Re: How good is the screening tests for Conn's?

[Guest guest]

Then you find a doctor at Dr. Grim's recommendation that knows something about Conn's.

Bindner

Web Directory (links to my sites and blogs):

http://www.geocities.com/mikeybdc/index.html

http://mikeybdc.blogspot.com

From: georgewbill <georgewbill@...>Subject: How good is the screening tests for Conn's?hyperaldosteronism Date: Monday, September 7, 2009, 9:46 PM

While some of you may have had your Conn's show up in the first blood tests for Conn's many others seem to have to be tested a few times before they are told they have Conn's. I have also read that others have had negative tests but there doctors still go to the next tests and find they have Conn's.In the video Resistant Hypertension Dr.Domenic Sica says something about your aldosterone can be much lower then what the labs top normal numbers are and you can still have Conn's.If Dr Grimm is right about what he sees in my lab tests then I have Conn's even though the tests to other Doctors are very normal. So what good does it do to have the sreening tests done in many times they doen't show that you have Conn's and you do?

[Guest guest]

From other contacts I have had with Dr Grim I don't think he knows any one near

me.

>

>

> From: georgewbill <georgewbill@...>

> Subject: How good is the screening tests for Conn's?

> hyperaldosteronism

> Date: Monday, September 7, 2009, 9:46 PM

>

>

>  

>

>

>

> While some of you may have had your Conn's show up in the first blood tests

for Conn's many others seem to have to be tested a few times before they are

told they have Conn's. I have also read that others have had negative tests but

there doctors still go to the next tests and find they have Conn's.

>

> In the video Resistant Hypertension Dr.Domenic Sica says something about your

aldosterone can be much lower then what the labs top normal numbers are and you

can still have Conn's.

>

> If Dr Grimm is right about what he sees in my lab tests then I have Conn's

even though the tests to other Doctors are very normal. So what good does it do

to have the sreening tests done in many times they doen't show that you have

Conn's and you do?

>

[Guest guest]

The purpose of screening tests is to select those most likely to have or nor not have a diseAse. No screening test is 100% at both. These are the facts of science. If u read my evolution article it should becoE clear why tests are not "+" early in Conn's. Tiped sad Send form miiPhone ;-)May your pressure be low!CE Grim MDSpecializing in DifficultHypertensionOn Sep 7, 2009, at 10:25 PM, georgewbill <georgewbill@...> wrote:

From other contacts I have had with Dr Grim I don't think he knows any one near me.

>

>

> From: georgewbill <georgewbill@...>

> Subject: How good is the screening tests for Conn's?

> hyperaldosteronism

> Date: Monday, September 7, 2009, 9:46 PM

>

>

>

>

>

>

> While some of you may have had your Conn's show up in the first blood tests for Conn's many others seem to have to be tested a few times before they are told they have Conn's. I have also read that others have had negative tests but there doctors still go to the next tests and find they have Conn's.

>

> In the video Resistant Hypertension Dr.Domenic Sica says something about your aldosterone can be much lower then what the labs top normal numbers are and you can still have Conn's.

>

> If Dr Grimm is right about what he sees in my lab tests then I have Conn's even though the tests to other Doctors are very normal. So what good does it do to have the sreening tests done in many times they doen't show that you have Conn's and you do?

>

[Guest guest]

Of course u also need a thinking Dr. Tiped sad Send form miiPhone ;-)May your pressure be low!CE Grim MDSpecializing in DifficultHypertensionOn Sep 7, 2009, at 9:16 PM, Bindner <mikeybdc@...> wrote:

Then you find a doctor at Dr. Grim's recommendation that knows something about Conn's.

Bindner

Web Directory (links to my sites and blogs):

http://www.geocities.com/mikeybdc/index.html

http://mikeybdc.blogspot.com

From: georgewbill <georgewbill >Subject: How good is the screening tests for Conn's?hyperaldosteronism Date: Monday, September 7, 2009, 9:46 PM

While some of you may have had your Conn's show up in the first blood tests for Conn's many others seem to have to be tested a few times before they are told they have Conn's. I have also read that others have had negative tests but there doctors still go to the next tests and find they have Conn's.In the video Resistant Hypertension Dr.Domenic Sica says something about your aldosterone can be much lower then what the labs top normal numbers are and you can still have Conn's.If Dr Grimm is right about what he sees in my lab tests then I have Conn's even though the tests to other Doctors are very normal. So what good does it do to have the sreening tests done in many times they doen't show that you have Conn's and you do?

[Guest guest]

The problem is not many doctors think. Since the VA uses Quest labs I have

looked at what Quest labs has about the Conn's lab tests and they say to stop

all BP meds before doing the tests. something the VA didn't do with me. There

are other things that were going on with me at the time that probably could have

changed the tests Just two weeks before the blood test I had surgery At the time

of the test I had as yet to be treated UTI.

From the Darmouth blood test report I think thet ues the Mayo Lab. The Mayo lab

states that only ACE meds have to be stoped before the tests. So as far as this

goes Datmouth is right in saying the Meds I take didn't change any thing.

If the VA doctors or the Datmouth doctors knew any thing about Conn's then they

should have been looking closer at the tests. The first clue should have been

the adrenal adenoma with hidh blood presure. Of course a 2 CM adrenal adenoma

isn't very big so it can't be a problem. Have been told this many times.

> >

> > From: georgewbill <georgewbill@...>

> > Subject: How good is the screening tests for

> > Conn's?

> > hyperaldosteronism

> > Date: Monday, September 7, 2009, 9:46 PM

> >

> >

> > While some of you may have had your Conn's show up in the first

> > blood tests for Conn's many others seem to have to be tested a few

> > times before they are told they have Conn's. I have also read that

> > others have had negative tests but there doctors still go to the

> > next tests and find they have Conn's.

> >

> > In the video Resistant Hypertension Dr.Domenic Sica says something

> > about your aldosterone can be much lower then what the labs top

> > normal numbers are and you can still have Conn's.

> >

> > If Dr Grimm is right about what he sees in my lab tests then I have

> > Conn's even though the tests to other Doctors are very normal. So

> > what good does it do to have the sreening tests done in many times

> > they doen't show that you have Conn's and you do?

> >

> >

> >

>

[Guest guest]

Mine is 2 cm and while my PRA says PA, the Aldo alone would not.

Bindner

Web Directory (links to my sites and blogs):

http://www.geocities.com/mikeybdc/index.html

http://mikeybdc.blogspot.com

From: georgewbill <georgewbill@...>Subject: Re: How good is the screening tests for Conn's?hyperaldosteronism Date: Tuesday, September 8, 2009, 9:08 AM

The problem is not many doctors think. Since the VA uses Quest labs I have looked at what Quest labs has about the Conn's lab tests and they say to stop all BP meds before doing the tests. something the VA didn't do with me. There are other things that were going on with me at the time that probably could have changed the tests Just two weeks before the blood test I had surgery At the time of the test I had as yet to be treated UTI. From the Darmouth blood test report I think thet ues the Mayo Lab. The Mayo lab states that only ACE meds have to be stoped before the tests. So as far as this goes Datmouth is right in saying the Meds I take didn't change any thing. If the VA doctors or the Datmouth doctors knew any thing about Conn's then they should have been looking closer at the tests. The first clue should have been the adrenal adenoma with hidh blood presure. Of course a 2 CM adrenal adenoma isn't very big so it can't be a problem.

Have been told this many times. > >> > From: georgewbill <georgewbill@ ...>> > Subject: [hyperaldosteronism ] How good is the screening tests for > > Conn's?> > hyperaldosteronism> > Date: Monday, September 7, 2009, 9:46 PM> >> >> > While some of you may have had your Conn's show up in the first > > blood tests for Conn's many others seem to have to be tested a few > > times

before they are told they have Conn's. I have also read that > > others have had negative tests but there doctors still go to the > > next tests and find they have Conn's.> >> > In the video Resistant Hypertension Dr.Domenic Sica says something > > about your aldosterone can be much lower then what the labs top > > normal numbers are and you can still have Conn's.> >> > If Dr Grimm is right about what he sees in my lab tests then I have > > Conn's even though the tests to other Doctors are very normal. So > > what good does it do to have the sreening tests done in many times > > they doen't show that you have Conn's and you do?> >> >> >>

[Guest guest]

This is from my Darmouth Medical

LAB RESULTS: 00052074-2 03/04/2009

CO RT MDNITE SAL-MAYO 19*

(<:100-)

DHEAS <30 L *

(42-290)

RENIN ACTIVITY-MAYO 0.8*

(-)

ALDOSTERONE-MAYO 5.5*

(<=21-)

NORMETANE FREE-MAYO 0.86*

(<:0.90-)

METANEPHR FREE-MAYO <0.20 *

( <:0.50-)

Assessment:

Mr. Bill is a 61 years y.o. M with symptoms of daily lightheadednass and

exartional

SOB with an incidentally discovered 2.1cm left adrenal mass whom we saw in our

Endocrinology Clinic at DHMC on 03/03/2009 for evaluation of the adrenal mass.

We felt at the time the pt's symptoms were likely unrelated to this adrenal

incidentaloma especially since he has had an extensive negative work-up in the

past.

However, since most of his previous testing results were not available to us,

and

the patient would like to be retested, we rechecked levels of:

midnight salivary cortisol

renin and aldosterone

DHEA-S

serum metanephrine and normetanephrine

to rule this lesion out as a functioning adenoma.

The results above show that there is no evidence that this adenoma is producing

any

excess adrenal hormones.

Plan/Instructions:

Pt was counselled and reassured that this likely represents a benign finding,

especially since the lesion has been stable over time and an extensive work-up

in

the past has been negative as well. However, pt was asked to coordinate with his

PCP if he develops any new signs/symptoms or change in his present

signs/symptoms.

Tharsan Sivakumar MD

Endocrinology Fellow

I am being supervised by TURCO MD,JOHN H Endocrinology

Electronically signed by: SIVAKUMAR MD, THARSAN 03/13/ 2009 09:32

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

MULTI-AUTHOR NOTE

I agree with these recommendations.

Jack Turco, M.D.

Electronically signed by: TURCO MD, JOHN H 03/18/2009 17:01

Reason for Consultation:

symptoms of lightheadedness, SOB with incidentally discovered adrenal

lesion

Referred by:

self

BPI:

Francis B. Bill is a 61 years y.o. M with PMH as below has had symptoms of

all-day

lightheadedness and exertional shortness of breath for 3 years, which had been

worked up at the VA with CT, echo, Holter, and other studies which did not yield

any

etiology for these symptoms. Pt presented to the ER for these symptoms several

times as well.

CT scan of the chest performed in 2006 to evaluate for the SOB showed a well

defined

7mm right lower lung lobe nodule. A left 2.1cm adrenal nodule was found as well

with soft tissue attenuation likely representing an adenoma. According DHMC

Emergency Medicine notes, these have been stable over time.

PMSH:

hypertension, and dyslipidemia.

appendectomy, tonsil/adenoidectomy

Medications:

AMBULATORY MEDICATIONS· Last charted on· 03/03/2009

DRUG DOSE/ROUTE FREQUENCY

Aspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRN

Oral

Multivitamin Tablet 1 Tablet (s) / Oral Once daily

Furosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once daily

Oral

Potassium Chloride 10 mEg 20 MEQ = 2 Capsule(s) / Once daily

Capsule, Sustained Oral

Release

Atenolol 25 mg Tablet 25 MG = 1 Tablet (s) / Once daily

Oral

Triamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once daily

Oral

Allergies:

ADR/ALLERGIES: Last charted on: 03/03/2009

ADR/ALLERGY REACTION SEVERITY

Sulfonamides

Social. history:

Very brief smoking history during teenage years

Asbestos exposure 15 years in a boiler room

Denies ETOH

never married

no children

Famil.y Hx:

Thyroid dysfunction: Mother, sister

Thyroid cancer: No

Diabetes mellitus: No

Other auto-immune diseases: No

Vitiligo: No

Physical Exam

Vitals:

VITAL SIGNS (03/03/2009 @ 14·44)

Heart Rate 96

Systolic BP 156

Diastolic BP 91

Mean BP 112.67

Weight (kg) 137.16

Height (cm) 176.9

Body Surface Area (m2 ) 2.6

BMI (kg/m 2 ) 43.83

Pain Scale 0

Smoking

Smoke History Remote

General: NAD, morbidly obese

HEENT: EOMI, anicteric, PERRL, moist mucous membranes, full visual fundi

Neck: No LAD, no thyromegaly, no tenderness

CV: Sl S2, RRR

Lungs: CTAB

Abd: soft, NT, obese

Neuro: reflexes difficult to elicit

Extremities: trace ankle edema

Integumentary: Skin warm/dry/intact; no hyperpigmentation of hand creases or

gumline/ rash

06/06

K 4.0

08/06

TSH 2.34

cortisol 14:38 pm 12.0 ug/dL

03/2007

VMA 6.4 (ref 2.0-10.0)

Assessment and Plan:

Mr. Bill is a 61 years y.o. M as above with symptoms of daily lightheadedness

and

exertional SOB with an incidentally discovered 2.1cm left adrenal mass.

Pt's symptoms are likely unrelated to this adrenal incidentaloma especially

since he

has had an extensive negative work-up in the past. However, since most of these

results are not available to us, and the patient would like to be retested, we

will

check levels of:

midnight salivary cortisol

renin and aldosterone

DHEA-S

serum metanephrine and normetanephrine

to rule this lesion out as a functioning adenoma.

Pt was counselled and reassured that this likely represents a benign finding,

especially since the lesion has been stable over time. However, pt was asked to

coordinate with his PCP if he develops any new signs/symptoms or change in his

present signs/symptoms.

We have reviewed our plan outlined above with the patient and Mr. Bill

verbalized

understanding. All questions were answered.

Tharsan Sivakumar, MD

Endocrinology Fellow

I am being supervised by TURCO MD,JOHN H Endocrinology

Electronically signed by: SIVAKUMAR MD, THARSAN 03/03/2009 15:58

MULTI-AUTHOR NOTE

I have interviewed and examined this patient along with Dr. Sivakumar and agree

with

this note and also these recommendations. The patient will be contacted with

final

recommendations when results of testing are complete.

>50% of the 60 minute appointment was spent in face to face counseling the

patient

about the possible significance and evaluation of his adrenal abnormality.

Jack Turco, M.D.

Communication sent to: L. Durand 03/03/2009 17:28

Electronically signed by: TURCO MD, JOHN H 03/03/2009 17:28

DARTMOUTH-HITCHCOCK MEDICAL CENTER

ENCOUNTER DATE: 08/06/ 2009

OFFICE NOTES

BILL,FRANCIS H

Nephrology Clinic New Patient Visit

Francis H. Bill

August 6, 2009

ID: 62 years old male seen at the request of Dr. Mogielnicki for? Conns

Syndrome.

Past Medical History:

HTN diagnosed about 5 yrs ago

Chronic Fatigue Syndrome

Chronic dyspnea

Chronic dizziness

s/p appendectomy in Dec 2008

Multiple granulomas in the Lungs

Exophytic cyst Lt kidney

History of Present Illness:

Mr Bill presents today for a second opinion regarding whether he might have

Conns

Syndrome. In 2006, he underwent w/u for SOB. He had a CT scan of the chest which

showed a 2.1 cm soft tisuue mass in the Lt adrenal gland. Subsequent tests

showed

that the adenoma was non secretory. He has since undergone several chest CT and

the

adrenal mass has not grown is size. In March 2009, he was seen by endocrinology

at

DHMC. He again underwent testing including cortisol, PRA, aldosterone,

metanephrines

etc, all of which were within normal limits. Patient was reassured that this

likely

represents an incidentaloma.

Over the past 3-4 yrs, he has had chronic SOB and dizziness . He has undergone

extensive testing for both including EKG, stress tests, echocardiograms, Holter

montior, MRI brain (to r/o acoustic neuroma), sleep studies, PFTs etc all of

which

have not identified an abnormality.

In Dec 2008, he presented with abd pain and was found to have appendicitis on CT

scan. It also showed an exophytic mass in the L kidney for which he unerwent an

ultrasound. He was told by his PCP that he needs f /u CT scan for the lesion. I

do

not have records relating to this issue today.

He has normal renal fucnti on ( Cr from VA records has ranged from 0.8-1.1 in

the

past 3 yrs) .

AMBULATORY MEDICATIONS· Last charted on· 08/06/2009

DRUG DOSE/ROUTE FREQUENCY

Aspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRN

Oral

Furosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once daily

Oral

Potassium Chloride 10 mEq 20 MEQ = 2 Capsule(s) / Once daily

Capsule, Sustained Oral

Release

Atenolol 25 mg Tablet 25 MG = 1 Tablet(s) / Once daily

Triamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once daily

Oral

Multivitamin Tablet 1 Tablet (s) / Oral

ADR/ALLERGIES: Last charted on: 08/06/2009

ADR/ALLERGY REACTION SEVERITY

Sulfonamides

Family History:

No family h/o renal disease. He denies family h/o DM and CAD.

Social History:

Lives in Enfield NH. Vietnam war vet, now on disability 2 to chronic fatigue

syndrme. Quit smoking 40 yrs ago, denies ETOH ot illicit drug use.

Review of Systems:

System Abnormalities

Constitutional gained 40 Ibs over the past 3-4 yrs, + cheonic fatigue

Eye denies visual changes

ENT denies sorethroay, odynophagia

CV denies CP, palp

Resp + SOB, + DOE, denies cough, PND or orthopnea

GI denies loss appetite, change in bowel habit

GU denies hematuria, dysuria, voiding difficulties

Skin denies rash, hype rp igment at ion

Allergy

Endocrine no h/o DM, denies exessive sweating, heat or cold intolerance

Neurologic denies h/o seizures, headahces

Musculoskeletal denies muscle aches, joint swelling

Lymph

Psych denies depression

All other systems reviewed and negative.

Physical Examination:

VITAL SIGNS (08/06/2009 @ 13:28)

Temperature © 36.61

Route Oral

Heart Rate 82

Rhythm Regular

Method Radial

Systolic BP 149

Diastolic BP 72

Patient Position Sitting

Extremity Left Arm

Method NIBP

Mean BP 97.67

Weight (kg) 140.61

Height (cm) 177.8

Body Surface Area (m2 ) 2.64

BMI (kg/m 2 ) 44.48

General: elderly man, NAD, dishevelled

Eye: no scleral icterus, EOM intact

ENT: no pharyngeal erythema or thrush, poor dentition

Neck: no JVD, no thyromegaly

CV: sl s2 reg, no murmur

Resp: CTAB

Abd: + BS, NT/NO, obese

Lymph: no cervical adenopathy

Ext: no LE Edema

Skin: no rash, hyperpigmentation

Neuro: no focal motor deficit, sensations intact

Psych: alert and oriented. affect appropriate

Labs:

LAB RESULTS: 00052074-2 03/04/2009

CO RT MDNITE SAL-MAYO 19*

(<:100-)

DHEAS <30 L *

(42-290)

RENIN ACTIVITY-MAYO 0.8*

(-)

ALDOSTERONE-MAYO 5.5*

(<=21-)

NORMETANE FREE-MAYO 0.86*

(<:0.90-)

METANEPHR FREE-MAYO <0.20 *

( <:0.50-)

Records from WRJVA reviewed and will be scanned into CIS.

AlP:

62 M with chronic fatigue, dyspnea and dizziness, who was incidentally found to

have

a 2 cm It adrenal adenoma.

He is here today for an opinion as to whether he has Conns syndrome and if his

symptoms are related to the adrenal adenoma.

He has undergone testing multiple times and there is no evidence that this is a

fucntional adenoma. It most likely represents an incidentaloma that has not

increased in size over the past 3 yrs based on CT scanning. His symptoms are

also

probably unrelated to the incidentaloma. He also does not have any evidence to

support a diagnosis of Conns Syndrome.

HTN - Not at goal. Discussed occasional home BP checks to help adjust medication

regimen. If needed, would add ACEI /ARB or CCB for better control. Discussed wt

loss

and dietary salt restiriction.

Lt renal mass - I do not have records available today regarding this issue but

would

recommed urology evaluation.

He does not routine flu with nephrology unless a new issue arises.

Thank you for allowing me to participate in the care of this interesting

patient.

Please call if I can be of further assistance.

Please CC to:

None

No PCP Address on record

No PCP Tel# on record

I am being supervised by KANEKO MD,THOMAS M Hypertension/Nephrology

Electronically signed by: RANGAN MD, YASHASWINI 08/06/2009 19:18

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

MULTI-AUTHOR NOTE

Seen and examined with Dr. Rangan.

additions:

I agree with her above note with the following

Renin/aldo levels are normal; no evidence of hyperaldosteronism. H/o hypokalemia

on

furosemide is not unusual. BP is mildly elevated but likely essential

hypertension.

If BP remains above 140/90 would consider addition of ACEI as these synergize

well

with diuretics and may also help mitigate hypokalemia. Reportedly has an

exophytic

mass on his kidney that does not meet criteria for a simple cyst, although I do

not

have the images to review personally. Recommend urology evalution for this.

Communication sent to: R Mogielnicki 08/11/2009 15:05

Electronically signed by: KANEKO MD, THOMAS M 08/11/2009 15:05

> > >

> > > From: georgewbill <georgewbill@ ...>

> > > Subject: [hyperaldosteronism ] How good is the screening tests for

> > > Conn's?

> > > hyperaldosteronism

> > > Date: Monday, September 7, 2009, 9:46 PM

> > >

> > >

> > > While some of you may have had your Conn's show up in the first

> > > blood tests for Conn's many others seem to have to be tested a few

> > > times before they are told they have Conn's. I have also read that

> > > others have had negative tests but there doctors still go to the

> > > next tests and find they have Conn's.

> > >

> > > In the video Resistant Hypertension Dr.Domenic Sica says something

> > > about your aldosterone can be much lower then what the labs top

> > > normal numbers are and you can still have Conn's.

> > >

> > > If Dr Grimm is right about what he sees in my lab tests then I have

> > > Conn's even though the tests to other Doctors are very normal. So

> > > what good does it do to have the sreening tests done in many times

> > > they doen't show that you have Conn's and you do?

> > >

> > >

> > >

> >

>

[Guest guest]

You have a PRA of 7, however your meds might be yielding a false negative. Show the doctors the guidelines or have someone else test who knows that you need to be off meds.

