278.2 🩺 國考版

278.2.1 高頻考點

278.2.1.1 Workup Algorithm for Resistant / Suspected Secondary HTN

1. Confirm with ABPM (rule out white coat)
2. Adherence + lifestyle
3. Aldosterone/renin ratio (PA)
4. Plasma metanephrines (pheo)
5. 24h UFC + 1mg DST (Cushing)
6. Polysomnography (OSA)
7. Renal Doppler / CTA (RAS)
8. Cr, UA, eGFR, electrolytes
9. TSH, Ca, PTH

278.2.1.2 Top Diagnostic Pearls

• PA = #1 endocrine cause; ARR screening
• Pheo: 5 Ps; α before β
• RAS: bruit, flash pulmonary edema, AKI on ACEi
• OSA: snoring + sleepy + obese + AF
• Cushing: striae, central obesity, hypokalemia

278.2.1.3 Treatment Choices

• ARAS: OMT (statin + ACEi + BP) > stent (CORAL)
• FMD: balloon angioplasty
• PA adenoma: surgery; PA bilateral: spironolactone
• Pheo: α-blockade → β-blockade → surgery; genetic testing
• Cushing: surgery + ketoconazole/osilodrostat
• OSA: CPAP

278.2.2 易混淆比較

Condition	Key Lab/Test	First Treatment
Primary aldosteronism	↑ Aldo, ↓ Renin, ARR > 20	Surgery (APA) or MRA (BAH)
Pheochromocytoma	↑ Plasma free metanephrines	α-block → β → surgery
Cushing’s	↑ 24h UFC, ↑ midnight cortisol	Surgery (transsphenoidal)
RAS	Renal Doppler / CTA	OMT (ARAS) or angio (FMD)
OSA	Polysomnography (AHI)	CPAP
Coarctation	Arm-leg BP gradient	Surgery or balloon

278.2.3 Special Topics

278.2.3.1 Hypokalemia + HTN Differential

• Primary aldosteronism
• Cushing’s
• Liddle syndrome (pseudoaldosteronism — SCNN1 mutations)
• Apparent mineralocorticoid excess (AME — 11β-HSD2 deficiency; licorice)
• GRA (glucocorticoid-remediable aldosteronism)
• Diuretic use
• Renovascular HTN (secondary hyperaldosteronism)

278.2.3.2 Useful Adrenal Imaging Pearls

• Adenoma: < 4 cm, lipid-rich, < 10 HU on unenhanced CT
• Pheo: > 4 cm common, > 10 HU unenhanced, T2-bright on MRI
• Carcinoma: > 4 cm, irregular, heterogenous, calcification

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