52yo man comes to the physician for a f/up exam. he has a 4y hx of HTN and a 1y hx of hypokalemia. current meds include labetolol, enalapril and KCl. his BP is 154/90. the remainder of the exam shows no abnormalities. his fasting serum aldosterone:renin ratio is increased. a CT scan shows a 1cm L adrenal mass. adrenal vein sampling before and after administration of ACTH shows b/l hypersecretion of aldosterone. which of the following is the most appropriate next step in management?
a. candesartan therapy
b. furosemide therapy
c. spironolactone therapy
d. b/l adrenalectomy
e. u/l adrenalectomy

The scenario suggests hyperaldosteronism (HTN and hypokalemia). Increased aldosterone:renin ratio suggests primary hyperaldosteronism (i.e. aldosterone is being produced due to a stimulus that is inside the gland itself). The mass on CT suggests it to be Adrenal adenoma whose main treatment is surgical removal. Spironolactone is given for bilateral adrenal hyperplasia. Furosemide is given in cases of fluid overload. b/l adrenalectomy will result in adrenal crisis or insufficiency and lifetime dependence on steroids.