Bindner

Web Directory (links to my sites and blogs):

http://www.geocities.com/mikeybdc/index.html

http://mikeybdc.blogspot.com

From: georgewbill <georgewbill@...>Subject: Re: How good is the screening tests for Conn's?hyperaldosteronism Date: Tuesday, September 8, 2009, 8:50 PM

This is from my Darmouth MedicalLAB RESULTS: 00052074-2 03/04/2009CO RT MDNITE SAL-MAYO 19*(<:100-)DHEAS <30 L *(42-290)RENIN ACTIVITY-MAYO 0.8*(-)ALDOSTERONE- MAYO 5.5*(<=21-)NORMETANE FREE-MAYO 0.86*(<:0.90-)METANEPHR FREE-MAYO <0.20 *( <:0.50-)Assessment:Mr. Bill is a 61 years y.o. M with symptoms of daily lightheadednass and exartionalSOB with an incidentally discovered 2.1cm left adrenal mass whom we saw in ourEndocrinology Clinic at DHMC on 03/03/2009 for evaluation of the adrenal mass.We felt at the time the pt's symptoms were likely unrelated to this adrenalincidentaloma especially since he has had an extensive negative work-up in the past.However, since most of his previous testing results were not available to us, andthe patient would like to be retested, we rechecked levels of:midnight salivary

cortisolrenin and aldosteroneDHEA-Sserum metanephrine and normetanephrineto rule this lesion out as a functioning adenoma.The results above show that there is no evidence that this adenoma is producing anyexcess adrenal hormones.Plan/Instructions:Pt was counselled and reassured that this likely represents a benign finding,especially since the lesion has been stable over time and an extensive work-up inthe past has been negative as well. However, pt was asked to coordinate with hisPCP if he develops any new signs/symptoms or change in his present signs/symptoms.Tharsan Sivakumar MDEndocrinology FellowI am being supervised by TURCO MD,JOHN H EndocrinologyElectronically signed by: SIVAKUMAR MD, THARSAN 03/13/ 2009 09:32+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +MULTI-AUTHOR NOTEI agree with these recommendations.Jack Turco, M.D.Electronically

signed by: TURCO MD, JOHN H 03/18/2009 17:01Reason for Consultation:symptoms of lightheadedness, SOB with incidentally discovered adrenallesionReferred by:selfBPI:Francis B. Bill is a 61 years y.o. M with PMH as below has had symptoms of all-daylightheadedness and exertional shortness of breath for 3 years, which had beenworked up at the VA with CT, echo, Holter, and other studies which did not yield anyetiology for these symptoms. Pt presented to the ER for these symptoms severaltimes as well.CT scan of the chest performed in 2006 to evaluate for the SOB showed a well defined7mm right lower lung lobe nodule. A left 2.1cm adrenal nodule was found as wellwith soft tissue attenuation likely representing an adenoma. According DHMCEmergency Medicine notes, these have been stable over time.PMSH:hypertension, and dyslipidemia.appendectomy, tonsil/adenoidectom

yMedications:AMBULATORY MEDICATIONS· Last charted on· 03/03/2009DRUG DOSE/ROUTE FREQUENCYAspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRNOralMultivitamin Tablet 1 Tablet (s) / Oral Once dailyFurosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once dailyOralPotassium Chloride 10 mEg 20 MEQ = 2 Capsule(s) / Once dailyCapsule, Sustained OralReleaseAtenolol 25 mg Tablet 25 MG = 1 Tablet (s) / Once dailyOralTriamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once dailyOralAllergies:ADR/ALLERGIES: Last charted on: 03/03/2009ADR/ALLERGY REACTION SEVERITYSulfonamidesSocial. history:Very brief smoking history during teenage yearsAsbestos exposure 15 years in a boiler roomDenies ETOHnever marriedno childrenFamil.y Hx:Thyroid dysfunction: Mother, sisterThyroid cancer: NoDiabetes mellitus: NoOther auto-immune diseases: NoVitiligo:

NoPhysical ExamVitals:VITAL SIGNS (03/03/2009 @ 14·44)Heart Rate 96Systolic BP 156Diastolic BP 91Mean BP 112.67Weight (kg) 137.16Height (cm) 176.9Body Surface Area (m2 ) 2.6BMI (kg/m 2 ) 43.83Pain Scale 0SmokingSmoke History RemoteGeneral: NAD, morbidly obeseHEENT: EOMI, anicteric, PERRL, moist mucous membranes, full visual fundiNeck: No LAD, no thyromegaly, no tendernessCV: Sl S2, RRRLungs: CTABAbd: soft, NT, obeseNeuro: reflexes difficult to elicitExtremities: trace ankle edemaIntegumentary: Skin warm/dry/intact; no hyperpigmentation of hand creases orgumline/ rash06/06K 4.008/06TSH 2.34cortisol 14:38 pm 12.0 ug/dL03/2007VMA 6.4 (ref 2.0-10.0)Assessment and Plan:Mr. Bill is a 61 years y.o. M as above with symptoms of daily lightheadedness andexertional SOB with an incidentally discovered 2.1cm left adrenal

mass.Pt's symptoms are likely unrelated to this adrenal incidentaloma especially since hehas had an extensive negative work-up in the past. However, since most of theseresults are not available to us, and the patient would like to be retested, we willcheck levels of:midnight salivary cortisolrenin and aldosteroneDHEA-Sserum metanephrine and normetanephrineto rule this lesion out as a functioning adenoma.Pt was counselled and reassured that this likely represents a benign finding,especially since the lesion has been stable over time. However, pt was asked tocoordinate with his PCP if he develops any new signs/symptoms or change in hispresent signs/symptoms.We have reviewed our plan outlined above with the patient and Mr. Bill verbalizedunderstanding. All questions were answered.Tharsan Sivakumar, MDEndocrinology FellowI am being supervised by TURCO MD,JOHN H

EndocrinologyElectronically signed by: SIVAKUMAR MD, THARSAN 03/03/2009 15:58MULTI-AUTHOR NOTEI have interviewed and examined this patient along with Dr. Sivakumar and agree withthis note and also these recommendations. The patient will be contacted with finalrecommendations when results of testing are complete.>50% of the 60 minute appointment was spent in face to face counseling the patientabout the possible significance and evaluation of his adrenal abnormality.Jack Turco, M.D.Communication sent to: L. Durand 03/03/2009 17:28Electronically signed by: TURCO MD, JOHN H 03/03/2009 17:28DARTMOUTH-HITCHCOCK MEDICAL CENTERENCOUNTER DATE: 08/06/ 2009OFFICE NOTESBILL,FRANCIS HNephrology Clinic New Patient VisitFrancis H. BillAugust 6, 2009ID: 62 years old male seen at the request of Dr. Mogielnicki for? Conns Syndrome.Past Medical History:HTN diagnosed

about 5 yrs agoChronic Fatigue SyndromeChronic dyspneaChronic dizzinesss/p appendectomy in Dec 2008Multiple granulomas in the LungsExophytic cyst Lt kidneyHistory of Present Illness:Mr Bill presents today for a second opinion regarding whether he might have ConnsSyndrome. In 2006, he underwent w/u for SOB. He had a CT scan of the chest whichshowed a 2.1 cm soft tisuue mass in the Lt adrenal gland. Subsequent tests showedthat the adenoma was non secretory. He has since undergone several chest CT and theadrenal mass has not grown is size. In March 2009, he was seen by endocrinology atDHMC. He again underwent testing including cortisol, PRA, aldosterone, metanephrinesetc, all of which were within normal limits. Patient was reassured that this likelyrepresents an incidentaloma.Over the past 3-4 yrs, he has had chronic SOB and dizziness . He has undergoneextensive testing for both

including EKG, stress tests, echocardiograms, Holtermontior, MRI brain (to r/o acoustic neuroma), sleep studies, PFTs etc all of whichhave not identified an abnormality.In Dec 2008, he presented with abd pain and was found to have appendicitis on CTscan. It also showed an exophytic mass in the L kidney for which he unerwent anultrasound. He was told by his PCP that he needs f /u CT scan for the lesion. I donot have records relating to this issue today.He has normal renal fucnti on ( Cr from VA records has ranged from 0.8-1.1 in thepast 3 yrs) .AMBULATORY MEDICATIONS· Last charted on· 08/06/2009DRUG DOSE/ROUTE FREQUENCYAspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRNOralFurosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once dailyOralPotassium Chloride 10 mEq 20 MEQ = 2 Capsule(s) / Once dailyCapsule, Sustained OralReleaseAtenolol 25 mg Tablet 25 MG = 1 Tablet(s) / Once

dailyTriamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once dailyOralMultivitamin Tablet 1 Tablet (s) / OralADR/ALLERGIES: Last charted on: 08/06/2009ADR/ALLERGY REACTION SEVERITYSulfonamidesFamily History:No family h/o renal disease. He denies family h/o DM and CAD.Social History:Lives in Enfield NH. Vietnam war vet, now on disability 2 to chronic fatiguesyndrme. Quit smoking 40 yrs ago, denies ETOH ot illicit drug use.Review of Systems:System AbnormalitiesConstitutional gained 40 Ibs over the past 3-4 yrs, + cheonic fatigueEye denies visual changesENT denies sorethroay, odynophagiaCV denies CP, palpResp + SOB, + DOE, denies cough, PND or orthopneaGI denies loss appetite, change in bowel habitGU denies hematuria, dysuria, voiding difficultiesSkin denies rash, hype rp igment at ionAllergyEndocrine no h/o DM, denies exessive sweating, heat or cold

intoleranceNeurologic denies h/o seizures, headahcesMusculoskeletal denies muscle aches, joint swellingLymphPsych denies depressionAll other systems reviewed and negative.Physical Examination:VITAL SIGNS (08/06/2009 @ 13:28)Temperature © 36.61Route OralHeart Rate 82Rhythm RegularMethod RadialSystolic BP 149Diastolic BP 72Patient Position SittingExtremity Left ArmMethod NIBPMean BP 97.67Weight (kg) 140.61Height (cm) 177.8Body Surface Area (m2 ) 2.64BMI (kg/m 2 ) 44.48General: elderly man, NAD, dishevelledEye: no scleral icterus, EOM intactENT: no pharyngeal erythema or thrush, poor dentitionNeck: no JVD, no thyromegalyCV: sl s2 reg, no murmurResp: CTABAbd: + BS, NT/NO, obeseLymph: no cervical adenopathyExt: no LE EdemaSkin: no rash, hyperpigmentationNeuro: no focal motor deficit, sensations intactPsych: alert

and oriented. affect appropriateLabs:LAB RESULTS: 00052074-2 03/04/2009CO RT MDNITE SAL-MAYO 19*(<:100-)DHEAS <30 L *(42-290)RENIN ACTIVITY-MAYO 0.8*(-)ALDOSTERONE- MAYO 5.5*(<=21-)NORMETANE FREE-MAYO 0.86*(<:0.90-)METANEPHR FREE-MAYO <0.20 *( <:0.50-)Records from WRJVA reviewed and will be scanned into CIS.AlP:62 M with chronic fatigue, dyspnea and dizziness, who was incidentally found to havea 2 cm It adrenal adenoma.He is here today for an opinion as to whether he has Conns syndrome and if hissymptoms are related to the adrenal adenoma.He has undergone testing multiple times and there is no evidence that this is afucntional adenoma. It most likely represents an incidentaloma that has notincreased in size over the past 3 yrs based on CT scanning. His symptoms are alsoprobably unrelated to the incidentaloma. He

also does not have any evidence tosupport a diagnosis of Conns Syndrome.HTN - Not at goal. Discussed occasional home BP checks to help adjust medicationregimen. If needed, would add ACEI /ARB or CCB for better control. Discussed wt lossand dietary salt restiriction.Lt renal mass - I do not have records available today regarding this issue but wouldrecommed urology evaluation.He does not routine flu with nephrology unless a new issue arises.Thank you for allowing me to participate in the care of this interesting patient.Please call if I can be of further assistance.Please CC to:NoneNo PCP Address on recordNo PCP Tel# on recordI am being supervised by KANEKO MD,THOMAS M Hypertension/ NephrologyElectronically signed by: RANGAN MD, YASHASWINI 08/06/2009 19:18+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +MULTI-AUTHOR NOTESeen and examined with Dr.

Rangan.additions:I agree with her above note with the followingRenin/aldo levels are normal; no evidence of hyperaldosteronism. H/o hypokalemia onfurosemide is not unusual. BP is mildly elevated but likely essential hypertension.If BP remains above 140/90 would consider addition of ACEI as these synergize wellwith diuretics and may also help mitigate hypokalemia. Reportedly has an exophyticmass on his kidney that does not meet criteria for a simple cyst, although I do nothave the images to review personally. Recommend urology evalution for this.Communication sent to: R Mogielnicki 08/11/2009 15:05Electronically signed by: KANEKO MD, THOMAS M 08/11/2009 15:05> > >> > > From: georgewbill <georgewbill@ ...>> > > Subject: [hyperaldosteronism ] How good is the screening tests for > > > Conn's?> > > hyperaldosteronism> > > Date: Monday, September 7, 2009, 9:46 PM> > >> > >> > > While some of you may have had your Conn's show up in the first > > > blood tests for Conn's many others seem to have to be tested a

few > > > times before they are told they have Conn's. I have also read that > > > others have had negative tests but there doctors still go to the > > > next tests and find they have Conn's.> > >> > > In the video Resistant Hypertension Dr.Domenic Sica says something > > > about your aldosterone can be much lower then what the labs top > > > normal numbers are and you can still have Conn's.> > >> > > If Dr Grimm is right about what he sees in my lab tests then I have > > > Conn's even though the tests to other Doctors are very normal. So > > > what good does it do to have the sreening tests done in many times > > > they doen't show that you have Conn's and you do?> > >> > >> > >> >>

[Guest guest]

In brief not all adrenal bumps are Conn's. Yet. Tiped sad Send form miiPhone ;-)May your pressure be low!CE Grim MDSpecializing in DifficultHypertensionOn Sep 8, 2009, at 8:28 PM, Bindner <mikeybdc@...> wrote:

You have a PRA of 7, however your meds might be yielding a false negative. Show the doctors the guidelines or have someone else test who knows that you need to be off meds.

Bindner

Web Directory (links to my sites and blogs):

http://www.geocities.com/mikeybdc/index.html

http://mikeybdc.blogspot.com

From: georgewbill <georgewbill >Subject: Re: How good is the screening tests for Conn's?hyperaldosteronism Date: Tuesday, September 8, 2009, 8:50 PM

This is from my Darmouth MedicalLAB RESULTS: 00052074-2 03/04/2009CO RT MDNITE SAL-MAYO 19*(<:100-)DHEAS <30 L *(42-290)RENIN ACTIVITY-MAYO 0.8*(-)ALDOSTERONE- MAYO 5.5*(<=21-)NORMETANE FREE-MAYO 0.86*(<:0.90-)METANEPHR FREE-MAYO <0.20 *( <:0.50-)Assessment:Mr. Bill is a 61 years y.o. M with symptoms of daily lightheadednass and exartionalSOB with an incidentally discovered 2.1cm left adrenal mass whom we saw in ourEndocrinology Clinic at DHMC on 03/03/2009 for evaluation of the adrenal mass.We felt at the time the pt's symptoms were likely unrelated to this adrenalincidentaloma especially since he has had an extensive negative work-up in the past.However, since most of his previous testing results were not available to us, andthe patient would like to be retested, we rechecked levels of:midnight salivary

cortisolrenin and aldosteroneDHEA-Sserum metanephrine and normetanephrineto rule this lesion out as a functioning adenoma.The results above show that there is no evidence that this adenoma is producing anyexcess adrenal hormones.Plan/Instructions:Pt was counselled and reassured that this likely represents a benign finding,especially since the lesion has been stable over time and an extensive work-up inthe past has been negative as well. However, pt was asked to coordinate with hisPCP if he develops any new signs/symptoms or change in his present signs/symptoms.Tharsan Sivakumar MDEndocrinology FellowI am being supervised by TURCO MD,JOHN H EndocrinologyElectronically signed by: SIVAKUMAR MD, THARSAN 03/13/ 2009 09:32+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +MULTI-AUTHOR NOTEI agree with these recommendations.Jack Turco, M.D.Electronically

signed by: TURCO MD, JOHN H 03/18/2009 17:01Reason for Consultation:symptoms of lightheadedness, SOB with incidentally discovered adrenallesionReferred by:selfBPI:Francis B. Bill is a 61 years y.o. M with PMH as below has had symptoms of all-daylightheadedness and exertional shortness of breath for 3 years, which had beenworked up at the VA with CT, echo, Holter, and other studies which did not yield anyetiology for these symptoms. Pt presented to the ER for these symptoms severaltimes as well.CT scan of the chest performed in 2006 to evaluate for the SOB showed a well defined7mm right lower lung lobe nodule. A left 2.1cm adrenal nodule was found as wellwith soft tissue attenuation likely representing an adenoma. According DHMCEmergency Medicine notes, these have been stable over time.PMSH:hypertension, and dyslipidemia.appendectomy, tonsil/adenoidectom

yMedications:AMBULATORY MEDICATIONS· Last charted on· 03/03/2009DRUG DOSE/ROUTE FREQUENCYAspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRNOralMultivitamin Tablet 1 Tablet (s) / Oral Once dailyFurosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once dailyOralPotassium Chloride 10 mEg 20 MEQ = 2 Capsule(s) / Once dailyCapsule, Sustained OralReleaseAtenolol 25 mg Tablet 25 MG = 1 Tablet (s) / Once dailyOralTriamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once dailyOralAllergies:ADR/ALLERGIES: Last charted on: 03/03/2009ADR/ALLERGY REACTION SEVERITYSulfonamidesSocial. history:Very brief smoking history during teenage yearsAsbestos exposure 15 years in a boiler roomDenies ETOHnever marriedno childrenFamil.y Hx:Thyroid dysfunction: Mother, sisterThyroid cancer: NoDiabetes mellitus: NoOther auto-immune diseases: NoVitiligo:

NoPhysical ExamVitals:VITAL SIGNS (03/03/2009 @ 14·44)Heart Rate 96Systolic BP 156Diastolic BP 91Mean BP 112.67Weight (kg) 137.16Height (cm) 176.9Body Surface Area (m2 ) 2.6BMI (kg/m 2 ) 43.83Pain Scale 0SmokingSmoke History RemoteGeneral: NAD, morbidly obeseHEENT: EOMI, anicteric, PERRL, moist mucous membranes, full visual fundiNeck: No LAD, no thyromegaly, no tendernessCV: Sl S2, RRRLungs: CTABAbd: soft, NT, obeseNeuro: reflexes difficult to elicitExtremities: trace ankle edemaIntegumentary: Skin warm/dry/intact; no hyperpigmentation of hand creases orgumline/ rash06/06K 4.008/06TSH 2.34cortisol 14:38 pm 12.0 ug/dL03/2007VMA 6.4 (ref 2.0-10.0)Assessment and Plan:Mr. Bill is a 61 years y.o. M as above with symptoms of daily lightheadedness andexertional SOB with an incidentally discovered 2.1cm left adrenal

mass.Pt's symptoms are likely unrelated to this adrenal incidentaloma especially since hehas had an extensive negative work-up in the past. However, since most of theseresults are not available to us, and the patient would like to be retested, we willcheck levels of:midnight salivary cortisolrenin and aldosteroneDHEA-Sserum metanephrine and normetanephrineto rule this lesion out as a functioning adenoma.Pt was counselled and reassured that this likely represents a benign finding,especially since the lesion has been stable over time. However, pt was asked tocoordinate with his PCP if he develops any new signs/symptoms or change in hispresent signs/symptoms.We have reviewed our plan outlined above with the patient and Mr. Bill verbalizedunderstanding. All questions were answered.Tharsan Sivakumar, MDEndocrinology FellowI am being supervised by TURCO MD,JOHN H

