaying puberty or

delaying bone maturation.
13
Thank you
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OSCE

Supervised by: Dr. Maitham Al-Khateeb

Presented by: Dr. Ahmad Jassim

- What is the differential diagnosis?

- What’s your approach to the definitive diagnosis?

If imaging reveals a mass → pheochromocytoma .

- What is the diagnosis?

▷ Mycobacterium tuberculosis complex spreads to the

▷ Investigations: (the test must be repeated at least twice to confirm the

➡ Adrenal adenoma: are rarely bilateral → unilateral adrenalectomy is most

➡ Adrenal carcinoma: should be completely removed whenever possible +/-

➡ Pituitary disease: → bilateral adrenalectomy, with lifelong steroid therapy.

- What is the diagnosis?

▷ Management: he would be benefited from a left subcostal

Left adrenalectomy postoperative specimen

A 52-year-old man presented to the Emergency department

✓ Serum cortisol is low

✓ Serum glucose is low

▷ Treatment of all forms of CAH may include any of:

1. Supplying enough glucocorticoid to reduce hyperplasia and

2. Providing replacement mineralocorticoid and extra salt if the person is

3. Providing replacement testosterone or estrogens at puberty if the

4. Additional treatments to optimize growth by delaying puberty or

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