Mrs Shikha Kedia 44 year old female Married , 2 children City Indonesia C/o Headache and sweating occasional , lower limb pain , fatigue Increase frequency of urination at night 3-4 times B/l lower limb swelling Weight gain 10kg since 1yrs No H/o diplopia/ occipital Headache/limb weakness / Tremors No h/o palpitations / giddiness / syncope / chest pain / breathlessness/ othpnea / pnd No H/o cough / fever / cold No h/o abdominal pain / decrease urine output/ nausea and vomiting No h/o weight loss / night sweats No licorice consumption K/c/o HTN since 12 yrs 4 admission for Hypertensive emergency in past Recently June 2026 admitted I/v/o hypertensive emergency and hypokalemia (Received inj NTG / Potassium replacement / 2d echo : Concentric LVH No RWMA EF - 60% , No PAH ) H/o Hypokalemia since last 5 years (details unavailable) No H/o DM / Thyroid d/o / COPD / TB Family history : father : HTN Mother DM / HTN Sister : HTN Grandmother : HTN Grandfather: HTN Menstural Cycles: irregular since 2 months LMP: 19/7/26 Drug Allergy absent Appetite Normal / Bowel - unaltered / addiction -alcohol occasional Sleep adequate Veg diet Medication history Till 2014 - Olmesartan 20 mg od On/off took Tab Amlo 5mg sos Later increase to olmesartan 40 mg od Till aug 2024- Olmestartan 40 mg once daily Aug 2024- june 2026 Telista ch 40 once daily June 2026 onwards Cilacart T twice daily *On going Meds * Tab cilacar T 10/40mg 1-0-1 Home monitoring of bp 27/8/26 2 pm - 145/96 8 pm - 147/98 28/8/26 6 am - 150/100 2 pm - 142/95 8 pm - 154/100 29/8/26 6 am - 153/99 2:40 pm - 149/101 BP recordings 30/8/26 6am- 142/97 8pm - 158/102 31/8/26 7 am - 144/98 2 pm - 148/96 1/9/26 7 am - 143/99 2/9/26 7 am - 159/109 ( after this reading added 1 tab of minipress) 2pm - 126/88 6:30pm- 154/103Olmestartan 40 mg once daily 11/6/25 CPK- 45.3 normal CPK MB - 8.7 normal Aptt - 27.6 control - 31 .1 Hb- 11.4 wbc 10800 plt - 227000 Sgot/Sgpt -23/24 Alkaline phosphates - 95 Total bilirubin - 0.4 GGT- 26 LDH -188 Bun 5.3 S creat - 0.49 Sodium -139.6 S Potassium - 2.50 S Chloride - 93.30 Uric acid -3.2 14/6/26 Metanephrine -87.08 ( 30-165 ) Nor Metanephrine - 389.99 (105-375) Epinephrine- 13.5 (3.70-82) Nor epinephrine - 978 .17 (80-499) 2decho - (11/6/26) HYPERTENSIVE HEART DISEASE • CONCENTRIC LVH PRESENT • NORMAL SIZED OTHER CARDIAC CHAMBERS • NO RWMA SEEN • NORMAL LV SYSTOLIC FUNCTION, LVEF ~ 60% • GRADE - I LV DIASTOLIC DYSFUNCTION • TRIVIAL TR, NO SIGNIFICANT PAH • OTHER VALVES ARE NORMAL •IAS/IVSINTACT • NO CLOT/MASS/PE SEEN 12/6/26 Hb - 11.5 WBC- 11900 Plt - 230000 S creat 0.49 Uric acid -3.2 S. Albumin -3.8 globulin 2.4 S. Sodium -139 S. Potasssium - 3.39 S.Chloride - 97.1 Ultrasonography Abdomen - Normal Renal Doppler : B/l renal artery origin and cm is segment not visualised due to overline bowel gases B/l renal artery at hilium show normal velocity and wave form . Both kidney show normal intrarenal arterial follow pattern . 