EndocrinologyElectronically signed by: SIVAKUMAR MD, THARSAN 03/03/2009 15:58MULTI-AUTHOR NOTEI have interviewed and examined this patient along with Dr. Sivakumar and agree withthis note and also these recommendations. The patient will be contacted with finalrecommendations when results of testing are complete.>50% of the 60 minute appointment was spent in face to face counseling the patientabout the possible significance and evaluation of his adrenal abnormality.Jack Turco, M.D.Communication sent to: L. Durand 03/03/2009 17:28Electronically signed by: TURCO MD, JOHN H 03/03/2009 17:28DARTMOUTH-HITCHCOCK MEDICAL CENTERENCOUNTER DATE: 08/06/ 2009OFFICE NOTESBILL,FRANCIS HNephrology Clinic New Patient VisitFrancis H. BillAugust 6, 2009ID: 62 years old male seen at the request of Dr. Mogielnicki for? Conns Syndrome.Past Medical History:HTN diagnosed

about 5 yrs agoChronic Fatigue SyndromeChronic dyspneaChronic dizzinesss/p appendectomy in Dec 2008Multiple granulomas in the LungsExophytic cyst Lt kidneyHistory of Present Illness:Mr Bill presents today for a second opinion regarding whether he might have ConnsSyndrome. In 2006, he underwent w/u for SOB. He had a CT scan of the chest whichshowed a 2.1 cm soft tisuue mass in the Lt adrenal gland. Subsequent tests showedthat the adenoma was non secretory. He has since undergone several chest CT and theadrenal mass has not grown is size. In March 2009, he was seen by endocrinology atDHMC. He again underwent testing including cortisol, PRA, aldosterone, metanephrinesetc, all of which were within normal limits. Patient was reassured that this likelyrepresents an incidentaloma.Over the past 3-4 yrs, he has had chronic SOB and dizziness . He has undergoneextensive testing for both

including EKG, stress tests, echocardiograms, Holtermontior, MRI brain (to r/o acoustic neuroma), sleep studies, PFTs etc all of whichhave not identified an abnormality.In Dec 2008, he presented with abd pain and was found to have appendicitis on CTscan. It also showed an exophytic mass in the L kidney for which he unerwent anultrasound. He was told by his PCP that he needs f /u CT scan for the lesion. I donot have records relating to this issue today.He has normal renal fucnti on ( Cr from VA records has ranged from 0.8-1.1 in thepast 3 yrs) .AMBULATORY MEDICATIONS· Last charted on· 08/06/2009DRUG DOSE/ROUTE FREQUENCYAspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRNOralFurosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once dailyOralPotassium Chloride 10 mEq 20 MEQ = 2 Capsule(s) / Once dailyCapsule, Sustained OralReleaseAtenolol 25 mg Tablet 25 MG = 1 Tablet(s) / Once

dailyTriamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once dailyOralMultivitamin Tablet 1 Tablet (s) / OralADR/ALLERGIES: Last charted on: 08/06/2009ADR/ALLERGY REACTION SEVERITYSulfonamidesFamily History:No family h/o renal disease. He denies family h/o DM and CAD.Social History:Lives in Enfield NH. Vietnam war vet, now on disability 2 to chronic fatiguesyndrme. Quit smoking 40 yrs ago, denies ETOH ot illicit drug use.Review of Systems:System AbnormalitiesConstitutional gained 40 Ibs over the past 3-4 yrs, + cheonic fatigueEye denies visual changesENT denies sorethroay, odynophagiaCV denies CP, palpResp + SOB, + DOE, denies cough, PND or orthopneaGI denies loss appetite, change in bowel habitGU denies hematuria, dysuria, voiding difficultiesSkin denies rash, hype rp igment at ionAllergyEndocrine no h/o DM, denies exessive sweating, heat or cold

intoleranceNeurologic denies h/o seizures, headahcesMusculoskeletal denies muscle aches, joint swellingLymphPsych denies depressionAll other systems reviewed and negative.Physical Examination:VITAL SIGNS (08/06/2009 @ 13:28)Temperature © 36.61Route OralHeart Rate 82Rhythm RegularMethod RadialSystolic BP 149Diastolic BP 72Patient Position SittingExtremity Left ArmMethod NIBPMean BP 97.67Weight (kg) 140.61Height (cm) 177.8Body Surface Area (m2 ) 2.64BMI (kg/m 2 ) 44.48General: elderly man, NAD, dishevelledEye: no scleral icterus, EOM intactENT: no pharyngeal erythema or thrush, poor dentitionNeck: no JVD, no thyromegalyCV: sl s2 reg, no murmurResp: CTABAbd: + BS, NT/NO, obeseLymph: no cervical adenopathyExt: no LE EdemaSkin: no rash, hyperpigmentationNeuro: no focal motor deficit, sensations intactPsych: alert

and oriented. affect appropriateLabs:LAB RESULTS: 00052074-2 03/04/2009CO RT MDNITE SAL-MAYO 19*(<:100-)DHEAS <30 L *(42-290)RENIN ACTIVITY-MAYO 0.8*(-)ALDOSTERONE- MAYO 5.5*(<=21-)NORMETANE FREE-MAYO 0.86*(<:0.90-)METANEPHR FREE-MAYO <0.20 *( <:0.50-)Records from WRJVA reviewed and will be scanned into CIS.AlP:62 M with chronic fatigue, dyspnea and dizziness, who was incidentally found to havea 2 cm It adrenal adenoma.He is here today for an opinion as to whether he has Conns syndrome and if hissymptoms are related to the adrenal adenoma.He has undergone testing multiple times and there is no evidence that this is afucntional adenoma. It most likely represents an incidentaloma that has notincreased in size over the past 3 yrs based on CT scanning. His symptoms are alsoprobably unrelated to the incidentaloma. He

also does not have any evidence tosupport a diagnosis of Conns Syndrome.HTN - Not at goal. Discussed occasional home BP checks to help adjust medicationregimen. If needed, would add ACEI /ARB or CCB for better control. Discussed wt lossand dietary salt restiriction.Lt renal mass - I do not have records available today regarding this issue but wouldrecommed urology evaluation.He does not routine flu with nephrology unless a new issue arises.Thank you for allowing me to participate in the care of this interesting patient.Please call if I can be of further assistance.Please CC to:NoneNo PCP Address on recordNo PCP Tel# on recordI am being supervised by KANEKO MD,THOMAS M Hypertension/ NephrologyElectronically signed by: RANGAN MD, YASHASWINI 08/06/2009 19:18+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +MULTI-AUTHOR NOTESeen and examined with Dr.

Rangan.additions:I agree with her above note with the followingRenin/aldo levels are normal; no evidence of hyperaldosteronism. H/o hypokalemia onfurosemide is not unusual. BP is mildly elevated but likely essential hypertension.If BP remains above 140/90 would consider addition of ACEI as these synergize wellwith diuretics and may also help mitigate hypokalemia. Reportedly has an exophyticmass on his kidney that does not meet criteria for a simple cyst, although I do nothave the images to review personally. Recommend urology evalution for this.Communication sent to: R Mogielnicki 08/11/2009 15:05Electronically signed by: KANEKO MD, THOMAS M 08/11/2009 15:05>> Mine is 2 cm and while my PRA says PA, the Aldo alone would not.> > > > > > > Bindner> > Web Directory (links to my sites and blogs):> http://www.geocitie s.com/mikeybdc/ index.html>

[Guest guest]

Here is my problem with going someplace else. The next best place to go would be

Boston this is a three hour drive one way for me. I would have to make this trip

more then once.

Some days I have hard time going just a for a short trip. Since I have no

insurance I don't know how much I would end up paying for all the tests that

need to be done. The VA is where I go now. I was able to do paper work at

Darmouth so I gon't have to pay there Except for any Meds they may give me.

I would seem that someone at one of top ten teaching hospitals would know how to

test for Conn's. This doesn't see to be the case. And not only from looking at

my record. You will see that they are teaching other doctors to test wrong for

Conn's.

From what Dr Grim put in my other posting about the test results that you don't

alwas have to have high PRA number to have Conn's.

As to my understanding of the meds I am on Two of them can increse renin and

one of the can decrese aldosterone.

I don't get very far with my PCP when I tell him about something I have found on

the Internet about Conn's. I have changed PCP three times in the past four

years.

> > > >

> > > > From: georgewbill <georgewbill@ ...>

> > > > Subject: [hyperaldosteronism ] How good is the screening tests for

> > > > Conn's?

> > > > hyperaldosteronism

> > > > Date: Monday, September 7, 2009, 9:46 PM

> > > >

> > > >

> > > > While some of you may have had your Conn's show up in the first

> > > > blood tests for Conn's many others seem to have to be tested a few

> > > > times before they are told they have Conn's. I have also read that

> > > > others have had negative tests but there doctors still go to the

> > > > next tests and find they have Conn's.

> > > >

> > > > In the video Resistant Hypertension Dr.Domenic Sica says something

> > > > about your aldosterone can be much lower then what the labs top

> > > > normal numbers are and you can still have Conn's.

> > > >

> > > > If Dr Grimm is right about what he sees in my lab tests then I have

> > > > Conn's even though the tests to other Doctors are very normal. So

> > > > what good does it do to have the sreening tests done in many times

> > > > they doen't show that you have Conn's and you do?

> > > >

> > > >

> > > >

> > >

> >

>

[Guest guest]

PA will have low PRA HI ALDO. simplest would be to just try spiro for 1 month. OntbTiped sad Send form miiPhone ;-)May your pressure be low!CE Grim MDSpecializing in DifficultHypertensionOn Sep 8, 2009, at 9:28 PM, georgewbill <georgewbill@...> wrote:

Here is my problem with going someplace else. The next best place to go would be Boston this is a three hour drive one way for me. I would have to make this trip more then once.

Some days I have hard time going just a for a short trip. Since I have no insurance I don't know how much I would end up paying for all the tests that need to be done. The VA is where I go now. I was able to do paper work at Darmouth so I gon't have to pay there Except for any Meds they may give me.

I would seem that someone at one of top ten teaching hospitals would know how to test for Conn's. This doesn't see to be the case. And not only from looking at my record. You will see that they are teaching other doctors to test wrong for Conn's.

From what Dr Grim put in my other posting about the test results that you don't alwas have to have high PRA number to have Conn's.

As to my understanding of the meds I am on Two of them can increse renin and one of the can decrese aldosterone.

I don't get very far with my PCP when I tell him about something I have found on the Internet about Conn's. I have changed PCP three times in the past four years.

>

>

> From: georgewbill <georgewbill@...>

> Subject: Re: How good is the screening tests for Conn's?

> hyperaldosteronism

> Date: Tuesday, September 8, 2009, 8:50 PM

>

>

>

>

>

>

> This is from my Darmouth Medical

>

> LAB RESULTS: 00052074-2 03/04/2009

>

> CO RT MDNITE SAL-MAYO 19*

> (<:100-)

>

> DHEAS <30 L *

> (42-290)

>

> RENIN ACTIVITY-MAYO 0.8*

> (-)

>

> ALDOSTERONE- MAYO 5.5*

> (<=21-)

>

> NORMETANE FREE-MAYO 0.86*

> (<:0.90-)

>

> METANEPHR FREE-MAYO <0.20 *

> ( <:0.50-)

>

> Assessment:

>

> Mr. Bill is a 61 years y.o. M with symptoms of daily lightheadednass and exartional

> SOB with an incidentally discovered 2.1cm left adrenal mass whom we saw in our

> Endocrinology Clinic at DHMC on 03/03/2009 for evaluation of the adrenal mass.

> We felt at the time the pt's symptoms were likely unrelated to this adrenal

> incidentaloma especially since he has had an extensive negative work-up in the past.

> However, since most of his previous testing results were not available to us, and

> the patient would like to be retested, we rechecked levels of:

> midnight salivary cortisol

> renin and aldosterone

> DHEA-S

> serum metanephrine and normetanephrine

> to rule this lesion out as a functioning adenoma.

> The results above show that there is no evidence that this adenoma is producing any

> excess adrenal hormones.

>

> Plan/Instructions:

> Pt was counselled and reassured that this likely represents a benign finding,

> especially since the lesion has been stable over time and an extensive work-up in

> the past has been negative as well. However, pt was asked to coordinate with his

> PCP if he develops any new signs/symptoms or change in his present signs/symptoms.

> Tharsan Sivakumar MD

> Endocrinology Fellow

> I am being supervised by TURCO MD,JOHN H Endocrinology

> Electronically signed by: SIVAKUMAR MD, THARSAN 03/13/ 2009 09:32

> + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

> MULTI-AUTHOR NOTE

> I agree with these recommendations.

> Jack Turco, M.D.

> Electronically signed by: TURCO MD, JOHN H 03/18/2009 17:01

>

> Reason for Consultation:

> symptoms of lightheadedness, SOB with incidentally discovered adrenal

> lesion

> Referred by:

> self

> BPI:

> Francis B. Bill is a 61 years y.o. M with PMH as below has had symptoms of all-day

> lightheadedness and exertional shortness of breath for 3 years, which had been

> worked up at the VA with CT, echo, Holter, and other studies which did not yield any

> etiology for these symptoms. Pt presented to the ER for these symptoms several

> times as well.

> CT scan of the chest performed in 2006 to evaluate for the SOB showed a well defined

> 7mm right lower lung lobe nodule. A left 2.1cm adrenal nodule was found as well

> with soft tissue attenuation likely representing an adenoma. According DHMC

> Emergency Medicine notes, these have been stable over time.

>

> PMSH:

> hypertension, and dyslipidemia.

> appendectomy, tonsil/adenoidectom y

>

> Medications:

> AMBULATORY MEDICATIONS· Last charted on· 03/03/2009

> DRUG DOSE/ROUTE FREQUENCY

> Aspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRN

> Oral

> Multivitamin Tablet 1 Tablet (s) / Oral Once daily

> Furosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once daily

> Oral

> Potassium Chloride 10 mEg 20 MEQ = 2 Capsule(s) / Once daily

> Capsule, Sustained Oral

> Release

> Atenolol 25 mg Tablet 25 MG = 1 Tablet (s) / Once daily

> Oral

> Triamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once daily

> Oral

>

> Allergies:

> ADR/ALLERGIES: Last charted on: 03/03/2009

> ADR/ALLERGY REACTION SEVERITY

> Sulfonamides

>

> Social. history:

> Very brief smoking history during teenage years

> Asbestos exposure 15 years in a boiler room

> Denies ETOH

> never married

> no children

>

> Famil.y Hx:

> Thyroid dysfunction: Mother, sister

> Thyroid cancer: No

> Diabetes mellitus: No

> Other auto-immune diseases: No

> Vitiligo: No

>

> Physical Exam

> Vitals:

> VITAL SIGNS (03/03/2009 @ 14·44)

> Heart Rate 96

> Systolic BP 156

> Diastolic BP 91

> Mean BP 112.67

> Weight (kg) 137.16

> Height (cm) 176.9

> Body Surface Area (m2 ) 2.6

> BMI (kg/m 2 ) 43.83

> Pain Scale 0

> Smoking

> Smoke History Remote

> General: NAD, morbidly obese

> HEENT: EOMI, anicteric, PERRL, moist mucous membranes, full visual fundi

> Neck: No LAD, no thyromegaly, no tenderness

> CV: Sl S2, RRR

> Lungs: CTAB

> Abd: soft, NT, obese

> Neuro: reflexes difficult to elicit

> Extremities: trace ankle edema

> Integumentary: Skin warm/dry/intact; no hyperpigmentation of hand creases or

> gumline/ rash

> 06/06

> K 4.0

> 08/06

> TSH 2.34

> cortisol 14:38 pm 12.0 ug/dL

> 03/2007

> VMA 6.4 (ref 2.0-10.0)

> Assessment and Plan:

> Mr. Bill is a 61 years y.o. M as above with symptoms of daily lightheadedness and

> exertional SOB with an incidentally discovered 2.1cm left adrenal mass.

> Pt's symptoms are likely unrelated to this adrenal incidentaloma especially since he

> has had an extensive negative work-up in the past. However, since most of these

> results are not available to us, and the patient would like to be retested, we will

> check levels of:

> midnight salivary cortisol

> renin and aldosterone

> DHEA-S

> serum metanephrine and normetanephrine

> to rule this lesion out as a functioning adenoma.

> Pt was counselled and reassured that this likely represents a benign finding,

> especially since the lesion has been stable over time. However, pt was asked to

> coordinate with his PCP if he develops any new signs/symptoms or change in his

> present signs/symptoms.

> We have reviewed our plan outlined above with the patient and Mr. Bill verbalized

> understanding. All questions were answered.

> Tharsan Sivakumar, MD

> Endocrinology Fellow

> I am being supervised by TURCO MD,JOHN H Endocrinology

> Electronically signed by: SIVAKUMAR MD, THARSAN 03/03/2009 15:58

>

> MULTI-AUTHOR NOTE

> I have interviewed and examined this patient along with Dr. Sivakumar and agree with

> this note and also these recommendations. The patient will be contacted with final

> recommendations when results of testing are complete.

> >50% of the 60 minute appointment was spent in face to face counseling the patient

> about the possible significance and evaluation of his adrenal abnormality.

> Jack Turco, M.D.

> Communication sent to: L. Durand 03/03/2009 17:28

> Electronically signed by: TURCO MD, JOHN H 03/03/2009 17:28

>

> DARTMOUTH-HITCHCOCK MEDICAL CENTER

> ENCOUNTER DATE: 08/06/ 2009

> OFFICE NOTES

> BILL,FRANCIS H

>

> Nephrology Clinic New Patient Visit

> Francis H. Bill

>

> August 6, 2009

> ID: 62 years old male seen at the request of Dr. Mogielnicki for? Conns Syndrome.

> Past Medical History:

> HTN diagnosed about 5 yrs ago

> Chronic Fatigue Syndrome

> Chronic dyspnea

> Chronic dizziness

> s/p appendectomy in Dec 2008

> Multiple granulomas in the Lungs

> Exophytic cyst Lt kidney

>

> History of Present Illness:

> Mr Bill presents today for a second opinion regarding whether he might have Conns

> Syndrome. In 2006, he underwent w/u for SOB. He had a CT scan of the chest which

> showed a 2.1 cm soft tisuue mass in the Lt adrenal gland. Subsequent tests showed

> that the adenoma was non secretory. He has since undergone several chest CT and the

> adrenal mass has not grown is size. In March 2009, he was seen by endocrinology at

> DHMC. He again underwent testing including cortisol, PRA, aldosterone, metanephrines

> etc, all of which were within normal limits. Patient was reassured that this likely

> represents an incidentaloma.

> Over the past 3-4 yrs, he has had chronic SOB and dizziness . He has undergone

> extensive testing for both including EKG, stress tests, echocardiograms, Holter

> montior, MRI brain (to r/o acoustic neuroma), sleep studies, PFTs etc all of which

> have not identified an abnormality.

> In Dec 2008, he presented with abd pain and was found to have appendicitis on CT

> scan. It also showed an exophytic mass in the L kidney for which he unerwent an

> ultrasound. He was told by his PCP that he needs f /u CT scan for the lesion. I do

> not have records relating to this issue today.

> He has normal renal fucnti on ( Cr from VA records has ranged from 0.8-1.1 in the

> past 3 yrs) .

> AMBULATORY MEDICATIONS· Last charted on· 08/06/2009

> DRUG DOSE/ROUTE FREQUENCY

> Aspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRN

> Oral

> Furosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once daily

> Oral

> Potassium Chloride 10 mEq 20 MEQ = 2 Capsule(s) / Once daily

> Capsule, Sustained Oral

> Release

> Atenolol 25 mg Tablet 25 MG = 1 Tablet(s) / Once daily

> Triamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once daily

> Oral

> Multivitamin Tablet 1 Tablet (s) / Oral

> ADR/ALLERGIES: Last charted on: 08/06/2009

> ADR/ALLERGY REACTION SEVERITY

> Sulfonamides

>

> Family History:

> No family h/o renal disease. He denies family h/o DM and CAD.

> Social History:

> Lives in Enfield NH. Vietnam war vet, now on disability 2 to chronic fatigue

> syndrme. Quit smoking 40 yrs ago, denies ETOH ot illicit drug use.

>

> Review of Systems:

> System Abnormalities

> Constitutional gained 40 Ibs over the past 3-4 yrs, + cheonic fatigue

> Eye denies visual changes

> ENT denies sorethroay, odynophagia

> CV denies CP, palp

> Resp + SOB, + DOE, denies cough, PND or orthopnea

> GI denies loss appetite, change in bowel habit

> GU denies hematuria, dysuria, voiding difficulties

> Skin denies rash, hype rp igment at ion

> Allergy

> Endocrine no h/o DM, denies exessive sweating, heat or cold intolerance

> Neurologic denies h/o seizures, headahces

> Musculoskeletal denies muscle aches, joint swelling

> Lymph

> Psych denies depression

> All other systems reviewed and negative.

>

> Physical Examination:

> VITAL SIGNS (08/06/2009 @ 13:28)

> Temperature © 36.61

> Route Oral

> Heart Rate 82

> Rhythm Regular

> Method Radial

> Systolic BP 149

> Diastolic BP 72

> Patient Position Sitting

> Extremity Left Arm

> Method NIBP

> Mean BP 97.67

> Weight (kg) 140.61

> Height (cm) 177.8

> Body Surface Area (m2 ) 2.64

> BMI (kg/m 2 ) 44.48

>

> General: elderly man, NAD, dishevelled

> Eye: no scleral icterus, EOM intact

> ENT: no pharyngeal erythema or thrush, poor dentition

> Neck: no JVD, no thyromegaly

> CV: sl s2 reg, no murmur

> Resp: CTAB

> Abd: + BS, NT/NO, obese

> Lymph: no cervical adenopathy

> Ext: no LE Edema

> Skin: no rash, hyperpigmentation

> Neuro: no focal motor deficit, sensations intact

> Psych: alert and oriented. affect appropriate

> Labs:

> LAB RESULTS: 00052074-2 03/04/2009

>

> CO RT MDNITE SAL-MAYO 19*

> (<:100-)

>

> DHEAS <30 L *

> (42-290)

>

> RENIN ACTIVITY-MAYO 0.8*

> (-)

>

> ALDOSTERONE- MAYO 5.5*

> (<=21-)

>

> NORMETANE FREE-MAYO 0.86*

> (<:0.90-)

>

> METANEPHR FREE-MAYO <0.20 *

> ( <:0.50-)

>

> Records from WRJVA reviewed and will be scanned into CIS.

> AlP:

> 62 M with chronic fatigue,

[Guest guest]

Much easier to say then to do. My doctor isn't one to believe what is on the

Internet. So if I told him there is Dr Grim on the group web site that

thinks I should try spiro I don't think I would get very far. Since the blood

work to him doesn't give him a reason to change any of my meds in his mind there

is no reason for change.

Now if he can read something in some medical journal relating to this then maybe

he would do it. This has to be something that he can read someplace other then

the Internet.

I don't know how many of you have copies of your recordes but it is something

you should read. At least for me I find that there are big differences in what

you say to your doctor and what is written in the record. Some times you will

see that you denied things that were never asked you.

With me I have some what looks like small adnormal test results. Maybe by

themselves don't mean much but put together could mean a lot. I should not have

to be the one looking for answers that should be my doctors job. Something it

seem a lot of doctors don't seem to do.

> > >

> > >

> > > From: georgewbill <georgewbill@>

> > > Subject: Re: How good is the screening tests

> > for Conn's?

> > > hyperaldosteronism

> > > Date: Tuesday, September 8, 2009, 8:50 PM

> > >

> > >

> > >

> > >

> > >

> > >

> > > This is from my Darmouth Medical

> > >

> > > LAB RESULTS: 00052074-2 03/04/2009

> > >

> > > CO RT MDNITE SAL-MAYO 19*

> > > (<:100-)

> > >

> > > DHEAS <30 L *

> > > (42-290)

> > >

> > > RENIN ACTIVITY-MAYO 0.8*

> > > (-)

> > >

> > > ALDOSTERONE- MAYO 5.5*

> > > (<=21-)

> > >

> > > NORMETANE FREE-MAYO 0.86*

> > > (<:0.90-)

> > >

> > > METANEPHR FREE-MAYO <0.20 *

> > > ( <:0.50-)

> > >

> > > Assessment:

> > >

> > > Mr. Bill is a 61 years y.o. M with symptoms of daily

> > lightheadednass and exartional

> > > SOB with an incidentally discovered 2.1cm left adrenal mass whom

> > we saw in our

> > > Endocrinology Clinic at DHMC on 03/03/2009 for evaluation of the

> > adrenal mass.

> > > We felt at the time the pt's symptoms were likely unrelated to

> > this adrenal

> > > incidentaloma especially since he has had an extensive negative

> > work-up in the past.

