How to document and manage a 60-year-old male with hypertension, type 2 diabetes, dyslipidemia, hypothyroidism, and previous thyroidectomy, undergoing adrenalectomy?

SOAP Note Documentation and Management for Adrenalectomy Patient

Subjective

Chief Concern:

• Document reason for adrenalectomy (e.g., aldosterone-producing adenoma, pheochromocytoma, cortisol-secreting adenoma) 1, 2
• Duration of hypertension prior to diagnosis (critical prognostic factor—patients with <6 years duration have better outcomes) 3
• Current antihypertensive medication regimen and number of agents (≤2 medications predicts better postoperative resolution) 3
• Symptoms of hormone excess: headaches, palpitations, sweating episodes (pheochromocytoma), muscle weakness, polyuria (hyperaldosteronism) 1
• History of hypokalemia episodes and potassium supplementation requirements 1

Past Medical History:

• Hypertension: Document blood pressure control, number of medications, presence of resistant hypertension (BP >140/90 on ≥3 drugs including diuretic) 4, 1
• Type 2 Diabetes: Current HbA1c, medications, presence of end-organ damage 4
• Dyslipidemia: LDL-C, non-HDL-C, triglyceride levels, statin therapy 4
• Hypothyroidism/Thyroidectomy: Levothyroxine dose, TSH level, reason for thyroidectomy 4

Medications:

• List all antihypertensives with doses (critical for predicting postoperative outcomes) 5, 3
• Document if patient was on spironolactone or eplerenone (must be withdrawn ≥4 weeks before confirmatory testing) 1
• Levothyroxine dose 4
• Diabetes medications 4
• Lipid-lowering agents 4

Objective

Vital Signs:

• Blood pressure (sitting, after 5-15 minutes rest): Document if >180/110 mmHg (severe hypertension) or >140/90 mmHg (stage 1-2) 4
• Heart rate 4
• Weight, BMI, waist circumference 4

Laboratory Values:

Pre-operative Biochemical Confirmation:

• Aldosterone-to-Renin Ratio (ARR): Document if ≥20-30 with plasma aldosterone ≥10-15 ng/dL 1
• Serum aldosterone level: Values <350 pg/mL predict complete resolution of hypertension postoperatively 3
• Plasma renin activity: Should be suppressed in primary aldosteronism 1
• Serum potassium: Document baseline (hypokalemia present in only 50% of primary aldosteronism cases) 1
• 24-hour urine aldosterone or saline suppression test results (confirmatory testing) 1

Adrenal Venous Sampling (AVS):

• Mandatory before adrenalectomy to distinguish unilateral from bilateral disease (prevents unnecessary surgery in up to 25% of patients) 1, 6
• Document lateralization index confirming unilateral aldosterone hypersecretion 6

Diabetes Monitoring:

• HbA1c, fasting plasma glucose 4

Lipid Panel:

• LDL-C, non-HDL-C, HDL-C, triglycerides 4

Thyroid Function:

• TSH 4

Renal Function:

• Serum creatinine, eGFR, urine albumin-to-creatinine ratio (UACR) 4

Imaging:

• Adrenal protocol CT: Document size, laterality, Hounsfield units (<10 HU suggests benign adenoma) 7
• Note: CT findings alone are insufficient for surgical decisions—AVS is mandatory 1, 6

Physical Examination:

• Blood pressure in both arms 4
• Cardiovascular: heart sounds, peripheral pulses, signs of heart failure 4
• Extremities: edema 4
• Neurological: assess for stroke sequelae if applicable 4

Assessment

Primary Diagnosis:

• Primary aldosteronism with unilateral aldosterone-producing adenoma (confirmed by AVS) 1, 6
• OR Pheochromocytoma (if applicable) 2
• OR Cushing's syndrome from cortisol-secreting adenoma (if applicable) 2

Secondary Diagnoses:

• Hypertension, resistant (if on ≥3 medications including diuretic) 4, 1
• Type 2 diabetes mellitus with/without complications 4
• Dyslipidemia 4
• Hypothyroidism, status post thyroidectomy 4
• Chronic kidney disease (if eGFR <60 mL/min/1.73m²) 4

Prognostic Factors for Postoperative Hypertension Resolution:

