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Answer 4
  1. CT scan of the abdomen. The clinical presentation of this patient, along with the laboratory findings of suppressed PRA, elevated PAC, a high PAC:PRA ratio, and increased urinary aldosterone excretion, is diagnostic of primary hyperaldosteronism. The next step in his workup should be a CT scan of the abdomen to evaluate for the presence of an adrenal macroadenoma, unilateral or bilateral adrenal hyperplasia, or an adrenal carcinoma. This patient had a 2.2-cm unilateral adrenal adenoma. The treatment of choice in a young man with this lesion is surgical resection, which is often curative. Bilateral renal vein sampling is indicated following a CT scan in the following circumstances: (1) to exclude a nonfunctioning cortical adenoma in the patient who is older than 40 years, and (2) to assess for aldosterone lateralization in patients with normal-appearing adrenal glands, micronodular adrenal glands, or bilateral adrenal masses/hyperplasia. With a suppressed PRA, there is no evidence to support renovascular hypertension. Therefore, neither a renal angiogram nor a captopril renal scan is warranted.

     Brewster UC, Setaro JF, Perazella MA. The renin-angiotensin-aldosterone system: cardiorenal effects and implications of renal and cardiovascular disease states. Am J Med Sci 2003;326:15–24.

    2. Cruz DN, Perazella MA. Hypertension and hypokalemia: unusual syndromes. Connecticut Med 1997;61:67–75.

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