> > > However, since most of his previous testing results were not

> > available to us, and

> > > the patient would like to be retested, we rechecked levels of:

> > > midnight salivary cortisol

> > > renin and aldosterone

> > > DHEA-S

> > > serum metanephrine and normetanephrine

> > > to rule this lesion out as a functioning adenoma.

> > > The results above show that there is no evidence that this adenoma

> > is producing any

> > > excess adrenal hormones.

> > >

> > > Plan/Instructions:

> > > Pt was counselled and reassured that this likely represents a

> > benign finding,

> > > especially since the lesion has been stable over time and an

> > extensive work-up in

> > > the past has been negative as well. However, pt was asked to

> > coordinate with his

> > > PCP if he develops any new signs/symptoms or change in his present

> > signs/symptoms.

> > > Tharsan Sivakumar MD

> > > Endocrinology Fellow

> > > I am being supervised by TURCO MD,JOHN H Endocrinology

> > > Electronically signed by: SIVAKUMAR MD, THARSAN 03/13/ 2009 09:32

> > > + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

> > + + + + +

> > > MULTI-AUTHOR NOTE

> > > I agree with these recommendations.

> > > Jack Turco, M.D.

> > > Electronically signed by: TURCO MD, JOHN H 03/18/2009 17:01

> > >

> > > Reason for Consultation:

> > > symptoms of lightheadedness, SOB with incidentally discovered

> > adrenal

> > > lesion

> > > Referred by:

> > > self

> > > BPI:

> > > Francis B. Bill is a 61 years y.o. M with PMH as below has had

> > symptoms of all-day

> > > lightheadedness and exertional shortness of breath for 3 years,

> > which had been

> > > worked up at the VA with CT, echo, Holter, and other studies which

> > did not yield any

> > > etiology for these symptoms. Pt presented to the ER for these

> > symptoms several

> > > times as well.

> > > CT scan of the chest performed in 2006 to evaluate for the SOB

> > showed a well defined

> > > 7mm right lower lung lobe nodule. A left 2.1cm adrenal nodule was

> > found as well

> > > with soft tissue attenuation likely representing an adenoma.

> > According DHMC

> > > Emergency Medicine notes, these have been stable over time.

> > >

> > > PMSH:

> > > hypertension, and dyslipidemia.

> > > appendectomy, tonsil/adenoidectom y

> > >

> > > Medications:

> > > AMBULATORY MEDICATIONS· Last charted on· 03/03/2009

> > > DRUG DOSE/ROUTE FREQUENCY

> > > Aspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRN

> > > Oral

> > > Multivitamin Tablet 1 Tablet (s) / Oral Once daily

> > > Furosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once daily

> > > Oral

> > > Potassium Chloride 10 mEg 20 MEQ = 2 Capsule(s) / Once daily

> > > Capsule, Sustained Oral

> > > Release

> > > Atenolol 25 mg Tablet 25 MG = 1 Tablet (s) / Once daily

> > > Oral

> > > Triamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once daily

> > > Oral

> > >

> > > Allergies:

> > > ADR/ALLERGIES: Last charted on: 03/03/2009

> > > ADR/ALLERGY REACTION SEVERITY

> > > Sulfonamides

> > >

> > > Social. history:

> > > Very brief smoking history during teenage years

> > > Asbestos exposure 15 years in a boiler room

> > > Denies ETOH

> > > never married

> > > no children

> > >

> > > Famil.y Hx:

> > > Thyroid dysfunction: Mother, sister

> > > Thyroid cancer: No

> > > Diabetes mellitus: No

> > > Other auto-immune diseases: No

> > > Vitiligo: No

> > >

> > > Physical Exam

> > > Vitals:

> > > VITAL SIGNS (03/03/2009 @ 14·44)

> > > Heart Rate 96

> > > Systolic BP 156

> > > Diastolic BP 91

> > > Mean BP 112.67

> > > Weight (kg) 137.16

> > > Height (cm) 176.9

> > > Body Surface Area (m2 ) 2.6

> > > BMI (kg/m 2 ) 43.83

> > > Pain Scale 0

> > > Smoking

> > > Smoke History Remote

> > > General: NAD, morbidly obese

> > > HEENT: EOMI, anicteric, PERRL, moist mucous membranes, full visual

> > fundi

> > > Neck: No LAD, no thyromegaly, no tenderness

> > > CV: Sl S2, RRR

> > > Lungs: CTAB

> > > Abd: soft, NT, obese

> > > Neuro: reflexes difficult to elicit

> > > Extremities: trace ankle edema

> > > Integumentary: Skin warm/dry/intact; no hyperpigmentation of hand

> > creases or

> > > gumline/ rash

> > > 06/06

> > > K 4.0

> > > 08/06

> > > TSH 2.34

> > > cortisol 14:38 pm 12.0 ug/dL

> > > 03/2007

> > > VMA 6.4 (ref 2.0-10.0)

> > > Assessment and Plan:

> > > Mr. Bill is a 61 years y.o. M as above with symptoms of daily

> > lightheadedness and

> > > exertional SOB with an incidentally discovered 2.1cm left adrenal

> > mass.

> > > Pt's symptoms are likely unrelated to this adrenal incidentaloma

> > especially since he

> > > has had an extensive negative work-up in the past. However, since

> > most of these

> > > results are not available to us, and the patient would like to be

> > retested, we will

> > > check levels of:

> > > midnight salivary cortisol

> > > renin and aldosterone

> > > DHEA-S

> > > serum metanephrine and normetanephrine

> > > to rule this lesion out as a functioning adenoma.

> > > Pt was counselled and reassured that this likely represents a

> > benign finding,

> > > especially since the lesion has been stable over time. However, pt

> > was asked to

> > > coordinate with his PCP if he develops any new signs/symptoms or

> > change in his

> > > present signs/symptoms.

> > > We have reviewed our plan outlined above with the patient and Mr.

> > Bill verbalized

> > > understanding. All questions were answered.

> > > Tharsan Sivakumar, MD

> > > Endocrinology Fellow

> > > I am being supervised by TURCO MD,JOHN H Endocrinology

> > > Electronically signed by: SIVAKUMAR MD, THARSAN 03/03/2009 15:58

> > >

> > > MULTI-AUTHOR NOTE

> > > I have interviewed and examined this patient along with Dr.

> > Sivakumar and agree with

> > > this note and also these recommendations. The patient will be

> > contacted with final

> > > recommendations when results of testing are complete.

> > > >50% of the 60 minute appointment was spent in face to face

> > counseling the patient

> > > about the possible significance and evaluation of his adrenal

> > abnormality.

> > > Jack Turco, M.D.

> > > Communication sent to: L. Durand 03/03/2009 17:28

> > > Electronically signed by: TURCO MD, JOHN H 03/03/2009 17:28

> > >

> > > DARTMOUTH-HITCHCOCK MEDICAL CENTER

> > > ENCOUNTER DATE: 08/06/ 2009

> > > OFFICE NOTES

> > > BILL,FRANCIS H

> > >

> > > Nephrology Clinic New Patient Visit

> > > Francis H. Bill

> > >

> > > August 6, 2009

> > > ID: 62 years old male seen at the request of Dr. Mogielnicki for?

> > Conns Syndrome.

> > > Past Medical History:

> > > HTN diagnosed about 5 yrs ago

> > > Chronic Fatigue Syndrome

> > > Chronic dyspnea

> > > Chronic dizziness

> > > s/p appendectomy in Dec 2008

> > > Multiple granulomas in the Lungs

> > > Exophytic cyst Lt kidney

> > >

> > > History of Present Illness:

> > > Mr Bill presents today for a second opinion regarding whether he

> > might have Conns

> > > Syndrome. In 2006, he underwent w/u for SOB. He had a CT scan of

> > the chest which

> > > showed a 2.1 cm soft tisuue mass in the Lt adrenal gland.

> > Subsequent tests showed

> > > that the adenoma was non secretory. He has since undergone several

> > chest CT and the

> > > adrenal mass has not grown is size. In March 2009, he was seen by

> > endocrinology at

> > > DHMC. He again underwent testing including cortisol, PRA,

> > aldosterone, metanephrines

> > > etc, all of which were within normal limits. Patient was reassured

> > that this likely

> > > represents an incidentaloma.

> > > Over the past 3-4 yrs, he has had chronic SOB and dizziness . He

> > has undergone

> > > extensive testing for both including EKG, stress tests,

> > echocardiograms, Holter

> > > montior, MRI brain (to r/o acoustic neuroma), sleep studies, PFTs

> > etc all of which

> > > have not identified an abnormality.

> > > In Dec 2008, he presented with abd pain and was found to have

> > appendicitis on CT

> > > scan. It also showed an exophytic mass in the L kidney for which

> > he unerwent an

> > > ultrasound. He was told by his PCP that he needs f /u CT scan for

> > the lesion. I do

> > > not have records relating to this issue today.

> > > He has normal renal fucnti on ( Cr from VA records has ranged from

> > 0.8-1.1 in the

> > > past 3 yrs) .

> > > AMBULATORY MEDICATIONS· Last charted on· 08/06/2009

> > > DRUG DOSE/ROUTE FREQUENCY

> > > Aspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRN

> > > Oral

> > > Furosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once daily

> > > Oral

> > > Potassium Chloride 10 mEq 20 MEQ = 2 Capsule(s) / Once daily

> > > Capsule, Sustained Oral

> > > Release

> > > Atenolol 25 mg Tablet 25 MG = 1 Tablet(s) / Once daily

> > > Triamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once daily

> > > Oral

> > > Multivitamin Tablet 1 Tablet (s) / Oral

> > > ADR/ALLERGIES: Last charted on: 08/06/2009

> > > ADR/ALLERGY REACTION SEVERITY

> > > Sulfonamides

> > >

> > > Family History:

> > > No family h/o renal disease. He denies family h/o DM and CAD.

> > > Social History:

> > > Lives in Enfield NH. Vietnam war vet, now on disability 2 to

> > chronic fatigue

> > > syndrme. Quit smoking 40 yrs ago, denies ETOH ot illicit drug use.

> > >

> > > Review of Systems:

> > > System Abnormalities

> > > Constitutional gained 40 Ibs over the past 3-4 yrs, + cheonic

> > fatigue

> > > Eye denies visual changes

> > > ENT denies sorethroay, odynophagia

> > > CV denies CP, palp

> > > Resp + SOB, + DOE, denies cough, PND or orthopnea

> > > GI denies loss appetite, change in bowel habit

> > > GU denies hematuria, dysuria, voiding difficulties

> > > Skin denies rash, hype rp igment at ion

> > > Allergy

> > > Endocrine no h/o DM, denies exessive sweating, heat or cold

> > intolerance

> > > Neurologic denies h/o seizures, headahces

> > > Musculoskeletal denies muscle aches, joint swelling

> > > Lymph

> > > Psych denies depression

> > > All other systems reviewed and negative.

> > >

> > > Physical Examination:

> > > VITAL SIGNS (08/06/2009 @ 13:28)

> > > Temperature © 36.61

> > > Route Oral

> > > Heart Rate 82

> > > Rhythm Regular

> > > Method Radial

> > > Systolic BP 149

> > > Diastolic BP 72

> > > Patient Position Sitting

> > > Extremity Left Arm

> > > Method NIBP

> > > Mean BP 97.67

> > > Weight (kg) 140.61

> > > Height (cm) 177.8

> > > Body Surface Area (m2 ) 2.64

> > > BMI (kg/m 2 ) 44.48

> > >

> > > General: elderly man, NAD, dishevelled

> > > Eye: no scleral icterus, EOM intact

> > > ENT: no pharyngeal erythema or thrush, poor dentition

> > > Neck: no JVD, no thyromegaly

> > > CV: sl s2 reg, no murmur

> > > Resp: CTAB

> > > Abd: + BS, NT/NO, obese

> > > Lymph: no cervical adenopathy

> > > Ext: no LE Edema

> > > Skin: no rash, hyperpigmentation

> > > Neuro: no focal motor deficit, sensations intact

> > > Psych: alert and oriented. affect appropriate

> > > Labs:

> > > LAB RESULTS: 00052074-2 03/04/2009

> > >

> > > CO RT MDNITE SAL-MAYO 19*

> > > (<:100-)

> > >

> > > DHEAS <30 L *

> > > (42-290)

> > >

> > > RENIN ACTIVITY-MAYO 0.8*

> > > (-)

> > >

> > > ALDOSTERONE- MAYO 5.5*

> > > (<=21-)

> > >

> > > NORMETANE FREE-MAYO 0.86*

> > > (<:0.90-)

> > >

> > > METANEPHR FREE-MAYO <0.20 *

> > > ( <:0.50-)

> > >

> > > Records from WRJVA reviewed and will be scanned into CIS.

> > > AlP:

> > > 62 M with chronic fatigue,

>

[Guest guest]

, At the risk of losing my bedside manner award, I'll tell you like it is.

I'm not a DR but if I was, I wouldn't prescribe meds for hyperaldo, because you do not have the data to indicate that.

My renin is low, 0.2, and aldo 10 in range, and I do NOT have hyper aldo.

I have LREH.

You're problem, according to your data is you are too FAT, as in BMI 44. That makes you tired and sore.

Get the "Rice Diet Solutions" book.

Regards

Re: How good is the screening tests > > for Conn's?> > > hyperaldosteronism > > > Date: Tuesday, September 8, 2009, 8:50 PM> > >> > >> > >> > >> > >> > >> > > This is from my Darmouth Medical> > >> > > LAB RESULTS: 00052074-2 03/04/2009> > >> > > CO RT MDNITE SAL-MAYO 19*> > > (<:100-)> > >> > > DHEAS <30 L *> > > (42-290)> > >> > > RENIN ACTIVITY-MAYO 0.8*> > > (-)> > >> > > ALDOSTERONE- MAYO 5.5*> > > (<=21-)> > >> > > NORMETANE FREE-MAYO 0.86*> > > (<:0.90-)> > >> > > METANEPHR FREE-MAYO <0.20 *> > > ( <:0.50-)> > >> > > Assessment:> > >> > > Mr. Bill is a 61 years y.o. M with symptoms of daily > > lightheadednass and exartional> > > SOB with an incidentally discovered 2.1cm left adrenal mass whom > > we saw in our> > > Endocrinology Clinic at DHMC on 03/03/2009 for evaluation of the > > adrenal mass.> > > We felt at the time the pt's symptoms were likely unrelated to > > this adrenal> > > incidentaloma especially since he has had an extensive negative > > work-up in the past.> > > However, since most of his previous testing results were not > > available to us, and> > > the patient would like to be retested, we rechecked levels of:> > > midnight salivary cortisol> > > renin and aldosterone> > > DHEA-S> > > serum metanephrine and normetanephrine> > > to rule this lesion out as a functioning adenoma.> > > The results above show that there is no evidence that this adenoma > > is producing any> > > excess adrenal hormones.> > >> > > Plan/Instructions:> > > Pt was counselled and reassured that this likely represents a > > benign finding,> > > especially since the lesion has been stable over time and an > > extensive work-up in> > > the past has been negative as well. However, pt was asked to > > coordinate with his> > > PCP if he develops any new signs/symptoms or change in his present > > signs/symptoms.> > > Tharsan Sivakumar MD> > > Endocrinology Fellow> > > I am being supervised by TURCO MD,JOHN H Endocrinology> > > Electronically signed by: SIVAKUMAR MD, THARSAN 03/13/ 2009 09:32> > > + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + > > + + + + +> > > MULTI-AUTHOR NOTE> > > I agree with these recommendations.> > > Jack Turco, M.D.> > > Electronically signed by: TURCO MD, JOHN H 03/18/2009 17:01> > >> > > Reason for Consultation:> > > symptoms of lightheadedness, SOB with incidentally discovered > > adrenal> > > lesion> > > Referred by:> > > self> > > BPI:> > > Francis B. Bill is a 61 years y.o. M with PMH as below has had > > symptoms of all-day> > > lightheadedness and exertional shortness of breath for 3 years, > > which had been> > > worked up at the VA with CT, echo, Holter, and other studies which > > did not yield any> > > etiology for these symptoms. Pt presented to the ER for these > > symptoms several> > > times as well.> > > CT scan of the chest performed in 2006 to evaluate for the SOB > > showed a well defined> > > 7mm right lower lung lobe nodule. A left 2.1cm adrenal nodule was > > found as well> > > with soft tissue attenuation likely representing an adenoma. > > According DHMC> > > Emergency Medicine notes, these have been stable over time.> > >> > > PMSH:> > > hypertension, and dyslipidemia.> > > appendectomy, tonsil/adenoidectom y> > >> > > Medications:> > > AMBULATORY MEDICATIONS· Last charted on· 03/03/2009> > > DRUG DOSE/ROUTE FREQUENCY> > > Aspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRN> > > Oral> > > Multivitamin Tablet 1 Tablet (s) / Oral Once daily> > > Furosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once daily> > > Oral> > > Potassium Chloride 10 mEg 20 MEQ = 2 Capsule(s) / Once daily> > > Capsule, Sustained Oral> > > Release> > > Atenolol 25 mg Tablet 25 MG = 1 Tablet (s) / Once daily> > > Oral> > > Triamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once daily> > > Oral> > >> > > Allergies:> > > ADR/ALLERGIES: Last charted on: 03/03/2009> > > ADR/ALLERGY REACTION SEVERITY> > > Sulfonamides> > >> > > Social. history:> > > Very brief smoking history during teenage years> > > Asbestos exposure 15 years in a boiler room> > > Denies ETOH> > > never married> > > no children> > >> > > Famil.y Hx:> > > Thyroid dysfunction: Mother, sister> > > Thyroid cancer: No> > > Diabetes mellitus: No> > > Other auto-immune diseases: No> > > Vitiligo: No> > >> > > Physical Exam> > > Vitals:> > > VITAL SIGNS (03/03/2009 @ 14·44)> > > Heart Rate 96> > > Systolic BP 156> > > Diastolic BP 91> > > Mean BP 112.67> > > Weight (kg) 137.16> > > Height (cm) 176.9> > > Body Surface Area (m2 ) 2.6> > > BMI (kg/m 2 ) 43.83> > > Pain Scale 0> > > Smoking> > > Smoke History Remote> > > General: NAD, morbidly obese> > > HEENT: EOMI, anicteric, PERRL, moist mucous membranes, full visual > > fundi> > > Neck: No LAD, no thyromegaly, no tenderness> > > CV: Sl S2, RRR> > > Lungs: CTAB> > > Abd: soft, NT, obese> > > Neuro: reflexes difficult to elicit> > > Extremities: trace ankle edema> > > Integumentary: Skin warm/dry/intact; no hyperpigmentation of hand > > creases or> > > gumline/ rash> > > 06/06> > > K 4.0> > > 08/06> > > TSH 2.34> > > cortisol 14:38 pm 12.0 ug/dL> > > 03/2007> > > VMA 6.4 (ref 2.0-10.0)> > > Assessment and Plan:> > > Mr. Bill is a 61 years y.o. M as above with symptoms of daily > > lightheadedness and> > > exertional SOB with an incidentally discovered 2.1cm left adrenal > > mass.> > > Pt's symptoms are likely unrelated to this adrenal incidentaloma > > especially since he> > > has had an extensive negative work-up in the past. However, since > > most of these> > > results are not available to us, and the patient would like to be > > retested, we will> > > check levels of:> > > midnight salivary cortisol> > > renin and aldosterone> > > DHEA-S> > > serum metanephrine and normetanephrine> > > to rule this lesion out as a functioning adenoma.> > > Pt was counselled and reassured that this likely represents a > > benign finding,> > > especially since the lesion has been stable over time. However, pt > > was asked to> > > coordinate with his PCP if he develops any new signs/symptoms or > > change in his> > > present signs/symptoms.> > > We have reviewed our plan outlined above with the patient and Mr. > > Bill verbalized> > > understanding. All questions were answered.> > > Tharsan Sivakumar, MD> > > Endocrinology Fellow> > > I am being supervised by TURCO MD,JOHN H Endocrinology> > > Electronically signed by: SIVAKUMAR MD, THARSAN 03/03/2009 15:58> > >> > > MULTI-AUTHOR NOTE> > > I have interviewed and examined this patient along with Dr. > > Sivakumar and agree with> > > this note and also these recommendations. The patient will be > > contacted with final> > > recommendations when results of testing are complete.> > > >50% of the 60 minute appointment was spent in face to face > > counseling the patient> > > about the possible significance and evaluation of his adrenal > > abnormality.> > > Jack Turco, M.D.> > > Communication sent to: L. Durand 03/03/2009 17:28> > > Electronically signed by: TURCO MD, JOHN H 03/03/2009 17:28> > >> > > DARTMOUTH-HITCHCOCK MEDICAL CENTER> > > ENCOUNTER DATE: 08/06/ 2009> > > OFFICE NOTES> > > BILL,FRANCIS H> > >> > > Nephrology Clinic New Patient Visit> > > Francis H. Bill> > >> > > August 6, 2009> > > ID: 62 years old male seen at the request of Dr. Mogielnicki for? > > Conns Syndrome.> > > Past Medical History:> > > HTN diagnosed about 5 yrs ago> > > Chronic Fatigue Syndrome> > > Chronic dyspnea> > > Chronic dizziness> > > s/p appendectomy in Dec 2008> > > Multiple granulomas in the Lungs> > > Exophytic cyst Lt kidney> > >> > > History of Present Illness:> > > Mr Bill presents today for a second opinion regarding whether he > > might have Conns> > > Syndrome. In 2006, he underwent w/u for SOB. He had a CT scan of > > the chest which> > > showed a 2.1 cm soft tisuue mass in the Lt adrenal gland. > > Subsequent tests showed> > > that the adenoma was non secretory. He has since undergone several > > chest CT and the> > > adrenal mass has not grown is size. In March 2009, he was seen by > > endocrinology at> > > DHMC. He again underwent testing including cortisol, PRA, > > aldosterone, metanephrines> > > etc, all of which were within normal limits. Patient was reassured > > that this likely> > > represents an incidentaloma.> > > Over the past 3-4 yrs, he has had chronic SOB and dizziness . He > > has undergone> > > extensive testing for both including EKG, stress tests, > > echocardiograms, Holter> > > montior, MRI brain (to r/o acoustic neuroma), sleep studies, PFTs > > etc all of which> > > have not identified an abnormality.> > > In Dec 2008, he presented with abd pain and was found to have > > appendicitis on CT> > > scan. It also showed an exophytic mass in the L kidney for which > > he unerwent an> > > ultrasound. He was told by his PCP that he needs f /u CT scan for > > the lesion. I do> > > not have records relating to this issue today.> > > He has normal renal fucnti on ( Cr from VA records has ranged from > > 0.8-1.1 in the> > > past 3 yrs) .> > > AMBULATORY MEDICATIONS· Last charted on· 08/06/2009> > > DRUG DOSE/ROUTE FREQUENCY> > > Aspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRN> > > Oral> > > Furosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once daily> > > Oral> > > Potassium Chloride 10 mEq 20 MEQ = 2 Capsule(s) / Once daily> > > Capsule, Sustained Oral> > > Release> > > Atenolol 25 mg Tablet 25 MG = 1 Tablet(s) / Once daily> > > Triamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once daily> > > Oral> > > Multivitamin Tablet 1 Tablet (s) / Oral> > > ADR/ALLERGIES: Last charted on: 08/06/2009> > > ADR/ALLERGY REACTION SEVERITY> > > Sulfonamides> > >> > > Family History:> > > No family h/o renal disease. He denies family h/o DM and CAD.> > > Social History:> > > Lives in Enfield NH. Vietnam war vet, now on disability 2 to > > chronic fatigue> > > syndrme. Quit smoking 40 yrs ago, denies ETOH ot illicit drug use.> > >> > > Review of Systems:> > > System Abnormalities> > > Constitutional gained 40 Ibs over the past 3-4 yrs, + cheonic > > fatigue> > > Eye denies visual changes> > > ENT denies sorethroay, odynophagia> > > CV denies CP, palp> > > Resp + SOB, + DOE, denies cough, PND or orthopnea> > > GI denies loss appetite, change in bowel habit> > > GU denies hematuria, dysuria, voiding difficulties> > > Skin denies rash, hype rp igment at ion> > > Allergy> > > Endocrine no h/o DM, denies exessive sweating, heat or cold > > intolerance> > > Neurologic denies h/o seizures, headahces> > > Musculoskeletal denies muscle aches, joint swelling> > > Lymph> > > Psych denies depression> > > All other systems reviewed and negative.> > >> > > Physical Examination:> > > VITAL SIGNS (08/06/2009 @ 13:28)> > > Temperature © 36.61> > > Route Oral> > > Heart Rate 82> > > Rhythm Regular> > > Method Radial> > > Systolic BP 149> > > Diastolic BP 72> > > Patient Position Sitting> > > Extremity Left Arm> > > Method NIBP> > > Mean BP 97.67> > > Weight (kg) 140.61> > > Height (cm) 177.8> > > Body Surface Area (m2 ) 2.64> > > BMI (kg/m 2 ) 44.48> > >> > > General: elderly man, NAD, dishevelled> > > Eye: no scleral icterus, EOM intact> > > ENT: no pharyngeal erythema or thrush, poor dentition> > > Neck: no JVD, no thyromegaly> > > CV: sl s2 reg, no murmur> > > Resp: CTAB> > > Abd: + BS, NT/NO, obese> > > Lymph: no cervical adenopathy> > > Ext: no LE Edema> > > Skin: no rash, hyperpigmentation> > > Neuro: no focal motor deficit, sensations intact> > > Psych: alert and oriented. affect appropriate> > > Labs:> > > LAB RESULTS: 00052074-2 03/04/2009> > >> > > CO RT MDNITE SAL-MAYO 19*> > > (<:100-)> > >> > > DHEAS <30 L *> > > (42-290)> > >> > > RENIN ACTIVITY-MAYO 0.8*> > > (-)> > >> > > ALDOSTERONE- MAYO 5.5*> > > (<=21-)> > >> > > NORMETANE FREE-MAYO 0.86*> > > (<:0.90-)> > >> > > METANEPHR FREE-MAYO <0.20 *> > > ( <:0.50-)> > >> > > Records from WRJVA reviewed and will be scanned into CIS.> > > AlP:> > > 62 M with chronic fatigue,>__________ NOD32 4389 (20090902) Information __________This message was checked by NOD32 antivirus system.http://www.eset.com