• Favorable: ≤2 antihypertensive medications, hypertension duration <6 years, serum aldosterone <350 pg/mL 3
• Unfavorable: Male gender, elderly age, longer duration of hypertension 8

Plan

Pre-operative Management

Blood Pressure Control:

• Target BP <180/110 mmHg before elective surgery 4
• Continue current antihypertensive regimen; adjust as needed 4
• For primary aldosteronism, mineralocorticoid receptor antagonists (spironolactone 50-100 mg daily or eplerenone) provide optimal BP control 1
• Avoid abrupt discontinuation of beta-blockers perioperatively 4

Pheochromocytoma-Specific (if applicable):

• Alpha-blockade mandatory 1-3 weeks preoperatively to prevent intraoperative catecholamine surge 2
• Phenoxybenzamine or selective alpha-blockers 2

Diabetes Management:

• Target HbA1c <7-7.5% perioperatively 4
• Continue current diabetes medications; adjust insulin regimen perioperatively as needed 4

Thyroid Hormone Replacement:

• Continue levothyroxine at current dose 4
• Verify TSH within normal range 4

Potassium Repletion:

• Ensure serum potassium 4.0-5.0 mEq/L before surgery (hypokalemia suppresses aldosterone production and affects surgical outcomes) 1

Cardiovascular Risk Reduction:

• Continue statin therapy for dyslipidemia 4
• Aspirin if indicated for cardiovascular disease 9

Surgical Approach

Laparoscopic Adrenalectomy:

• Recommended as treatment of choice for unilateral aldosterone-producing adenoma (improves BP in virtually 100% of patients, cures hypertension in approximately 50%) 1, 10, 5
• Lower morbidity compared to open adrenalectomy 10, 7
• Expected outcomes: 0% conversion rate, 0% 30-day mortality, minimal complications 5

Surgical Considerations:

• Transperitoneal or retroperitoneal approach based on surgeon expertise and tumor characteristics 7
• Expected operating time ~260 minutes, blood loss ~200 mL 8
• Ambulation typically day 1-2 postoperatively 8

Post-operative Management

Immediate Post-operative (Day 1):

• Monitor blood pressure closely (expect significant reduction) 10, 5
• Check morning cortisol or cosyntropin stimulation test to determine need for glucocorticoid replacement (not typically needed for aldosterone-producing adenoma, but essential for cortisol-secreting tumors) 7
• Monitor serum potassium (expect normalization) 10, 8

Short-term (2-4 weeks):

• Verify serum aldosterone normalization 8
• Reassess antihypertensive medication needs (expect reduction or discontinuation in 59-88% of patients) 10, 5, 3
• Patients with pheochromocytoma more likely to discontinue all medications (80%) compared to aldosterone-producing adenoma (20%) 5

Long-term Follow-up:

• Monitor blood pressure at regular intervals 10, 5
• Continue diabetes management with HbA1c monitoring every 3-6 months 4
• Continue lipid management with LDL-C monitoring 4
• Monitor renal function (eGFR, UACR) annually 4
• TSH monitoring for hypothyroidism 4

Lifestyle Modifications:

• Sodium restriction <1500 mg/day 4
• Weight loss if BMI >25 4
• Physical activity 90-150 minutes/week 4
• Smoking cessation if applicable 4
• Alcohol moderation (≤1 drink/day for women, ≤2 drinks/day for men) 4

Patient Education

Realistic Expectations:

• Complete hypertension resolution occurs in 50-59% of patients 10, 3
• 26-41% will require reduced antihypertensive medications postoperatively 10, 3
• 15% may have persistent uncontrolled hypertension despite surgery 3
• Predictors of persistent hypertension: male gender, elderly age, longer duration of hypertension, higher preoperative aldosterone levels 3, 8

Medication Management:

• Expect significant reduction in antihypertensive medication requirements (from average 2-3 medications preoperatively to 0.3-1.2 postoperatively) 5
• Continue diabetes and lipid medications as prescribed 4
• Continue levothyroxine indefinitely 4

Warning Signs:

• Severe hypertension (BP >180/110 mmHg) 4
• Hypotension or dizziness (may indicate excessive medication reduction) 4
• Hyperkalemia symptoms if on ACE inhibitors/ARBs (muscle weakness, palpitations) 1
• Signs of adrenal insufficiency if cortisol-secreting tumor removed (fatigue, nausea, hypotension) 4, 7