13/6/26 Hb - 12.1 WBC- 10100 Plt - 208000 S creat 0.39 BUN 3.6 Uric acid -2.6 S. Albumin -3.9 globulin 2.5 S. Sodium -139 S. Potasssium - 2.92 S.Chloride - 94.8 Urine microalbumin 52.9 mg/L and microalbumin-to-creatinine ratio 70.53 mg/g creatinine. 3/7/26 Sodium - 141 Potassium - 3.7 Serum Cortisol (7am - 9am ) - 11.73 ( 7-25) 4/9/26 Sodium - 142 Potassium - 3.4 Chloride - 103 Old previous reports : 3/7/26 Cerebral MRA - Impression: Normal Cerebral MRA. Nonspecific T2 white matter hyperintensities in bilateral cerebral hemisphere. MRI brain with contrast (November 2024 ) SELLA An ovoid lesion appears in the posterior pituitary with delayed enhancement compared to the gland parenchyma other pituitary. Measures +- 2.5 * 2.8 mm - Image of microadenoma in the posterior pituitary. Currently there are no significant abnormalities in cerebellum , cerebrum and brain stem . 03. Jul. 2026 CT-Scan of the Abdomen (plain & contrast) FINDINGS IN ABDOMEN: LIVER: Normal GALLBLADDER: Contracted gallbladder noted. PANCREAS: Normal SPLEEN: Normal Left suprarenal gland is normal in size, outline and density. No focal lesion seen. Approximately 14.2 x 15.4 x 8.2 mm size elliptical nodule noted in posterior limb of the right suprarenal gland. It shows HU value of approximately 14.5 in non-contrast study with HU ranging from -31 to 57. Fat density area also noted within it. Absolute Washout value is 43.2%. Relative Washout value is 28.6%. RIGHT KIDNEY: Normal in size (12.1 cm), position, outline and attenuation. Tiny cortical cyst noted in upper and interpolar cortex. No calculus or hydronephrotic changes seen. Prompt excretion of contrast seen from right kidney. No abnormality seen in perirenal area. LEFT KIDNEY: Normal in size (12.1 cm), position, outline and attenuation. No focal lesion seen. Approximately 6.0 mm diameter hyperdense calculus noted in lower pole calyx with average HU of +937. No hydronephrotic changes seen. Prompt excretion of contrast seen from left kidney. No abnormality seen in perirenal area. URINARY BLADDER: Normal UTERUS: Normal Single renal arteries are noted in both side. Mild narrowing (<40%) of the right renal artery noted adjacent to its origin. IMPRESSION: Elliptical mild to moderately enhancing nodule in posterior limb of the right suprarenal gland with indeterminate absolute and relative washout value. Overall features more infavor of adrenal adenoma. Mild stenosis of the right renal artery adjacent to its origin. Left nephrolithiasis. Tiny right renal cortical cyst. 21/7/25 Hb - 13.5 wbc - 11400 plt- 246000 Crp - 7.4 lipase - 108 Sgot - 16.9 sgpt - 15.4 Alkaline phosphate 152 Albumin - 4.14 Iron - 74.5 UIBC 288.3 TIBC- 363 TS - 21 Sodium - 142 potassium 2.94 cl- 97.9 Cholesterol 188 S TAG 87.5 HDL -54.4 LDL 115.10 VLDL- 18 Amylase -47 S calcium - 9.06 Bun - 10.6 magnesium 2.13 Uric acid 3.5 creat - 0.52 Homocysteine 12.13 Cortisol 8am 13.6 Anti CCP- negative DHEA - 174.3 Total testosterone- 49.57 B12 -471 Anti TPO- 0.72 Vit d -33 Anti transglutmainase - negative T3 -117 T4 - 7.17 TSH- 1.460 Ferritin - 170 Urine r/m NAd Folic acid - 1297 Kindly advise further management.