[Guest guest]

jwwright Are you saying you know more ther Dr Grim dose about Conn's He is the

one that is saying I should try meds for hyperaldo. He has said this more then

once based on what I have in this and other postings.

> > > >

> > > >

> > > > From: georgewbill <georgewbill@>

> > > > Subject: Re: How good is the screening tests

> > > for Conn's?

> > > > hyperaldosteronism

> > > > Date: Tuesday, September 8, 2009, 8:50 PM

> > > >

> > > >

> > > >

> > > >

> > > >

> > > >

> > > > This is from my Darmouth Medical

> > > >

> > > > LAB RESULTS: 00052074-2 03/04/2009

> > > >

> > > > CO RT MDNITE SAL-MAYO 19*

> > > > (<:100-)

> > > >

> > > > DHEAS <30 L *

> > > > (42-290)

> > > >

> > > > RENIN ACTIVITY-MAYO 0.8*

> > > > (-)

> > > >

> > > > ALDOSTERONE- MAYO 5.5*

> > > > (<=21-)

> > > >

> > > > NORMETANE FREE-MAYO 0.86*

> > > > (<:0.90-)

> > > >

> > > > METANEPHR FREE-MAYO <0.20 *

> > > > ( <:0.50-)

> > > >

> > > > Assessment:

> > > >

> > > > Mr. Bill is a 61 years y.o. M with symptoms of daily

> > > lightheadednass and exartional

> > > > SOB with an incidentally discovered 2.1cm left adrenal mass whom

> > > we saw in our

> > > > Endocrinology Clinic at DHMC on 03/03/2009 for evaluation of the

> > > adrenal mass.

> > > > We felt at the time the pt's symptoms were likely unrelated to

> > > this adrenal

> > > > incidentaloma especially since he has had an extensive negative

> > > work-up in the past.

> > > > However, since most of his previous testing results were not

> > > available to us, and

> > > > the patient would like to be retested, we rechecked levels of:

> > > > midnight salivary cortisol

> > > > renin and aldosterone

> > > > DHEA-S

> > > > serum metanephrine and normetanephrine

> > > > to rule this lesion out as a functioning adenoma.

> > > > The results above show that there is no evidence that this adenoma

> > > is producing any

> > > > excess adrenal hormones.

> > > >

> > > > Plan/Instructions:

> > > > Pt was counselled and reassured that this likely represents a

> > > benign finding,

> > > > especially since the lesion has been stable over time and an

> > > extensive work-up in

> > > > the past has been negative as well. However, pt was asked to

> > > coordinate with his

> > > > PCP if he develops any new signs/symptoms or change in his present

> > > signs/symptoms.

> > > > Tharsan Sivakumar MD

> > > > Endocrinology Fellow

> > > > I am being supervised by TURCO MD,JOHN H Endocrinology

> > > > Electronically signed by: SIVAKUMAR MD, THARSAN 03/13/ 2009 09:32

> > > > + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

> > > + + + + +

> > > > MULTI-AUTHOR NOTE

> > > > I agree with these recommendations.

> > > > Jack Turco, M.D.

> > > > Electronically signed by: TURCO MD, JOHN H 03/18/2009 17:01

> > > >

> > > > Reason for Consultation:

> > > > symptoms of lightheadedness, SOB with incidentally discovered

> > > adrenal

> > > > lesion

> > > > Referred by:

> > > > self

> > > > BPI:

> > > > Francis B. Bill is a 61 years y.o. M with PMH as below has had

> > > symptoms of all-day

> > > > lightheadedness and exertional shortness of breath for 3 years,

> > > which had been

> > > > worked up at the VA with CT, echo, Holter, and other studies which

> > > did not yield any

> > > > etiology for these symptoms. Pt presented to the ER for these

> > > symptoms several

> > > > times as well.

> > > > CT scan of the chest performed in 2006 to evaluate for the SOB

> > > showed a well defined

> > > > 7mm right lower lung lobe nodule. A left 2.1cm adrenal nodule was

> > > found as well

> > > > with soft tissue attenuation likely representing an adenoma.

> > > According DHMC

> > > > Emergency Medicine notes, these have been stable over time.

> > > >

> > > > PMSH:

> > > > hypertension, and dyslipidemia.

> > > > appendectomy, tonsil/adenoidectom y

> > > >

> > > > Medications:

> > > > AMBULATORY MEDICATIONS· Last charted on· 03/03/2009

> > > > DRUG DOSE/ROUTE FREQUENCY

> > > > Aspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRN

> > > > Oral

> > > > Multivitamin Tablet 1 Tablet (s) / Oral Once daily

> > > > Furosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once daily

> > > > Oral

> > > > Potassium Chloride 10 mEg 20 MEQ = 2 Capsule(s) / Once daily

> > > > Capsule, Sustained Oral

> > > > Release

> > > > Atenolol 25 mg Tablet 25 MG = 1 Tablet (s) / Once daily

> > > > Oral

> > > > Triamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once daily

> > > > Oral

> > > >

> > > > Allergies:

> > > > ADR/ALLERGIES: Last charted on: 03/03/2009

> > > > ADR/ALLERGY REACTION SEVERITY

> > > > Sulfonamides

> > > >

> > > > Social. history:

> > > > Very brief smoking history during teenage years

> > > > Asbestos exposure 15 years in a boiler room

> > > > Denies ETOH

> > > > never married

> > > > no children

> > > >

> > > > Famil.y Hx:

> > > > Thyroid dysfunction: Mother, sister

> > > > Thyroid cancer: No

> > > > Diabetes mellitus: No

> > > > Other auto-immune diseases: No

> > > > Vitiligo: No

> > > >

> > > > Physical Exam

> > > > Vitals:

> > > > VITAL SIGNS (03/03/2009 @ 14·44)

> > > > Heart Rate 96

> > > > Systolic BP 156

> > > > Diastolic BP 91

> > > > Mean BP 112.67

> > > > Weight (kg) 137.16

> > > > Height (cm) 176.9

> > > > Body Surface Area (m2 ) 2.6

> > > > BMI (kg/m 2 ) 43.83

> > > > Pain Scale 0

> > > > Smoking

> > > > Smoke History Remote

> > > > General: NAD, morbidly obese

> > > > HEENT: EOMI, anicteric, PERRL, moist mucous membranes, full visual

> > > fundi

> > > > Neck: No LAD, no thyromegaly, no tenderness

> > > > CV: Sl S2, RRR

> > > > Lungs: CTAB

> > > > Abd: soft, NT, obese

> > > > Neuro: reflexes difficult to elicit

> > > > Extremities: trace ankle edema

> > > > Integumentary: Skin warm/dry/intact; no hyperpigmentation of hand

> > > creases or

> > > > gumline/ rash

> > > > 06/06

> > > > K 4.0

> > > > 08/06

> > > > TSH 2.34

> > > > cortisol 14:38 pm 12.0 ug/dL

> > > > 03/2007

> > > > VMA 6.4 (ref 2.0-10.0)

> > > > Assessment and Plan:

> > > > Mr. Bill is a 61 years y.o. M as above with symptoms of daily

> > > lightheadedness and

> > > > exertional SOB with an incidentally discovered 2.1cm left adrenal

> > > mass.

> > > > Pt's symptoms are likely unrelated to this adrenal incidentaloma

> > > especially since he

> > > > has had an extensive negative work-up in the past. However, since

> > > most of these

> > > > results are not available to us, and the patient would like to be

> > > retested, we will

> > > > check levels of:

> > > > midnight salivary cortisol

> > > > renin and aldosterone

> > > > DHEA-S

> > > > serum metanephrine and normetanephrine

> > > > to rule this lesion out as a functioning adenoma.

> > > > Pt was counselled and reassured that this likely represents a

> > > benign finding,

> > > > especially since the lesion has been stable over time. However, pt

> > > was asked to

> > > > coordinate with his PCP if he develops any new signs/symptoms or

> > > change in his

> > > > present signs/symptoms.

> > > > We have reviewed our plan outlined above with the patient and Mr.

> > > Bill verbalized

> > > > understanding. All questions were answered.

> > > > Tharsan Sivakumar, MD

> > > > Endocrinology Fellow

> > > > I am being supervised by TURCO MD,JOHN H Endocrinology

> > > > Electronically signed by: SIVAKUMAR MD, THARSAN 03/03/2009 15:58

> > > >

> > > > MULTI-AUTHOR NOTE

> > > > I have interviewed and examined this patient along with Dr.

> > > Sivakumar and agree with

> > > > this note and also these recommendations. The patient will be

> > > contacted with final

> > > > recommendations when results of testing are complete.

> > > > >50% of the 60 minute appointment was spent in face to face

> > > counseling the patient

> > > > about the possible significance and evaluation of his adrenal

> > > abnormality.

> > > > Jack Turco, M.D.

> > > > Communication sent to: L. Durand 03/03/2009 17:28

> > > > Electronically signed by: TURCO MD, JOHN H 03/03/2009 17:28

> > > >

> > > > DARTMOUTH-HITCHCOCK MEDICAL CENTER

> > > > ENCOUNTER DATE: 08/06/ 2009

> > > > OFFICE NOTES

> > > > BILL,FRANCIS H

> > > >

> > > > Nephrology Clinic New Patient Visit

> > > > Francis H. Bill

> > > >

> > > > August 6, 2009

> > > > ID: 62 years old male seen at the request of Dr. Mogielnicki for?

> > > Conns Syndrome.

> > > > Past Medical History:

> > > > HTN diagnosed about 5 yrs ago

> > > > Chronic Fatigue Syndrome

> > > > Chronic dyspnea

> > > > Chronic dizziness

> > > > s/p appendectomy in Dec 2008

> > > > Multiple granulomas in the Lungs

> > > > Exophytic cyst Lt kidney

> > > >

> > > > History of Present Illness:

> > > > Mr Bill presents today for a second opinion regarding whether he

> > > might have Conns

> > > > Syndrome. In 2006, he underwent w/u for SOB. He had a CT scan of

> > > the chest which

> > > > showed a 2.1 cm soft tisuue mass in the Lt adrenal gland.

> > > Subsequent tests showed

> > > > that the adenoma was non secretory. He has since undergone several

> > > chest CT and the

> > > > adrenal mass has not grown is size. In March 2009, he was seen by

> > > endocrinology at

> > > > DHMC. He again underwent testing including cortisol, PRA,

> > > aldosterone, metanephrines

> > > > etc, all of which were within normal limits. Patient was reassured

> > > that this likely

> > > > represents an incidentaloma.

> > > > Over the past 3-4 yrs, he has had chronic SOB and dizziness . He

> > > has undergone

> > > > extensive testing for both including EKG, stress tests,

> > > echocardiograms, Holter

> > > > montior, MRI brain (to r/o acoustic neuroma), sleep studies, PFTs

> > > etc all of which

> > > > have not identified an abnormality.

> > > > In Dec 2008, he presented with abd pain and was found to have

> > > appendicitis on CT

> > > > scan. It also showed an exophytic mass in the L kidney for which

> > > he unerwent an

> > > > ultrasound. He was told by his PCP that he needs f /u CT scan for

> > > the lesion. I do

> > > > not have records relating to this issue today.

> > > > He has normal renal fucnti on ( Cr from VA records has ranged from

> > > 0.8-1.1 in the

> > > > past 3 yrs) .

> > > > AMBULATORY MEDICATIONS· Last charted on· 08/06/2009

> > > > DRUG DOSE/ROUTE FREQUENCY

> > > > Aspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRN

> > > > Oral

> > > > Furosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once daily

> > > > Oral

> > > > Potassium Chloride 10 mEq 20 MEQ = 2 Capsule(s) / Once daily

> > > > Capsule, Sustained Oral

> > > > Release

> > > > Atenolol 25 mg Tablet 25 MG = 1 Tablet(s) / Once daily

> > > > Triamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once daily

> > > > Oral

> > > > Multivitamin Tablet 1 Tablet (s) / Oral

> > > > ADR/ALLERGIES: Last charted on: 08/06/2009

> > > > ADR/ALLERGY REACTION SEVERITY

> > > > Sulfonamides

> > > >

> > > > Family History:

> > > > No family h/o renal disease. He denies family h/o DM and CAD.

> > > > Social History:

> > > > Lives in Enfield NH. Vietnam war vet, now on disability 2 to

> > > chronic fatigue

> > > > syndrme. Quit smoking 40 yrs ago, denies ETOH ot illicit drug use.

> > > >

> > > > Review of Systems:

> > > > System Abnormalities

> > > > Constitutional gained 40 Ibs over the past 3-4 yrs, + cheonic

> > > fatigue

> > > > Eye denies visual changes

> > > > ENT denies sorethroay, odynophagia

> > > > CV denies CP, palp

> > > > Resp + SOB, + DOE, denies cough, PND or orthopnea

> > > > GI denies loss appetite, change in bowel habit

> > > > GU denies hematuria, dysuria, voiding difficulties

> > > > Skin denies rash, hype rp igment at ion

> > > > Allergy

> > > > Endocrine no h/o DM, denies exessive sweating, heat or cold

> > > intolerance

> > > > Neurologic denies h/o seizures, headahces

> > > > Musculoskeletal denies muscle aches, joint swelling

> > > > Lymph

> > > > Psych denies depression

> > > > All other systems reviewed and negative.

> > > >

> > > > Physical Examination:

> > > > VITAL SIGNS (08/06/2009 @ 13:28)

> > > > Temperature © 36.61

> > > > Route Oral

> > > > Heart Rate 82

> > > > Rhythm Regular

> > > > Method Radial

> > > > Systolic BP 149

> > > > Diastolic BP 72

> > > > Patient Position Sitting

> > > > Extremity Left Arm

> > > > Method NIBP

> > > > Mean BP 97.67

> > > > Weight (kg) 140.61

> > > > Height (cm) 177.8

> > > > Body Surface Area (m2 ) 2.64

> > > > BMI (kg/m 2 ) 44.48

> > > >

> > > > General: elderly man, NAD, dishevelled

> > > > Eye: no scleral icterus, EOM intact

> > > > ENT: no pharyngeal erythema or thrush, poor dentition

> > > > Neck: no JVD, no thyromegaly

> > > > CV: sl s2 reg, no murmur

> > > > Resp: CTAB

> > > > Abd: + BS, NT/NO, obese

> > > > Lymph: no cervical adenopathy

> > > > Ext: no LE Edema

> > > > Skin: no rash, hyperpigmentation

> > > > Neuro: no focal motor deficit, sensations intact

> > > > Psych: alert and oriented. affect appropriate

> > > > Labs:

> > > > LAB RESULTS: 00052074-2 03/04/2009

> > > >

> > > > CO RT MDNITE SAL-MAYO 19*

> > > > (<:100-)

> > > >

> > > > DHEAS <30 L *

> > > > (42-290)

> > > >

> > > > RENIN ACTIVITY-MAYO 0.8*

> > > > (-)

> > > >

> > > > ALDOSTERONE- MAYO 5.5*

> > > > (<=21-)

> > > >

> > > > NORMETANE FREE-MAYO 0.86*

> > > > (<:0.90-)

> > > >

> > > > METANEPHR FREE-MAYO <0.20 *

> > > > ( <:0.50-)

> > > >

> > > > Records from WRJVA reviewed and will be scanned into CIS.

> > > > AlP:

> > > > 62 M with chronic fatigue,

> >

>

>

>

>

>

>

> __________ NOD32 4389 (20090902) Information __________

>

> This message was checked by NOD32 antivirus system.

> http://www.eset.com

>

[Guest guest]

My doctor was the same - however, I printed off Dr Grim's paper on Conn's, and brought it to my appointment, and I asked him what he thought of the information. In that way, it was his idea to pursue, not me telling a trained medical professional how to do their job.Hope that helps. SueFrom: georgewbill <georgewbill@...>hyperaldosteronism Sent: Thursday, 10 September, 2009 3:02:08 AMSubject: Re: How good is the screening tests for Conn's?

Much easier to say then to do. My doctor isn't one to believe what is on the Internet. So if I told him there is Dr Grim on the group web site that thinks I should try spiro I don't think I would get very far. Since the blood work to him doesn't give him a reason to change any of my meds in his mind there is no reason for change.

Now if he can read something in some medical journal relating to this then maybe he would do it. This has to be something that he can read someplace other then the Internet.

I don't know how many of you have copies of your recordes but it is something you should read. At least for me I find that there are big differences in what you say to your doctor and what is written in the record. Some times you will see that you denied things that were never asked you.

With me I have some what looks like small adnormal test results. Maybe by themselves don't mean much but put together could mean a lot. I should not have to be the one looking for answers that should be my doctors job. Something it seem a lot of doctors don't seem to do.

> > >

> > >

> > > From: georgewbill <georgewbill@ >

> > > Subject: [hyperaldosteronism ] Re: How good is the screening tests

> > for Conn's?

> > > hyperaldosteronism

> > > Date: Tuesday, September 8, 2009, 8:50 PM

> > >

> > >

> > >

> > >

> > >

> > >

> > > This is from my Darmouth Medical

> > >

> > > LAB RESULTS: 00052074-2 03/04/2009

> > >

> > > CO RT MDNITE SAL-MAYO 19*

> > > (<:100-)

> > >

> > > DHEAS <30 L *

> > > (42-290)

> > >

> > > RENIN ACTIVITY-MAYO 0.8*

> > > (-)

> > >

> > > ALDOSTERONE- MAYO 5.5*

> > > (<=21-)

> > >

> > > NORMETANE FREE-MAYO 0.86*

> > > (<:0.90-)

> > >

> > > METANEPHR FREE-MAYO <0.20 *

> > > ( <:0.50-)

> > >

> > > Assessment:

> > >

> > > Mr. Bill is a 61 years y.o. M with symptoms of daily

> > lightheadednass and exartional

> > > SOB with an incidentally discovered 2.1cm left adrenal mass whom

> > we saw in our

> > > Endocrinology Clinic at DHMC on 03/03/2009 for evaluation of the

> > adrenal mass.

> > > We felt at the time the pt's symptoms were likely unrelated to

> > this adrenal

> > > incidentaloma especially since he has had an extensive negative

> > work-up in the past.

> > > However, since most of his previous testing results were not

> > available to us, and

> > > the patient would like to be retested, we rechecked levels of:

> > > midnight salivary cortisol

> > > renin and aldosterone

> > > DHEA-S

> > > serum metanephrine and normetanephrine

> > > to rule this lesion out as a functioning adenoma.

> > > The results above show that there is no evidence that this adenoma

> > is producing any

> > > excess adrenal hormones.

> > >

> > > Plan/Instructions:

> > > Pt was counselled and reassured that this likely represents a

> > benign finding,

> > > especially since the lesion has been stable over time and an

> > extensive work-up in

> > > the past has been negative as well. However, pt was asked to

> > coordinate with his

> > > PCP if he develops any new signs/symptoms or change in his present

> > signs/symptoms.

> > > Tharsan Sivakumar MD

> > > Endocrinology Fellow

> > > I am being supervised by TURCO MD,JOHN H Endocrinology

> > > Electronically signed by: SIVAKUMAR MD, THARSAN 03/13/ 2009 09:32

> > > + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

> > + + + + +

> > > MULTI-AUTHOR NOTE

> > > I agree with these recommendations.

> > > Jack Turco, M.D.

> > > Electronically signed by: TURCO MD, JOHN H 03/18/2009 17:01

> > >

> > > Reason for Consultation:

> > > symptoms of lightheadedness, SOB with incidentally discovered

> > adrenal

> > > lesion

> > > Referred by:

> > > self

> > > BPI:

> > > Francis B. Bill is a 61 years y.o. M with PMH as below has had

> > symptoms of all-day

> > > lightheadedness and exertional shortness of breath for 3 years,

> > which had been

> > > worked up at the VA with CT, echo, Holter, and other studies which

> > did not yield any

> > > etiology for these symptoms. Pt presented to the ER for these

> > symptoms several

> > > times as well.

> > > CT scan of the chest performed in 2006 to evaluate for the SOB

> > showed a well defined

> > > 7mm right lower lung lobe nodule. A left 2.1cm adrenal nodule was

> > found as well

> > > with soft tissue attenuation likely representing an adenoma.

> > According DHMC

> > > Emergency Medicine notes, these have been stable over time.

> > >

> > > PMSH:

> > > hypertension, and dyslipidemia.

> > > appendectomy, tonsil/adenoidectom y

> > >

> > > Medications:

> > > AMBULATORY MEDICATIONS· Last charted on· 03/03/2009

> > > DRUG DOSE/ROUTE FREQUENCY

> > > Aspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRN

> > > Oral

> > > Multivitamin Tablet 1 Tablet (s) / Oral Once daily

> > > Furosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once daily

> > > Oral

> > > Potassium Chloride 10 mEg 20 MEQ = 2 Capsule(s) / Once daily

> > > Capsule, Sustained Oral

> > > Release

> > > Atenolol 25 mg Tablet 25 MG = 1 Tablet (s) / Once daily

> > > Oral

> > > Triamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once daily

> > > Oral

> > >

> > > Allergies:

> > > ADR/ALLERGIES: Last charted on: 03/03/2009

> > > ADR/ALLERGY REACTION SEVERITY

> > > Sulfonamides

> > >

> > > Social. history:

> > > Very brief smoking history during teenage years

> > > Asbestos exposure 15 years in a boiler room

> > > Denies ETOH

> > > never married

> > > no children

> > >

> > > Famil.y Hx:

> > > Thyroid dysfunction: Mother, sister

> > > Thyroid cancer: No

> > > Diabetes mellitus: No

> > > Other auto-immune diseases: No

> > > Vitiligo: No

> > >

> > > Physical Exam

> > > Vitals:

> > > VITAL SIGNS (03/03/2009 @ 14·44)

> > > Heart Rate 96

> > > Systolic BP 156

> > > Diastolic BP 91

> > > Mean BP 112.67

> > > Weight (kg) 137.16

> > > Height (cm) 176.9

> > > Body Surface Area (m2 ) 2.6

> > > BMI (kg/m 2 ) 43.83

> > > Pain Scale 0

> > > Smoking

> > > Smoke History Remote

> > > General: NAD, morbidly obese

> > > HEENT: EOMI, anicteric, PERRL, moist mucous membranes, full visual

> > fundi

> > > Neck: No LAD, no thyromegaly, no tenderness

> > > CV: Sl S2, RRR

> > > Lungs: CTAB

> > > Abd: soft, NT, obese

> > > Neuro: reflexes difficult to elicit

> > > Extremities: trace ankle edema

> > > Integumentary: Skin warm/dry/intact; no hyperpigmentation of hand

> > creases or

> > > gumline/ rash

> > > 06/06

> > > K 4.0

> > > 08/06

> > > TSH 2.34

> > > cortisol 14:38 pm 12.0 ug/dL

> > > 03/2007

> > > VMA 6.4 (ref 2.0-10.0)

> > > Assessment and Plan:

> > > Mr. Bill is a 61 years y.o. M as above with symptoms of daily

> > lightheadedness and

> > > exertional SOB with an incidentally discovered 2.1cm left adrenal

> > mass.

> > > Pt's symptoms are likely unrelated to this adrenal incidentaloma

> > especially since he

> > > has had an extensive negative work-up in the past. However, since

> > most of these

> > > results are not available to us, and the patient would like to be

> > retested, we will

> > > check levels of:

> > > midnight salivary cortisol

> > > renin and aldosterone

> > > DHEA-S

> > > serum metanephrine and normetanephrine

> > > to rule this lesion out as a functioning adenoma.

> > > Pt was counselled and reassured that this likely represents a

> > benign finding,

> > > especially since the lesion has been stable over time. However, pt

> > was asked to

> > > coordinate with his PCP if he develops any new signs/symptoms or

> > change in his

> > > present signs/symptoms.

> > > We have reviewed our plan outlined above with the patient and Mr.

> > Bill verbalized

> > > understanding. All questions were answered.

> > > Tharsan Sivakumar, MD

> > > Endocrinology Fellow

> > > I am being supervised by TURCO MD,JOHN H Endocrinology

> > > Electronically signed by: SIVAKUMAR MD, THARSAN 03/03/2009 15:58

> > >

> > > MULTI-AUTHOR NOTE

> > > I have interviewed and examined this patient along with Dr.

> > Sivakumar and agree with

> > > this note and also these recommendations. The patient will be

> > contacted with final

> > > recommendations when results of testing are complete.

> > > >50% of the 60 minute appointment was spent in face to face

> > counseling the patient

> > > about the possible significance and evaluation of his adrenal

> > abnormality.

> > > Jack Turco, M.D.

> > > Communication sent to: L. Durand 03/03/2009 17:28

> > > Electronically signed by: TURCO MD, JOHN H 03/03/2009 17:28

> > >

> > > DARTMOUTH-HITCHCOCK MEDICAL CENTER

> > > ENCOUNTER DATE: 08/06/ 2009

> > > OFFICE NOTES

> > > BILL,FRANCIS H

> > >

> > > Nephrology Clinic New Patient Visit

> > > Francis H. Bill

> > >

> > > August 6, 2009

> > > ID: 62 years old male seen at the request of Dr. Mogielnicki for?

> > Conns Syndrome.

> > > Past Medical History:

> > > HTN diagnosed about 5 yrs ago

> > > Chronic Fatigue Syndrome

> > > Chronic dyspnea

> > > Chronic dizziness

> > > s/p appendectomy in Dec 2008

> > > Multiple granulomas in the Lungs

> > > Exophytic cyst Lt kidney

> > >

> > > History of Present Illness:

> > > Mr Bill presents today for a second opinion regarding whether he

> > might have Conns

> > > Syndrome. In 2006, he underwent w/u for SOB. He had a CT scan of

> > the chest which

> > > showed a 2.1 cm soft tisuue mass in the Lt adrenal gland.

> > Subsequent tests showed

> > > that the adenoma was non secretory. He has since undergone several

> > chest CT and the

> > > adrenal mass has not grown is size. In March 2009, he was seen by

> > endocrinology at

> > > DHMC. He again underwent testing including cortisol, PRA,

> > aldosterone, metanephrines

> > > etc, all of which were within normal limits. Patient was reassured

> > that this likely

> > > represents an incidentaloma.

> > > Over the past 3-4 yrs, he has had chronic SOB and dizziness . He

> > has undergone

> > > extensive testing for both including EKG, stress tests,

> > echocardiograms, Holter

> > > montior, MRI brain (to r/o acoustic neuroma), sleep studies, PFTs

> > etc all of which

> > > have not identified an abnormality.

> > > In Dec 2008, he presented with abd pain and was found to have

> > appendicitis on CT

> > > scan. It also showed an exophytic mass in the L kidney for which

> > he unerwent an

> > > ultrasound. He was told by his PCP that he needs f /u CT scan for

> > the lesion. I do

> > > not have records relating to this issue today.

> > > He has normal renal fucnti on ( Cr from VA records has ranged from

> > 0.8-1.1 in the

> > > past 3 yrs) .

> > > AMBULATORY MEDICATIONS· Last charted on· 08/06/2009

> > > DRUG DOSE/ROUTE FREQUENCY

> > > Aspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRN

> > > Oral

> > > Furosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once daily

> > > Oral

> > > Potassium Chloride 10 mEq 20 MEQ = 2 Capsule(s) / Once daily

> > > Capsule, Sustained Oral

> > > Release

> > > Atenolol 25 mg Tablet 25 MG = 1 Tablet(s) / Once daily

> > > Triamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once daily

> > > Oral

> > > Multivitamin Tablet 1 Tablet (s) / Oral

> > > ADR/ALLERGIES: Last charted on: 08/06/2009

> > > ADR/ALLERGY REACTION SEVERITY

> > > Sulfonamides

> > >

> > > Family History:

> > > No family h/o renal disease. He denies family h/o DM and CAD.

> > > Social History:

> > > Lives in Enfield NH. Vietnam war vet, now on disability 2 to

> > chronic fatigue

> > > syndrme. Quit smoking 40 yrs ago, denies ETOH ot illicit drug use.

> > >

> > > Review of Systems:

> > > System Abnormalities

> > > Constitutional gained 40 Ibs over the past 3-4 yrs, + cheonic

> > fatigue

> > > Eye denies visual changes

> > > ENT denies sorethroay, odynophagia

> > > CV denies CP, palp

> > > Resp + SOB, + DOE, denies cough, PND or orthopnea

> > > GI denies loss appetite, change in bowel habit

> > > GU denies hematuria, dysuria, voiding difficulties

> > > Skin denies rash, hype rp igment at ion

> > > Allergy

> > > Endocrine no h/o DM, denies exessive sweating, heat or cold

> > intolerance

> > > Neurologic denies h/o seizures, headahces

> > > Musculoskeletal denies muscle aches, joint swelling

> > > Lymph

> > > Psych denies depression

> > > All other systems reviewed and negative.

> > >

> > > Physical Examination:

> > > VITAL SIGNS (08/06/2009 @ 13:28)

> > > Temperature © 36.61

> > > Route Oral

> > > Heart Rate 82

> > > Rhythm Regular

> > > Method Radial

> > > Systolic BP 149

> > > Diastolic BP 72

> > > Patient Position Sitting

> > > Extremity Left Arm

> > > Method NIBP

> > > Mean BP 97.67

> > > Weight (kg) 140.61

> > > Height (cm) 177.8

> > > Body Surface Area (m2 ) 2.64

> > > BMI (kg/m 2 ) 44.48

> > >

> > > General: elderly man, NAD, dishevelled

> > > Eye: no scleral icterus, EOM intact

> > > ENT: no pharyngeal erythema or thrush, poor dentition

> > > Neck: no JVD, no thyromegaly

> > > CV: sl s2 reg, no murmur

> > > Resp: CTAB

> > > Abd: + BS, NT/NO, obese

> > > Lymph: no cervical adenopathy

> > > Ext: no LE Edema

> > > Skin: no rash, hyperpigmentation

> > > Neuro: no focal motor deficit, sensations intact

> > > Psych: alert and oriented. affect appropriate

> > > Labs:

> > > LAB RESULTS: 00052074-2 03/04/2009

> > >

> > > CO RT MDNITE SAL-MAYO 19*

> > > (<:100-)

> > >

> > > DHEAS <30 L *

> > > (42-290)

> > >

> > > RENIN ACTIVITY-MAYO 0.8*

> > > (-)

> > >

> > > ALDOSTERONE- MAYO 5.5*

> > > (<=21-)

> > >

> > > NORMETANE FREE-MAYO 0.86*

> > > (<:0.90-)

> > >

> > > METANEPHR FREE-MAYO <0.20 *

> > > ( <:0.50-)

> > >

> > > Records from WRJVA reviewed and will be scanned into CIS.

> > > AlP:

> > > 62 M with chronic fatigue,

>

Email slow, clunky, unreliable? Switch to Xtra Mail, New Zealand's new email address.

[Guest guest]

Spiro not working is probably a good sign you don't have PA

Bindner

From: jwwright <jwwright@...>Subject: Re: Re: How good is the screening tests for Conn's?hyperaldosteronism Date: Wednesday, September 9, 2009, 9:01 PM

Re: [hyperaldosteronism ] Re: How good is the screening tests forConn's?My doctor was the same - however, I printed off Dr Grim's paper on Conn's,and brought it to my appointment, and I asked him what he thought of theinformation. In that way, it was his idea to pursue, not me telling atrained medical professional how to do their job.Hope that helps. SueThanks, Sue,I think that's the kind of repoire we must have with our Dr's.I'm lucky to get an appt 4 weeks ahead, they're so busy.But I can call and get just about everything I want to try.Last year I

tried Spironoalctone - to no avail.Regards

[Guest guest]

LREH is early PA. See my review and the paper we did in 70s showing that most have adrenal hyperplasia. Tiped sad Send form miiPhone ;-)May your pressure be low!CE Grim MDSpecializing in DifficultHypertensionOn Sep 9, 2009, at 7:29 PM, jwwright <jwwright@...> wrote:

No, you should try it.

So why have you not called the Dr and gotten a prescription?

We went thru this before. He won't give it to you.

The rest is just agonizing about your Dr or the distance, etc.

So you have a quandary.

Meanwhile work the weight.

Regards

Re: How good is the screening tests for Conn's?

jwwright Are you saying you know more ther Dr Grim dose about Conn's He is the one that is saying I should try meds for hyperaldo. He has said this more then once based on what I have in this and other postings. > > > > > Here is my problem with going someplace else. The next best place to > > > go would be Boston this is a three hour drive one way for me. I > > > would have to make this trip more then once.> > >> > > Some days I have hard time going just a for a short trip. Since I > > > have no insurance I don't know how much I would end up paying for > > > all the tests that need to be done. The VA is where I go now. I was > > > able to do paper work at Darmouth so I gon't have to pay there > > > Except for any Meds they may give me.> > >> > > > Nephrology Clinic New Patient Visit> > > > Francis H. Bill

..

[Guest guest]

Good to hear some are amenable to new info. Tiped sad Send form miiPhone ;-)May your pressure be low!CE Grim MDSpecializing in DifficultHypertensionOn Sep 9, 2009, at 5:19 PM, marysue hopper <marysuehopper@...> wrote:

My doctor was the same - however, I printed off Dr Grim's paper on Conn's, and brought it to my appointment, and I asked him what he thought of the information. In that way, it was his idea to pursue, not me telling a trained medical professional how to do their job.Hope that helps. SueFrom: georgewbill <georgewbill >hyperaldosteronism Sent: Thursday, 10 September, 2009 3:02:08 AMSubject: Re: How good is the screening tests for Conn's?

Much easier to say then to do. My doctor isn't one to believe what is on the Internet. So if I told him there is Dr Grim on the group web site that thinks I should try spiro I don't think I would get very far. Since the blood work to him doesn't give him a reason to change any of my meds in his mind there is no reason for change.

Now if he can read something in some medical journal relating to this then maybe he would do it. This has to be something that he can read someplace other then the Internet.

I don't know how many of you have copies of your recordes but it is something you should read. At least for me I find that there are big differences in what you say to your doctor and what is written in the record. Some times you will see that you denied things that were never asked you.

With me I have some what looks like small adnormal test results. Maybe by themselves don't mean much but put together could mean a lot. I should not have to be the one looking for answers that should be my doctors job. Something it seem a lot of doctors don't seem to do.

> > >

> > >

> > > From: georgewbill <georgewbill@ >

> > > Subject: [hyperaldosteronism ] Re: How good is the screening tests

> > for Conn's?

> > > hyperaldosteronism

> > > Date: Tuesday, September 8, 2009, 8:50 PM

> > >

> > >

> > >

> > >

> > >

> > >

> > > This is from my Darmouth Medical

> > >

> > > LAB RESULTS: 00052074-2 03/04/2009

> > >

> > > CO RT MDNITE SAL-MAYO 19*

> > > (<:100-)

> > >

> > > DHEAS <30 L *

> > > (42-290)

> > >

> > > RENIN ACTIVITY-MAYO 0.8*

> > > (-)

> > >

> > > ALDOSTERONE- MAYO 5.5*

> > > (<=21-)

> > >

> > > NORMETANE FREE-MAYO 0.86*

> > > (<:0.90-)

> > >

> > > METANEPHR FREE-MAYO <0.20 *

> > > ( <:0.50-)

> > >

> > > Assessment:

> > >

> > > Mr. Bill is a 61 years y.o. M with symptoms of daily

> > lightheadednass and exartional

> > > SOB with an incidentally discovered 2.1cm left adrenal mass whom

> > we saw in our

> > > Endocrinology Clinic at DHMC on 03/03/2009 for evaluation of the

> > adrenal mass.

> > > We felt at the time the pt's symptoms were likely unrelated to

> > this adrenal

> > > incidentaloma especially since he has had an extensive negative

> > work-up in the past.

> > > However, since most of his previous testing results were not

> > available to us, and

> > > the patient would like to be retested, we rechecked levels of:

> > > midnight salivary cortisol

> > > renin and aldosterone

> > > DHEA-S

> > > serum metanephrine and normetanephrine

> > > to rule this lesion out as a functioning adenoma.

> > > The results above show that there is no evidence that this adenoma

> > is producing any

> > > excess adrenal hormones.

> > >

> > > Plan/Instructions:

> > > Pt was counselled and reassured that this likely represents a

> > benign finding,

> > > especially since the lesion has been stable over time and an

> > extensive work-up in

> > > the past has been negative as well. However, pt was asked to

> > coordinate with his

> > > PCP if he develops any new signs/symptoms or change in his present

> > signs/symptoms.

> > > Tharsan Sivakumar MD

> > > Endocrinology Fellow

> > > I am being supervised by TURCO MD,JOHN H Endocrinology

> > > Electronically signed by: SIVAKUMAR MD, THARSAN 03/13/ 2009 09:32

> > > + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

> > + + + + +

> > > MULTI-AUTHOR NOTE

> > > I agree with these recommendations.

> > > Jack Turco, M.D.

> > > Electronically signed by: TURCO MD, JOHN H 03/18/2009 17:01

> > >

> > > Reason for Consultation:

> > > symptoms of lightheadedness, SOB with incidentally discovered

> > adrenal

> > > lesion

> > > Referred by:

> > > self

> > > BPI:

> > > Francis B. Bill is a 61 years y.o. M with PMH as below has had

> > symptoms of all-day

> > > lightheadedness and exertional shortness of breath for 3 years,

> > which had been

> > > worked up at the VA with CT, echo, Holter, and other studies which

> > did not yield any

> > > etiology for these symptoms. Pt presented to the ER for these

> > symptoms several

> > > times as well.

> > > CT scan of the chest performed in 2006 to evaluate for the SOB

> > showed a well defined

> > > 7mm right lower lung lobe nodule. A left 2.1cm adrenal nodule was

> > found as well

> > > with soft tissue attenuation likely representing an adenoma.

> > According DHMC

> > > Emergency Medicine notes, these have been stable over time.

> > >

> > > PMSH:

> > > hypertension, and dyslipidemia.

> > > appendectomy, tonsil/adenoidectom y

> > >

> > > Medications:

> > > AMBULATORY MEDICATIONS· Last charted on· 03/03/2009

> > > DRUG DOSE/ROUTE FREQUENCY

> > > Aspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRN

> > > Oral

> > > Multivitamin Tablet 1 Tablet (s) / Oral Once daily

> > > Furosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once daily

> > > Oral

> > > Potassium Chloride 10 mEg 20 MEQ = 2 Capsule(s) / Once daily

> > > Capsule, Sustained Oral

> > > Release

> > > Atenolol 25 mg Tablet 25 MG = 1 Tablet (s) / Once daily

> > > Oral

> > > Triamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once daily

> > > Oral

> > >

> > > Allergies:

> > > ADR/ALLERGIES: Last charted on: 03/03/2009

> > > ADR/ALLERGY REACTION SEVERITY

> > > Sulfonamides

> > >

> > > Social. history:

> > > Very brief smoking history during teenage years

> > > Asbestos exposure 15 years in a boiler room

> > > Denies ETOH

> > > never married

> > > no children

> > >

> > > Famil.y Hx:

> > > Thyroid dysfunction: Mother, sister

> > > Thyroid cancer: No

> > > Diabetes mellitus: No

> > > Other auto-immune diseases: No

> > > Vitiligo: No

> > >

> > > Physical Exam

> > > Vitals:

> > > VITAL SIGNS (03/03/2009 @ 14·44)

> > > Heart Rate 96

> > > Systolic BP 156

> > > Diastolic BP 91

> > > Mean BP 112.67

> > > Weight (kg) 137.16

> > > Height (cm) 176.9

> > > Body Surface Area (m2 ) 2.6

> > > BMI (kg/m 2 ) 43.83

> > > Pain Scale 0

> > > Smoking

> > > Smoke History Remote

> > > General: NAD, morbidly obese

> > > HEENT: EOMI, anicteric, PERRL, moist mucous membranes, full visual

> > fundi

> > > Neck: No LAD, no thyromegaly, no tenderness

> > > CV: Sl S2, RRR

> > > Lungs: CTAB

> > > Abd: soft, NT, obese

> > > Neuro: reflexes difficult to elicit

> > > Extremities: trace ankle edema

> > > Integumentary: Skin warm/dry/intact; no hyperpigmentation of hand

> > creases or

> > > gumline/ rash

> > > 06/06

> > > K 4.0

> > > 08/06

> > > TSH 2.34

> > > cortisol 14:38 pm 12.0 ug/dL

> > > 03/2007

> > > VMA 6.4 (ref 2.0-10.0)

> > > Assessment and Plan:

> > > Mr. Bill is a 61 years y.o. M as above with symptoms of daily

> > lightheadedness and

> > > exertional SOB with an incidentally discovered 2.1cm left adrenal

> > mass.

> > > Pt's symptoms are likely unrelated to this adrenal incidentaloma

> > especially since he

> > > has had an extensive negative work-up in the past. However, since

> > most of these

> > > results are not available to us, and the patient would like to be

> > retested, we will

> > > check levels of:

> > > midnight salivary cortisol

> > > renin and aldosterone

> > > DHEA-S

> > > serum metanephrine and normetanephrine

> > > to rule this lesion out as a functioning adenoma.

> > > Pt was counselled and reassured that this likely represents a

> > benign finding,

> > > especially since the lesion has been stable over time. However, pt

> > was asked to

> > > coordinate with his PCP if he develops any new signs/symptoms or

> > change in his

> > > present signs/symptoms.

> > > We have reviewed our plan outlined above with the patient and Mr.

> > Bill verbalized

> > > understanding. All questions were answered.

> > > Tharsan Sivakumar, MD

> > > Endocrinology Fellow

> > > I am being supervised by TURCO MD,JOHN H Endocrinology

> > > Electronically signed by: SIVAKUMAR MD, THARSAN 03/03/2009 15:58

> > >

> > > MULTI-AUTHOR NOTE

> > > I have interviewed and examined this patient along with Dr.

> > Sivakumar and agree with

> > > this note and also these recommendations. The patient will be

> > contacted with final

> > > recommendations when results of testing are complete.

> > > >50% of the 60 minute appointment was spent in face to face

> > counseling the patient

> > > about the possible significance and evaluation of his adrenal

> > abnormality.

> > > Jack Turco, M.D.

> > > Communication sent to: L. Durand 03/03/2009 17:28

> > > Electronically signed by: TURCO MD, JOHN H 03/03/2009 17:28

> > >

> > > DARTMOUTH-HITCHCOCK MEDICAL CENTER

> > > ENCOUNTER DATE: 08/06/ 2009

> > > OFFICE NOTES

> > > BILL,FRANCIS H

> > >

> > > Nephrology Clinic New Patient Visit

> > > Francis H. Bill

> > >

> > > August 6, 2009

> > > ID: 62 years old male seen at the request of Dr. Mogielnicki for?

> > Conns Syndrome.

> > > Past Medical History:

> > > HTN diagnosed about 5 yrs ago

> > > Chronic Fatigue Syndrome

> > > Chronic dyspnea

> > > Chronic dizziness

> > > s/p appendectomy in Dec 2008

> > > Multiple granulomas in the Lungs

> > > Exophytic cyst Lt kidney

> > >

> > > History of Present Illness:

> > > Mr Bill presents today for a second opinion regarding whether he

> > might have Conns

> > > Syndrome. In 2006, he underwent w/u for SOB. He had a CT scan of

> > the chest which

> > > showed a 2.1 cm soft tisuue mass in the Lt adrenal gland.

> > Subsequent tests showed

> > > that the adenoma was non secretory. He has since undergone several

> > chest CT and the

> > > adrenal mass has not grown is size. In March 2009, he was seen by

> > endocrinology at

> > > DHMC. He again underwent testing including cortisol, PRA,

> > aldosterone, metanephrines

> > > etc, all of which were within normal limits. Patient was reassured

> > that this likely

> > > represents an incidentaloma.

> > > Over the past 3-4 yrs, he has had chronic SOB and dizziness . He

> > has undergone

> > > extensive testing for both including EKG, stress tests,

> > echocardiograms, Holter

> > > montior, MRI brain (to r/o acoustic neuroma), sleep studies, PFTs

> > etc all of which

> > > have not identified an abnormality.

> > > In Dec 2008, he presented with abd pain and was found to have

> > appendicitis on CT

> > > scan. It also showed an exophytic mass in the L kidney for which

> > he unerwent an

> > > ultrasound. He was told by his PCP that he needs f /u CT scan for

> > the lesion. I do

> > > not have records relating to this issue today.

> > > He has normal renal fucnti on ( Cr from VA records has ranged from

> > 0.8-1.1 in the

> > > past 3 yrs) .

> > > AMBULATORY MEDICATIONS· Last charted on· 08/06/2009

> > > DRUG DOSE/ROUTE FREQUENCY

> > > Aspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRN

> > > Oral

> > > Furosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once daily

> > > Oral

> > > Potassium Chloride 10 mEq 20 MEQ = 2 Capsule(s) / Once daily

> > > Capsule, Sustained Oral

> > > Release

> > > Atenolol 25 mg Tablet 25 MG = 1 Tablet(s) / Once daily

> > > Triamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once daily

> > > Oral

> > > Multivitamin Tablet 1 Tablet (s) / Oral

> > > ADR/ALLERGIES: Last charted on: 08/06/2009

> > > ADR/ALLERGY REACTION SEVERITY

> > > Sulfonamides

> > >

> > > Family History:

> > > No family h/o renal disease. He denies family h/o DM and CAD.

> > > Social History:

> > > Lives in Enfield NH. Vietnam war vet, now on disability 2 to

> > chronic fatigue

> > > syndrme. Quit smoking 40 yrs ago, denies ETOH ot illicit drug use.

> > >

> > > Review of Systems:

> > > System Abnormalities

> > > Constitutional gained 40 Ibs over the past 3-4 yrs, + cheonic

> > fatigue

> > > Eye denies visual changes

> > > ENT denies sorethroay, odynophagia

> > > CV denies CP, palp

> > > Resp + SOB, + DOE, denies cough, PND or orthopnea

> > > GI denies loss appetite, change in bowel habit

> > > GU denies hematuria, dysuria, voiding difficulties

> > > Skin denies rash, hype rp igment at ion

> > > Allergy

> > > Endocrine no h/o DM, denies exessive sweating, heat or cold

> > intolerance

> > > Neurologic denies h/o seizures, headahces

> > > Musculoskeletal denies muscle aches, joint swelling

> > > Lymph

> > > Psych denies depression

> > > All other systems reviewed and negative.

> > >

> > > Physical Examination:

> > > VITAL SIGNS (08/06/2009 @ 13:28)

> > > Temperature © 36.61

> > > Route Oral

> > > Heart Rate 82

> > > Rhythm Regular

> > > Method Radial

> > > Systolic BP 149

> > > Diastolic BP 72

> > > Patient Position Sitting

> > > Extremity Left Arm

> > > Method NIBP

> > > Mean BP 97.67

> > > Weight (kg) 140.61

> > > Height (cm) 177.8

> > > Body Surface Area (m2 ) 2.64

> > > BMI (kg/m 2 ) 44.48

> > >

> > > General: elderly man, NAD, dishevelled

> > > Eye: no scleral icterus, EOM intact

> > > ENT: no pharyngeal erythema or thrush, poor dentition

> > > Neck: no JVD, no thyromegaly

> > > CV: sl s2 reg, no murmur

> > > Resp: CTAB

> > > Abd: + BS, NT/NO, obese

> > > Lymph: no cervical adenopathy

> > > Ext: no LE Edema

> > > Skin: no rash, hyperpigmentation

> > > Neuro: no focal motor deficit, sensations intact

> > > Psych: alert and oriented. affect appropriate

> > > Labs:

> > > LAB RESULTS: 00052074-2 03/04/2009

> > >

> > > CO RT MDNITE SAL-MAYO 19*

> > > (<:100-)

> > >

> > > DHEAS <30 L *

> > > (42-290)

> > >

> > > RENIN ACTIVITY-MAYO 0.8*

> > > (-)

> > >

> > > ALDOSTERONE- MAYO 5.5*

> > > (<=21-)

> > >

> > > NORMETANE FREE-MAYO 0.86*

> > > (<:0.90-)

> > >

> > > METANEPHR FREE-MAYO <0.20 *

> > > ( <:0.50-)

> > >

> > > Records from WRJVA reviewed and will be scanned into CIS.

> > > AlP:

> > > 62 M with chronic fatigue,

>

Email slow, clunky, unreliable? Switch to Xtra Mail, New Zealand's new email address.

[Guest guest]

Or u are out salting the spiro. Tiped sad Send form miiPhone ;-)May your pressure be low!CE Grim MDSpecializing in DifficultHypertensionOn Sep 9, 2009, at 6:39 PM, Bindner <mikeybdc@...> wrote:

Spiro not working is probably a good sign you don't have PA

Bindner

From: jwwright <jwwrighteastex (DOT) net>Subject: Re: Re: How good is the screening tests for Conn's?hyperaldosteronism Date: Wednesday, September 9, 2009, 9:01 PM

Re: [hyperaldosteronism ] Re: How good is the screening tests forConn's?My doctor was the same - however, I printed off Dr Grim's paper on Conn's,and brought it to my appointment, and I asked him what he thought of theinformation. In that way, it was his idea to pursue, not me telling atrained medical professional how to do their job.Hope that helps. SueThanks, Sue,I think that's the kind of repoire we must have with our Dr's.I'm lucky to get an appt 4 weeks ahead, they're so busy.But I can call and get just about everything I want to try.Last year I

tried Spironoalctone - to no avail.Regards

[Guest guest]

No, you should try it.

So why have you not called the Dr and gotten a prescription?

We went thru this before. He won't give it to you.

The rest is just agonizing about your Dr or the distance, etc.

So you have a quandary.

Meanwhile work the weight.

Regards

Re: How good is the screening tests for Conn's?

jwwright Are you saying you know more ther Dr Grim dose about Conn's He is the one that is saying I should try meds for hyperaldo. He has said this more then once based on what I have in this and other postings. > > > > > Here is my problem with going someplace else. The next best place to > > > go would be Boston this is a three hour drive one way for me. I > > > would have to make this trip more then once.> > >> > > Some days I have hard time going just a for a short trip. Since I > > > have no insurance I don't know how much I would end up paying for > > > all the tests that need to be done. The VA is where I go now. I was > > > able to do paper work at Darmouth so I gon't have to pay there > > > Except for any Meds they may give me.> > >> > > > Nephrology Clinic New Patient Visit> > > > Francis H. Bill

..

[Guest guest]

Refer him to my publications (n=220+). I agree muchon Internet is humbugTiped sad Send form miiPhone ;-)May your pressure be low!CE Grim MDSpecializing in DifficultHypertensionOn Sep 9, 2009, at 10:02 AM, georgewbill <georgewbill@...> wrote:

Much easier to say then to do. My doctor isn't one to believe what is on the Internet. So if I told him there is Dr Grim on the group web site that thinks I should try spiro I don't think I would get very far. Since the blood work to him doesn't give him a reason to change any of my meds in his mind there is no reason for change.

Now if he can read something in some medical journal relating to this then maybe he would do it. This has to be something that he can read someplace other then the Internet.

I don't know how many of you have copies of your recordes but it is something you should read. At least for me I find that there are big differences in what you say to your doctor and what is written in the record. Some times you will see that you denied things that were never asked you.

With me I have some what looks like small adnormal test results. Maybe by themselves don't mean much but put together could mean a lot. I should not have to be the one looking for answers that should be my doctors job. Something it seem a lot of doctors don't seem to do.

> > >

> > >

> > > From: georgewbill <georgewbill@>

> > > Subject: Re: How good is the screening tests

> > for Conn's?

> > > hyperaldosteronism

> > > Date: Tuesday, September 8, 2009, 8:50 PM

> > >

> > >

> > >

> > >

> > >

> > >

> > > This is from my Darmouth Medical

> > >

> > > LAB RESULTS: 00052074-2 03/04/2009

> > >

> > > CO RT MDNITE SAL-MAYO 19*

> > > (<:100-)

> > >

> > > DHEAS <30 L *

> > > (42-290)

> > >

> > > RENIN ACTIVITY-MAYO 0.8*

> > > (-)

> > >

> > > ALDOSTERONE- MAYO 5.5*

> > > (<=21-)

> > >

> > > NORMETANE FREE-MAYO 0.86*

> > > (<:0.90-)

> > >

> > > METANEPHR FREE-MAYO <0.20 *

> > > ( <:0.50-)

> > >

> > > Assessment:

> > >

> > > Mr. Bill is a 61 years y.o. M with symptoms of daily

> > lightheadednass and exartional

> > > SOB with an incidentally discovered 2.1cm left adrenal mass whom

> > we saw in our

> > > Endocrinology Clinic at DHMC on 03/03/2009 for evaluation of the

> > adrenal mass.

> > > We felt at the time the pt's symptoms were likely unrelated to

> > this adrenal

> > > incidentaloma especially since he has had an extensive negative

> > work-up in the past.

> > > However, since most of his previous testing results were not

> > available to us, and

> > > the patient would like to be retested, we rechecked levels of:

> > > midnight salivary cortisol

> > > renin and aldosterone

> > > DHEA-S

> > > serum metanephrine and normetanephrine

> > > to rule this lesion out as a functioning adenoma.

> > > The results above show that there is no evidence that this adenoma

> > is producing any

> > > excess adrenal hormones.

> > >

> > > Plan/Instructions:

> > > Pt was counselled and reassured that this likely represents a

> > benign finding,

> > > especially since the lesion has been stable over time and an

> > extensive work-up in

> > > the past has been negative as well. However, pt was asked to

> > coordinate with his

> > > PCP if he develops any new signs/symptoms or change in his present

> > signs/symptoms.

> > > Tharsan Sivakumar MD

> > > Endocrinology Fellow

> > > I am being supervised by TURCO MD,JOHN H Endocrinology

> > > Electronically signed by: SIVAKUMAR MD, THARSAN 03/13/ 2009 09:32

> > > + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

> > + + + + +

> > > MULTI-AUTHOR NOTE

> > > I agree with these recommendations.

> > > Jack Turco, M.D.

> > > Electronically signed by: TURCO MD, JOHN H 03/18/2009 17:01

> > >

> > > Reason for Consultation:

> > > symptoms of lightheadedness, SOB with incidentally discovered

> > adrenal

> > > lesion

> > > Referred by:

> > > self

> > > BPI:

> > > Francis B. Bill is a 61 years y.o. M with PMH as below has had

> > symptoms of all-day

> > > lightheadedness and exertional shortness of breath for 3 years,

> > which had been

> > > worked up at the VA with CT, echo, Holter, and other studies which

> > did not yield any

> > > etiology for these symptoms. Pt presented to the ER for these

> > symptoms several

> > > times as well.

> > > CT scan of the chest performed in 2006 to evaluate for the SOB

> > showed a well defined

> > > 7mm right lower lung lobe nodule. A left 2.1cm adrenal nodule was

> > found as well

> > > with soft tissue attenuation likely representing an adenoma.

> > According DHMC

> > > Emergency Medicine notes, these have been stable over time.

> > >

> > > PMSH:

> > > hypertension, and dyslipidemia.

> > > appendectomy, tonsil/adenoidectom y

> > >

> > > Medications:

> > > AMBULATORY MEDICATIONS· Last charted on· 03/03/2009

> > > DRUG DOSE/ROUTE FREQUENCY

> > > Aspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRN

> > > Oral

> > > Multivitamin Tablet 1 Tablet (s) / Oral Once daily

> > > Furosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once daily

> > > Oral

> > > Potassium Chloride 10 mEg 20 MEQ = 2 Capsule(s) / Once daily

> > > Capsule, Sustained Oral

> > > Release

> > > Atenolol 25 mg Tablet 25 MG = 1 Tablet (s) / Once daily

> > > Oral

> > > Triamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once daily

> > > Oral

> > >

> > > Allergies:

> > > ADR/ALLERGIES: Last charted on: 03/03/2009

> > > ADR/ALLERGY REACTION SEVERITY

> > > Sulfonamides

> > >

> > > Social. history:

> > > Very brief smoking history during teenage years

> > > Asbestos exposure 15 years in a boiler room

> > > Denies ETOH

> > > never married

> > > no children

> > >

> > > Famil.y Hx:

> > > Thyroid dysfunction: Mother, sister

> > > Thyroid cancer: No

> > > Diabetes mellitus: No

> > > Other auto-immune diseases: No

> > > Vitiligo: No

> > >

> > > Physical Exam

> > > Vitals:

> > > VITAL SIGNS (03/03/2009 @ 14·44)

> > > Heart Rate 96

> > > Systolic BP 156

> > > Diastolic BP 91

> > > Mean BP 112.67

> > > Weight (kg) 137.16

> > > Height (cm) 176.9

> > > Body Surface Area (m2 ) 2.6

> > > BMI (kg/m 2 ) 43.83

> > > Pain Scale 0

> > > Smoking

> > > Smoke History Remote

> > > General: NAD, morbidly obese

> > > HEENT: EOMI, anicteric, PERRL, moist mucous membranes, full visual

> > fundi

> > > Neck: No LAD, no thyromegaly, no tenderness

> > > CV: Sl S2, RRR

> > > Lungs: CTAB

> > > Abd: soft, NT, obese

> > > Neuro: reflexes difficult to elicit

> > > Extremities: trace ankle edema

> > > Integumentary: Skin warm/dry/intact; no hyperpigmentation of hand

> > creases or

> > > gumline/ rash

> > > 06/06

> > > K 4.0

> > > 08/06

> > > TSH 2.34

> > > cortisol 14:38 pm 12.0 ug/dL

> > > 03/2007

> > > VMA 6.4 (ref 2.0-10.0)

> > > Assessment and Plan:

> > > Mr. Bill is a 61 years y.o. M as above with symptoms of daily

> > lightheadedness and

> > > exertional SOB with an incidentally discovered 2.1cm left adrenal

> > mass.

> > > Pt's symptoms are likely unrelated to this adrenal incidentaloma

> > especially since he

> > > has had an extensive negative work-up in the past. However, since

> > most of these

> > > results are not available to us, and the patient would like to be

> > retested, we will

> > > check levels of:

> > > midnight salivary cortisol

> > > renin and aldosterone

> > > DHEA-S

> > > serum metanephrine and normetanephrine

> > > to rule this lesion out as a functioning adenoma.

> > > Pt was counselled and reassured that this likely represents a

> > benign finding,

> > > especially since the lesion has been stable over time. However, pt

> > was asked to

> > > coordinate with his PCP if he develops any new signs/symptoms or

> > change in his

> > > present signs/symptoms.

> > > We have reviewed our plan outlined above with the patient and Mr.

> > Bill verbalized

> > > understanding. All questions were answered.

> > > Tharsan Sivakumar, MD

> > > Endocrinology Fellow

> > > I am being supervised by TURCO MD,JOHN H Endocrinology

> > > Electronically signed by: SIVAKUMAR MD, THARSAN 03/03/2009 15:58

> > >

> > > MULTI-AUTHOR NOTE

> > > I have interviewed and examined this patient along with Dr.

> > Sivakumar and agree with

> > > this note and also these recommendations. The patient will be

> > contacted with final

> > > recommendations when results of testing are complete.

> > > >50% of the 60 minute appointment was spent in face to face

> > counseling the patient

> > > about the possible significance and evaluation of his adrenal

> > abnormality.

> > > Jack Turco, M.D.

> > > Communication sent to: L. Durand 03/03/2009 17:28

> > > Electronically signed by: TURCO MD, JOHN H 03/03/2009 17:28

> > >

> > > DARTMOUTH-HITCHCOCK MEDICAL CENTER

> > > ENCOUNTER DATE: 08/06/ 2009

> > > OFFICE NOTES

> > > BILL,FRANCIS H

> > >

> > > Nephrology Clinic New Patient Visit

> > > Francis H. Bill

> > >

> > > August 6, 2009

> > > ID: 62 years old male seen at the request of Dr. Mogielnicki for?

> > Conns Syndrome.

> > > Past Medical History:

> > > HTN diagnosed about 5 yrs ago

> > > Chronic Fatigue Syndrome

> > > Chronic dyspnea

> > > Chronic dizziness

> > > s/p appendectomy in Dec 2008

> > > Multiple granulomas in the Lungs

> > > Exophytic cyst Lt kidney

> > >

> > > History of Present Illness:

> > > Mr Bill presents today for a second opinion regarding whether he

> > might have Conns

> > > Syndrome. In 2006, he underwent w/u for SOB. He had a CT scan of

> > the chest which

> > > showed a 2.1 cm soft tisuue mass in the Lt adrenal gland.

> > Subsequent tests showed

> > > that the adenoma was non secretory. He has since undergone several

> > chest CT and the

> > > adrenal mass has not grown is size. In March 2009, he was seen by

> > endocrinology at

> > > DHMC. He again underwent testing including cortisol, PRA,

> > aldosterone, metanephrines

> > > etc, all of which were within normal limits. Patient was reassured

> > that this likely

> > > represents an incidentaloma.

> > > Over the past 3-4 yrs, he has had chronic SOB and dizziness . He

> > has undergone

> > > extensive testing for both including EKG, stress tests,

> > echocardiograms, Holter

> > > montior, MRI brain (to r/o acoustic neuroma), sleep studies, PFTs

> > etc all of which

> > > have not identified an abnormality.

> > > In Dec 2008, he presented with abd pain and was found to have

> > appendicitis on CT

> > > scan. It also showed an exophytic mass in the L kidney for which

> > he unerwent an

> > > ultrasound. He was told by his PCP that he needs f /u CT scan for

> > the lesion. I do

> > > not have records relating to this issue today.

> > > He has normal renal fucnti on ( Cr from VA records has ranged from

> > 0.8-1.1 in the

> > > past 3 yrs) .

> > > AMBULATORY MEDICATIONS· Last charted on· 08/06/2009

> > > DRUG DOSE/ROUTE FREQUENCY

> > > Aspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRN

> > > Oral

> > > Furosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once daily

> > > Oral

> > > Potassium Chloride 10 mEq 20 MEQ = 2 Capsule(s) / Once daily

> > > Capsule, Sustained Oral

> > > Release

> > > Atenolol 25 mg Tablet 25 MG = 1 Tablet(s) / Once daily

> > > Triamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once daily

> > > Oral

> > > Multivitamin Tablet 1 Tablet (s) / Oral

> > > ADR/ALLERGIES: Last charted on: 08/06/2009

> > > ADR/ALLERGY REACTION SEVERITY

> > > Sulfonamides

> > >

> > > Family History:

> > > No family h/o renal disease. He denies family h/o DM and CAD.

> > > Social History:

> > > Lives in Enfield NH. Vietnam war vet, now on disability 2 to

> > chronic fatigue

> > > syndrme. Quit smoking 40 yrs ago, denies ETOH ot illicit drug use.

> > >

> > > Review of Systems:

> > > System Abnormalities

> > > Constitutional gained 40 Ibs over the past 3-4 yrs, + cheonic

> > fatigue

> > > Eye denies visual changes

> > > ENT denies sorethroay, odynophagia

> > > CV denies CP, palp

> > > Resp + SOB, + DOE, denies cough, PND or orthopnea

> > > GI denies loss appetite, change in bowel habit

> > > GU denies hematuria, dysuria, voiding difficulties

> > > Skin denies rash, hype rp igment at ion

> > > Allergy

> > > Endocrine no h/o DM, denies exessive sweating, heat or cold

> > intolerance

> > > Neurologic denies h/o seizures, headahces

> > > Musculoskeletal denies muscle aches, joint swelling

> > > Lymph

> > > Psych denies depression

> > > All other systems reviewed and negative.

> > >

> > > Physical Examination:

> > > VITAL SIGNS (08/06/2009 @ 13:28)

> > > Temperature © 36.61

> > > Route Oral

> > > Heart Rate 82

> > > Rhythm Regular

> > > Method Radial

> > > Systolic BP 149

> > > Diastolic BP 72

> > > Patient Position Sitting

> > > Extremity Left Arm

> > > Method NIBP

> > > Mean BP 97.67

> > > Weight (kg) 140.61

> > > Height (cm) 177.8

> > > Body Surface Area (m2 ) 2.64

> > > BMI (kg/m 2 ) 44.48

> > >

> > > General: elderly man, NAD, dishevelled

> > > Eye: no scleral icterus, EOM intact

> > > ENT: no pharyngeal erythema or thrush, poor dentition

> > > Neck: no JVD, no thyromegaly

> > > CV: sl s2 reg, no murmur

> > > Resp: CTAB

> > > Abd: + BS, NT/NO, obese

> > > Lymph: no cervical adenopathy

> > > Ext: no LE Edema

> > > Skin: no rash, hyperpigmentation

> > > Neuro: no focal motor deficit, sensations intact

> > > Psych: alert and oriented. affect appropriate

> > > Labs:

> > > LAB RESULTS: 00052074-2 03/04/2009

> > >

> > > CO RT MDNITE SAL-MAYO 19*

> > > (<:100-)

> > >

> > > DHEAS <30 L *

> > > (42-290)

> > >

> > > RENIN ACTIVITY-MAYO 0.8*

> > > (-)

> > >

> > > ALDOSTERONE- MAYO 5.5*

> > > (<=21-)

> > >

> > > NORMETANE FREE-MAYO 0.86*

> > > (<:0.90-)

> > >

> > > METANEPHR FREE-MAYO <0.20 *

> > > ( <:0.50-)

> > >

> > > Records from WRJVA reviewed and will be scanned into CIS.

> > > AlP:

> > > 62 M with chronic fatigue,

>

[Guest guest]

Re: Re: How good is the screening tests for

Conn's?

My doctor was the same - however, I printed off Dr Grim's paper on Conn's,

and brought it to my appointment, and I asked him what he thought of the

information. In that way, it was his idea to pursue, not me telling a

trained medical professional how to do their job.

Hope that helps.

Sue

Thanks, Sue,

I think that's the kind of repoire we must have with our Dr's.

I'm lucky to get an appt 4 weeks ahead, they're so busy.

But I can call and get just about everything I want to try.

Last year I tried Spironoalctone - to no avail.

Regards

[Guest guest]

I will agree there is a lot of misinformation in the Internet. But if you do

enough research you can get part answers. Hopefuly by bringing the part answers

to your doctor you can get the complete answer. Is this publications (n=220+) in

the files of this group?

> > > > >

> > > > >

> > > > > From: georgewbill <georgewbill@>

> > > > > Subject: Re: How good is the screening

> > tests

> > > > for Conn's?

> > > > > hyperaldosteronism

> > > > > Date: Tuesday, September 8, 2009, 8:50 PM

> > > > >

> > > > >

> > > > >

> > > > >

> > > > >

> > > > >

> > > > > This is from my Darmouth Medical

> > > > >

> > > > > LAB RESULTS: 00052074-2 03/04/2009

> > > > >

> > > > > CO RT MDNITE SAL-MAYO 19*

> > > > > (<:100-)

> > > > >

> > > > > DHEAS <30 L *

> > > > > (42-290)

> > > > >

> > > > > RENIN ACTIVITY-MAYO 0.8*

> > > > > (-)

> > > > >

> > > > > ALDOSTERONE- MAYO 5.5*

> > > > > (<=21-)

> > > > >

> > > > > NORMETANE FREE-MAYO 0.86*

> > > > > (<:0.90-)

> > > > >

> > > > > METANEPHR FREE-MAYO <0.20 *

> > > > > ( <:0.50-)

> > > > >

> > > > > Assessment:

> > > > >

> > > > > Mr. Bill is a 61 years y.o. M with symptoms of daily

> > > > lightheadednass and exartional

> > > > > SOB with an incidentally discovered 2.1cm left adrenal mass whom

> > > > we saw in our

> > > > > Endocrinology Clinic at DHMC on 03/03/2009 for evaluation of the

> > > > adrenal mass.

> > > > > We felt at the time the pt's symptoms were likely unrelated to

> > > > this adrenal

> > > > > incidentaloma especially since he has had an extensive negative

> > > > work-up in the past.

> > > > > However, since most of his previous testing results were not

> > > > available to us, and

> > > > > the patient would like to be retested, we rechecked levels of:

> > > > > midnight salivary cortisol

> > > > > renin and aldosterone

> > > > > DHEA-S

> > > > > serum metanephrine and normetanephrine

> > > > > to rule this lesion out as a functioning adenoma.

> > > > > The results above show that there is no evidence that this

> > adenoma

> > > > is producing any

> > > > > excess adrenal hormones.

> > > > >

> > > > > Plan/Instructions:

> > > > > Pt was counselled and reassured that this likely represents a

> > > > benign finding,

> > > > > especially since the lesion has been stable over time and an

> > > > extensive work-up in

> > > > > the past has been negative as well. However, pt was asked to

> > > > coordinate with his

> > > > > PCP if he develops any new signs/symptoms or change in his

> > present

> > > > signs/symptoms.

> > > > > Tharsan Sivakumar MD

> > > > > Endocrinology Fellow

> > > > > I am being supervised by TURCO MD,JOHN H Endocrinology

> > > > > Electronically signed by: SIVAKUMAR MD, THARSAN 03/13/ 2009

> > 09:32

> > > > > + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

> > + +

> > > > + + + + +

> > > > > MULTI-AUTHOR NOTE

> > > > > I agree with these recommendations.

> > > > > Jack Turco, M.D.

> > > > > Electronically signed by: TURCO MD, JOHN H 03/18/2009 17:01

> > > > >

> > > > > Reason for Consultation:

> > > > > symptoms of lightheadedness, SOB with incidentally discovered

> > > > adrenal

> > > > > lesion

> > > > > Referred by:

> > > > > self

> > > > > BPI:

> > > > > Francis B. Bill is a 61 years y.o. M with PMH as below has had

> > > > symptoms of all-day

> > > > > lightheadedness and exertional shortness of breath for 3 years,

> > > > which had been

> > > > > worked up at the VA with CT, echo, Holter, and other studies

> > which

> > > > did not yield any

> > > > > etiology for these symptoms. Pt presented to the ER for these

> > > > symptoms several

> > > > > times as well.

> > > > > CT scan of the chest performed in 2006 to evaluate for the SOB

> > > > showed a well defined

> > > > > 7mm right lower lung lobe nodule. A left 2.1cm adrenal nodule

> > was

> > > > found as well

> > > > > with soft tissue attenuation likely representing an adenoma.

> > > > According DHMC

> > > > > Emergency Medicine notes, these have been stable over time.

> > > > >

> > > > > PMSH:

> > > > > hypertension, and dyslipidemia.

> > > > > appendectomy, tonsil/adenoidectom y

> > > > >

> > > > > Medications:

> > > > > AMBULATORY MEDICATIONS· Last charted on· 03/03/2009

> > > > > DRUG DOSE/ROUTE FREQUENCY

> > > > > Aspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRN

> > > > > Oral

> > > > > Multivitamin Tablet 1 Tablet (s) / Oral Once daily

> > > > > Furosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once daily

> > > > > Oral

> > > > > Potassium Chloride 10 mEg 20 MEQ = 2 Capsule(s) / Once daily

> > > > > Capsule, Sustained Oral

> > > > > Release

> > > > > Atenolol 25 mg Tablet 25 MG = 1 Tablet (s) / Once daily

> > > > > Oral

> > > > > Triamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once daily

> > > > > Oral

> > > > >

> > > > > Allergies:

> > > > > ADR/ALLERGIES: Last charted on: 03/03/2009

> > > > > ADR/ALLERGY REACTION SEVERITY

> > > > > Sulfonamides

> > > > >

> > > > > Social. history:

> > > > > Very brief smoking history during teenage years

> > > > > Asbestos exposure 15 years in a boiler room

> > > > > Denies ETOH

> > > > > never married

> > > > > no children

> > > > >

> > > > > Famil.y Hx:

> > > > > Thyroid dysfunction: Mother, sister

> > > > > Thyroid cancer: No

> > > > > Diabetes mellitus: No

> > > > > Other auto-immune diseases: No

> > > > > Vitiligo: No

> > > > >

> > > > > Physical Exam

> > > > > Vitals:

> > > > > VITAL SIGNS (03/03/2009 @ 14·44)

> > > > > Heart Rate 96

> > > > > Systolic BP 156

> > > > > Diastolic BP 91

> > > > > Mean BP 112.67

> > > > > Weight (kg) 137.16

> > > > > Height (cm) 176.9

> > > > > Body Surface Area (m2 ) 2.6

> > > > > BMI (kg/m 2 ) 43.83

> > > > > Pain Scale 0

> > > > > Smoking

> > > > > Smoke History Remote

> > > > > General: NAD, morbidly obese

> > > > > HEENT: EOMI, anicteric, PERRL, moist mucous membranes, full

> > visual

> > > > fundi

> > > > > Neck: No LAD, no thyromegaly, no tenderness

> > > > > CV: Sl S2, RRR

> > > > > Lungs: CTAB

> > > > > Abd: soft, NT, obese

> > > > > Neuro: reflexes difficult to elicit

> > > > > Extremities: trace ankle edema

> > > > > Integumentary: Skin warm/dry/intact; no hyperpigmentation of

> > hand

> > > > creases or

> > > > > gumline/ rash

> > > > > 06/06

> > > > > K 4.0

> > > > > 08/06

> > > > > TSH 2.34

> > > > > cortisol 14:38 pm 12.0 ug/dL

> > > > > 03/2007

> > > > > VMA 6.4 (ref 2.0-10.0)

> > > > > Assessment and Plan:

> > > > > Mr. Bill is a 61 years y.o. M as above with symptoms of daily

> > > > lightheadedness and

> > > > > exertional SOB with an incidentally discovered 2.1cm left

> > adrenal

> > > > mass.

> > > > > Pt's symptoms are likely unrelated to this adrenal incidentaloma

> > > > especially since he

> > > > > has had an extensive negative work-up in the past. However,

> > since

> > > > most of these

> > > > > results are not available to us, and the patient would like to

> > be

> > > > retested, we will

> > > > > check levels of:

> > > > > midnight salivary cortisol

> > > > > renin and aldosterone

> > > > > DHEA-S

> > > > > serum metanephrine and normetanephrine

> > > > > to rule this lesion out as a functioning adenoma.

> > > > > Pt was counselled and reassured that this likely represents a

> > > > benign finding,

> > > > > especially since the lesion has been stable over time.

> > However, pt

> > > > was asked to

> > > > > coordinate with his PCP if he develops any new signs/symptoms or

> > > > change in his

> > > > > present signs/symptoms.

> > > > > We have reviewed our plan outlined above with the patient and

> > Mr.

> > > > Bill verbalized

> > > > > understanding. All questions were answered.

> > > > > Tharsan Sivakumar, MD

> > > > > Endocrinology Fellow

> > > > > I am being supervised by TURCO MD,JOHN H Endocrinology

> > > > > Electronically signed by: SIVAKUMAR MD, THARSAN 03/03/2009 15:58

> > > > >

> > > > > MULTI-AUTHOR NOTE

> > > > > I have interviewed and examined this patient along with Dr.

> > > > Sivakumar and agree with

> > > > > this note and also these recommendations. The patient will be

> > > > contacted with final

> > > > > recommendations when results of testing are complete.

> > > > > >50% of the 60 minute appointment was spent in face to face

> > > > counseling the patient

> > > > > about the possible significance and evaluation of his adrenal

> > > > abnormality.

> > > > > Jack Turco, M.D.

> > > > > Communication sent to: L. Durand 03/03/2009 17:28

> > > > > Electronically signed by: TURCO MD, JOHN H 03/03/2009 17:28

> > > > >

> > > > > DARTMOUTH-HITCHCOCK MEDICAL CENTER

> > > > > ENCOUNTER DATE: 08/06/ 2009

> > > > > OFFICE NOTES

> > > > > BILL,FRANCIS H

> > > > >

> > > > > Nephrology Clinic New Patient Visit

> > > > > Francis H. Bill

> > > > >

> > > > > August 6, 2009

> > > > > ID: 62 years old male seen at the request of Dr. Mogielnicki

> > for?

> > > > Conns Syndrome.

> > > > > Past Medical History:

> > > > > HTN diagnosed about 5 yrs ago

> > > > > Chronic Fatigue Syndrome

> > > > > Chronic dyspnea

> > > > > Chronic dizziness

> > > > > s/p appendectomy in Dec 2008

> > > > > Multiple granulomas in the Lungs

> > > > > Exophytic cyst Lt kidney

> > > > >

> > > > > History of Present Illness:

> > > > > Mr Bill presents today for a second opinion regarding whether he

> > > > might have Conns

> > > > > Syndrome. In 2006, he underwent w/u for SOB. He had a CT scan of

> > > > the chest which

> > > > > showed a 2.1 cm soft tisuue mass in the Lt adrenal gland.

> > > > Subsequent tests showed

> > > > > that the adenoma was non secretory. He has since undergone

> > several

> > > > chest CT and the

> > > > > adrenal mass has not grown is size. In March 2009, he was seen

> > by

> > > > endocrinology at

> > > > > DHMC. He again underwent testing including cortisol, PRA,

> > > > aldosterone, metanephrines

> > > > > etc, all of which were within normal limits. Patient was

> > reassured

> > > > that this likely

> > > > > represents an incidentaloma.

> > > > > Over the past 3-4 yrs, he has had chronic SOB and dizziness . He

> > > > has undergone

> > > > > extensive testing for both including EKG, stress tests,

> > > > echocardiograms, Holter

> > > > > montior, MRI brain (to r/o acoustic neuroma), sleep studies,

> > PFTs

> > > > etc all of which

> > > > > have not identified an abnormality.

> > > > > In Dec 2008, he presented with abd pain and was found to have

> > > > appendicitis on CT

> > > > > scan. It also showed an exophytic mass in the L kidney for which

> > > > he unerwent an

> > > > > ultrasound. He was told by his PCP that he needs f /u CT scan

> > for

> > > > the lesion. I do

> > > > > not have records relating to this issue today.

> > > > > He has normal renal fucnti on ( Cr from VA records has ranged

> > from

> > > > 0.8-1.1 in the

> > > > > past 3 yrs) .

> > > > > AMBULATORY MEDICATIONS· Last charted on· 08/06/2009

> > > > > DRUG DOSE/ROUTE FREQUENCY

> > > > > Aspirin 325 mg Tablet 650 MG = 2 Tablet(s) / PRN

> > > > > Oral

> > > > > Furosemide 20 mg Tablet 60 MG = 3 Tablet(s) / Once daily

> > > > > Oral

> > > > > Potassium Chloride 10 mEq 20 MEQ = 2 Capsule(s) / Once daily

> > > > > Capsule, Sustained Oral

> > > > > Release

> > > > > Atenolol 25 mg Tablet 25 MG = 1 Tablet(s) / Once daily

> > > > > Triamterene 50 mg Capsule 50 MG = 1 Capsule (s) / Once daily

> > > > > Oral

> > > > > Multivitamin Tablet 1 Tablet (s) / Oral

> > > > > ADR/ALLERGIES: Last charted on: 08/06/2009

> > > > > ADR/ALLERGY REACTION SEVERITY

> > > > > Sulfonamides

> > > > >

> > > > > Family History:

> > > > > No family h/o renal disease. He denies family h/o DM and CAD.

> > > > > Social History:

> > > > > Lives in Enfield NH. Vietnam war vet, now on disability 2 to

> > > > chronic fatigue

> > > > > syndrme. Quit smoking 40 yrs ago, denies ETOH ot illicit drug

> > use.

> > > > >

> > > > > Review of Systems:

> > > > > System Abnormalities

> > > > > Constitutional gained 40 Ibs over the past 3-4 yrs, + cheonic

> > > > fatigue

> > > > > Eye denies visual changes

> > > > > ENT denies sorethroay, odynophagia

> > > > > CV denies CP, palp

> > > > > Resp + SOB, + DOE, denies cough, PND or orthopnea

> > > > > GI denies loss appetite, change in bowel habit

> > > > > GU denies hematuria, dysuria, voiding difficulties

> > > > > Skin denies rash, hype rp igment at ion

> > > > > Allergy

> > > > > Endocrine no h/o DM, denies exessive sweating, heat or cold

> > > > intolerance

> > > > > Neurologic denies h/o seizures, headahces

> > > > > Musculoskeletal denies muscle aches, joint swelling

> > > > > Lymph

> > > > > Psych denies depression

> > > > > All other systems reviewed and negative.

> > > > >

> > > > > Physical Examination:

> > > > > VITAL SIGNS (08/06/2009 @ 13:28)

> > > > > Temperature © 36.61

> > > > > Route Oral

> > > > > Heart Rate 82

> > > > > Rhythm Regular

> > > > > Method Radial

> > > > > Systolic BP 149

> > > > > Diastolic BP 72

> > > > > Patient Position Sitting

> > > > > Extremity Left Arm

> > > > > Method NIBP

> > > > > Mean BP 97.67

> > > > > Weight (kg) 140.61

> > > > > Height (cm) 177.8

> > > > > Body Surface Area (m2 ) 2.64

> > > > > BMI (kg/m 2 ) 44.48

> > > > >

> > > > > General: elderly man, NAD, dishevelled

> > > > > Eye: no scleral icterus, EOM intact

> > > > > ENT: no pharyngeal erythema or thrush, poor dentition

> > > > > Neck: no JVD, no thyromegaly

> > > > > CV: sl s2 reg, no murmur

> > > > > Resp: CTAB

> > > > > Abd: + BS, NT/NO, obese

> > > > > Lymph: no cervical adenopathy

> > > > > Ext: no LE Edema

> > > > > Skin: no rash, hyperpigmentation

> > > > > Neuro: no focal motor deficit, sensations intact

> > > > > Psych: alert and oriented. affect appropriate

> > > > > Labs:

> > > > > LAB RESULTS: 00052074-2 03/04/2009

> > > > >

> > > > > CO RT MDNITE SAL-MAYO 19*

> > > > > (<:100-)

> > > > >

> > > > > DHEAS <30 L *

> > > > > (42-290)

> > > > >

> > > > > RENIN ACTIVITY-MAYO 0.8*

> > > > > (-)

> > > > >

> > > > > ALDOSTERONE- MAYO 5.5*

> > > > > (<=21-)

> > > > >

> > > > > NORMETANE FREE-MAYO 0.86*

> > > > > (<:0.90-)

> > > > >

> > > > > METANEPHR FREE-MAYO <0.20 *

> > > > > ( <:0.50-)

> > > > >

> > > > > Records from WRJVA reviewed and will be scanned into CIS.

> > > > > AlP:

> > > > > 62 M with chronic fatigue,

> > >

> >

> >

>

[Guest guest]

, do you know why your weight has jumped so dramatically

in such a short time? If it is not

from plain over-eating, then that needs to be investigated.

Val

From: hyperaldosteronism

[mailto:hyperaldosteronism ] On Behalf Of georgewbill

jwwright Are you saying you know more ther Dr Grim dose

about Conn's He is the one that is saying I should try meds for hyperaldo. He

has said this more then once based on what I have in this and other postings.

>

> , At the risk of losing my bedside manner award, I'll tell you like

it is.

> I'm not a DR but if I was, I wouldn't prescribe meds for hyperaldo,

because you do not have the data to indicate that.

> My renin is low, 0.2, and aldo 10 in range, and I do NOT have hyper aldo.

> I have LREH.

>

> You're problem, according to your data is you are too FAT, as in BMI 44.

That makes you tired and sore.

>

> Get the " Rice Diet Solutions " book.

[Guest guest]

Some of the weight gain is fluid retention. Some is from being a lot less

active. The amount of weight gain isn't quite right in this record It is one of

the things that didn't get recored right I am Weighted very often at the VA They

have my first weight as 282 and the last weight as 309.

hyperaldosteronism , " Valarie " <val@...> wrote:

>

> , do you know why your weight has jumped so dramatically in such a

> short time? If it is not from plain over-eating, then that needs to be

> investigated.

>

> Val

>

> From: hyperaldosteronism

> [mailto:hyperaldosteronism ] On Behalf Of georgewbill

>

>

> jwwright Are you saying you know more ther Dr Grim dose about Conn's He is

> the one that is saying I should try meds for hyperaldo. He has said this

> more then once based on what I have in this and other postings.

>

>

> >

> > , At the risk of losing my bedside manner award, I'll tell you like

> it is.

> > I'm not a DR but if I was, I wouldn't prescribe meds for hyperaldo,

> because you do not have the data to indicate that.

> > My renin is low, 0.2, and aldo 10 in range, and I do NOT have hyper aldo.

> > I have LREH.

> >

> > You're problem, according to your data is you are too FAT, as in BMI 44.

> That makes you tired and sore.

> >

> > Get the " Rice Diet Solutions " book.

>